Child 1 witnessed mother's death in the family home in 2014 from multiple stab wounds caused by father. Child 1 sustained stab wounds including the partial amputation of finger during the incident. Child 1 was the eldest of three siblings, one of whom was also present in the home at the time of the incident. The children were not known to child protection agencies; they attended school and had no additional health needs. Father and mother were married for 16 years prior to the incident, but were experiencing marriage difficulties. The parents were attending marriage counselling both together and separately. Mother admitted to suffering domestic abuse and disclosed that she thought father bugged the house, her phone and computer and that she was frightened for her safety and that of her children. Both parents had been in contact with police with issues around domestic difficulties. The criminal investigation revealed that the family home was dominated by father's controlling behaviour. Issues identified include: a point of separation represents increased risk of harm to a victim of domestic abuse as well as children within the relationship; stalking behaviour in the context of domestic abuse is an indicator of high risk and is significantly associate with dangerous acts; the sharing of information between professional agencies is critical. Recommendations include: development of early help initiatives to help children talk about domestic abuse; publicising and promoting the role for independent domestic violence advocates; the use of public information notices to maximise the impact of warnings in cases of stalking.
      
 Title:  Child 1 LSCB: Warrington Safeguarding Children Board Author: Colleen Murphy Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1        Child 1 Author: Colleen Murphy 1st March 2017 WARRINGTON SAFEGUARDING CHILDREN BOARD             This report is written for publication in line with statutory guidance. In order to preserve the anonymity as far as is possible, the author has:  used numbers to reflect each child and generic “mother” and “father” terms to denote adults  made limited reference to the gender of person, other than where not to do so would compromise the reader’s understanding of the report  avoided the use of exact dates 2    1.        The circumstances which led to a Serious Case Review   1.1   Child 1 is the first born child within the marriage of mother, referred to as mother throughout the report and father, referred to as father throughout the report.  Two younger siblings followed the birth of Child 1, eighteen months and three years later. Both parents were employed, and the family lived together in a large mortgaged home in an affluent area.   1.2   Father had two children born within previous relationships. His first child was born within a former marriage and second child within a relatively short relationship. Father maintained a relationship with his first born child until that child’s adolescent years, but never had any relationship with his second child.   1.3   Father and mother were married for sixteen years prior to the incident which gave rise to this this Serious Case Review. Although to the outside world family life was presented as idyllic, in reality, the marriage was characterised by paternal dominance and both parents had had a relationship outside of the marriage.   1.4   Other than through the provision of standard universal child health and education services, the children of the family were little known to agencies with additional safeguarding responsibilities for children.  1.5   In November 2014, the lives of the children changed immeasurably when their father killed their mother in the family home in an act fully witnessed by Child 1, and whilst Child 3 was present in the family home. During the same incident, father caused Child 1’s hand to be injured by partial amputation of the middle finger and deep cuts across the finger and thumb area.  1.6   Quite remarkably, in the midst of the most traumatic experience imaginable for Child 1, Child 1 was able to use a mobile telephone to make a 999 telephone call to the police. Although not in a position to speak directly to the Police, Child 1 placed the telephone call on loudspeaker leaving the line open so that without father’s knowledge, and the call handler was able to hear father apologising to mother with the sound of children screaming in the 3  background. A second call in the same manner enabled the call handler to ascertain that mother had been stabbed.  1.7 An emergency response resulted in police officers and paramedics arriving at the family home within minutes. They discovered that mother had multiple stab wounds and attempted resuscitation unsuccessfully. The scene before them revealed that mother had been killed by father and that Child 1 had serious physical injuries that required urgent hospital treatment. Child 3 was present but not physically injured. 1.8 Father was arrested from a field at the back of the family home. He was subsequently charged with the murder of mother and attempted murder of Child 1.  2.    Decision to undertake a Serious Case Review  2.1 Three weeks after this fatal incident, a Criteria Panel was convened jointly between the Warrington Local Safeguarding Children Board, the Warrington Safeguarding Adult Board and the Warrington Community Safety Partnership to consider whether the grounds for both a Serious Case Review and a Domestic Homicide Review were met. 2.2 In reviewing the information available to the Panel, it was clear that a homicide had taken place that fell within the definition of the circumstances within which a Domestic Homicide Review should be convened, within Section 9 of the Domestic Violence, Crime and Victims Act 2004, and paragraph 5 of the Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (August 2013) and a recommendation was made to the Chair of the Warrington Community Safety Partnership that a Domestic Homicide Review should be held.  2.3 The Panel also gave consideration to the statutory guidance in respect of Serious Case Reviews as outlined in Working Together 2013. The Panel considered that the injury to Child 1, the potential additional harm caused to Child 1 and Child 3 through being present at their mother’s death, alongside the severe psychological damage to all three children warranted consideration under a child led review as to whether there is learning for 4  local safeguarding partners that would help protect children exposed to harm through domestic abuse.  A recommendation was therefore made for this to the Chair of the Warrington Safeguarding Children Board that an SCR should be held. 2.4 The Chairs of the Warrington Community Safety Partnership and the Warrington Safeguarding Children Board agreed that both Reviews were necessitated. The National Panel, the Department for Education and the Home Office were advised and informed of the decisions taken.  2.5 From the outset, an agreement was made that both Reviews would be run through a collaborative but not inter-dependent process. The Criteria Panel identified the need to minimise the impact of two statutory reviews on a grieving and vulnerable family, maximise efficiency of engagement with contributory agencies and ensure that learning was shared across adult and child facing safeguarding systems.  2.6 Accordingly collaboration and integration has been a guiding principle in how the two reviews have been conducted.  3.   Methodology 3.1        The Local Safeguarding Children Board commissioned an Independent Chair and an Independent Author, both of whom have substantial experience in undertaking Serious Case Reviews.  The Community Safety Partnership appointed an Independent Chair to facilitate and author the Domestic Homicide Review (subsequently referred to the Chair of the Domestic Homicide Review).  3.2        A Review Panel of senior officers from agencies contributing to the Review was established as follows:  Manager, Warrington Community Safety Partnership  Designated Nurse, Safeguarding Children and Children in Care, Warrington CCG  Designated Nurse, Safeguarding Adults, Warrington CCG 5   Named Nurse, Safeguarding Children, Bridgewater Community Health Care NHS Foundation Trust  Detective Constable, Cheshire Constabulary Major Crime Review team   Senior Operation Manager, Refuge   Manager, Citizens Advice Bureau Warrington     Head of Service, Quality Assurance and Safeguarding, Families and Wellbeing Directorate, Warrington Borough Council    Assistant Director, Children and Young People’s Targeted Services, Families and Wellbeing Directorate, Warrington Borough Council    Legal Services Team Manager, Warrington Borough Council    Head of Adult Safeguarding and Quality Assurance Division, Families and Wellbeing Directorate, Warrington Borough Council    Operational Director, Adult Social Services, Families and Wellbeing Directorate, Warrington Borough Council    Relate     Strategic Partnerships Officer, Warrington Borough Council    Business Manager, Warrington Local Safeguarding Children Board  The Panel provided support and oversight to the review and co-ordinated the involvement of the various agencies. The diversity of the Panel, which included voluntary sector representation to increase objectivity and a representative from a specialist national domestic abuse charity to increase challenge, led to genuinely challenging debate and consideration of the wider implications for local strategy and practice with regard to domestic abuse and child safeguarding.  3.3       The Panel sought a written contribution through an Individual Management Review from those agencies that had direct contact with either parent or the children in the months leading up to the precipitating incident, this included:   Cheshire Constabulary   Relate   Warrington Borough Council Children’s Social Care Services  Warrington Borough Council Adult Social Care Services 6   Ofsted   Primary and Secondary Schools attended by Child 1, 2 and 3  Warrington Clinical Commissioning Group  Bridgewater Community Healthcare NHS Foundation Trust  Warrington and Halton Hospitals NHS Foundation Trust  3.4       In addition each agency provided the Review with a chronology of contacts and interventions which was collated together in order to establish who knew what and when.  3.5      Working Together 2013 requires that Serious Case Reviews are conducted in such a way which:    recognises  the complex circumstances in which professionals work together to safeguard children;  seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  is transparent about the way that data is collected and analysed, and   makes use of relevant research and case evidence to inform the findings.  3.6       Although the Domestic Homicide Review sought information from a much wider range of sources, the Serious Case Review confined its activities to consulting directly with a small number of agencies. The only professionals who knew the children well were their respective schools and both willingly met with the Author of the Serious Case Review as did Cheshire Constabulary.   Although it was initially agreed that the Author of the Serious Case Review and Chair of the Domestic Homicide Review would meet with Relate, the organisation subsequently expressed that they did not wish to meet with the Authors, requesting written communication only. From a Serious Case Review perspective, this was a disappointing response, and one which impacted upon the Authors’ ability to engage in a reflective discussion to gain a better understanding of the practitioner’s perspective.  7  3.7       In order to make sense of what happened on the day that mother was killed by father, Cheshire Constabulary provided the Author of the Serious Case Review with access to the statements gathered for the purposes of the criminal investigation and prosecution of the father, as well as the video interviews of Child 1, 2 and 3 under achieving best evidence conditions.    4. Terms of reference and Timescales for Review 4.1 The first Panel meeting was essentially used to place a framework around both reviews, taking into account the statutory guidance for each and determining the areas of commonality and divergence.  4.2 The timeframe the review would cover was agreed as 1st September 2013 to 9th November 2014. This was agreed in order to consider the children’s full school year, which in essence meant three and half school terms, leading up to the precipitating incident and immediate actions. It was considered that this timeframe would facilitate agencies to consider any identifiable issues that may, albeit in hindsight, be significant to the build-up to the precipitating incident and the immediate actions that were taken afterwards. The Terms of Reference further requested that any historical agency records of incidents relating to safeguarding or domestic abuse should also be included in order to consider the historical context of the more recent events.  4.3 The relevant agencies were asked, through the Individual Management Reports,  to consider the following issues:   What appear to be the most important issues to address in identifying the learning in these matters?  Are local policies and procedures in place, and to what extent do they assist professionals in protecting children and/or those at risk of domestic abuse?  Are there any barriers to professionals complying with national and local policy guidance?  Were there any predictable risks of serious harm to the victims? If so, were they appropriately identified and acted upon? Were any 8  opportunities missed to safeguard the victims? What factors either promoted or detracted from protective practice?  Was there an appropriate exchange of inter- and intra-agency communication as required to protect children and/ or those at risk of domestic abuse?  Were staff supervised appropriately and were sufficient resources available to undertake the work required?  Additional Specific Key issues for the Serious Case Review:  What advice is available in the community for families, friends or neighbours who have suspicions that children are experiencing neglect or exposed to domestic abuse?  Were there opportunities for the child’s voice to be heard amongst relevant agencies?  To what extent did relevant agencies have an understanding of the child’s day to day life?    4.4 For both reviews, there was the will and desire to complete within an anticipated six month timescale in order that any learning could be embedded quickly for the purpose of enhancing the protection of children and vulnerable adults.  4.5 Although early progress was made in a timely fashion, significant delay occurred because of the impact of protracted criminal proceedings (as referenced in Section 5).  The delay in father’s criminal trial impacted upon the appropriateness of access to evidence gathered for criminal proceedings both in terms of statements and the potential risk of contamination of witness evidence by discussing matters necessary for the purposes of the Review prior to the giving of witness testimony at trial.  4.6 Following consultation with the Senior Investigating Officer from Cheshire Constabulary, a pro-active decision was made, through discussions that took place between the Chair of the Serious Case Review and the Chair of the Safeguarding Children Board, that the Reviews should be suspended until 9  after the criminal trial. The suspending of the Review did incur a greater delay than initially anticipated for reasons set out in Section 5 of this report. 5. Parallel Processes  The Serious Case Review was mindful of five parallel processes:  5.1 Criminal Proceedings  Father was charged with the murder of mother and attempted murder (later changed to Grievous Bodily Harm) of Child 1 in November 2014. As the review commenced, it was anticipated that the criminal trial would be concluded by the spring of 2015.  However, a series of judicial delays ensued related to the unexpected unavailability of the trial judge scheduled to hear the case, and a late decision, post-trial, by father to dismiss his legal advocates and seek application to vacate his original guilty plea, prevented this from being achieved. The legal matters were finally resolved in November 2015 at which point father was sentenced to life imprisonment for the murder of mother, with a minimum period of 27 years before he can be considered for parole and a concurrent 12 years imprisonment for the assault to Child 1.  In passing sentence, the Judge identified three central features which justified a lengthy prison sentence:  “One, you killed your wife in front of her and your own children in their home. The bloody savagery of your murderous violence provided an appalling spectacle liable to seriously scar their lives forever. Two, not only were Child 1 and 3 made to witness the murder of their mother but they were put in sustained and wholly realistic fear that they too might be killed. Three, your onslaught was protracted and punctuated by pauses which prolonged your wife’s agony”. 5.2 Family Law Proceedings  The children’s maternal family wished to quickly secure legal permanence for the children after the death of their mother at the hands of the only person who subsequently held Parental Responsibility. This necessitated private family law proceedings and an enormous adjustment for the children and their 10  extended family members. The Review Panel was ever mindful of the trauma and depth of adjustment facing this family, and that this could only have been exacerbated through the unexpected turn of events related to the criminal proceedings. Contact was maintained throughout by the Chair of the Domestic Homicide Review on behalf of both reviews, and the family were approached and agreed to meet following the Christmas period of 2015.  5.3 Domestic Homicide Review  The two reviews have worked together which has provided both additional support and challenge. The final Reviews will be presented within the same month to the relevant governance Boards and will be shared together with the family members.  5.4 Police  Due to the fact that Cheshire Constabulary had had five contacts with family members prior to the fatal incident, the case was referred to the Independent Police Complaints Commission (IPCC). The Commission considered the circumstances of the case and made a decision that the case should be reviewed at a local level without further involvement from the IPCC. This resulted in a very detailed local investigation, the analysis of which informed the Individual Management Review.  5.5      Coroner A coroner’s inquest into the death of mother was formally opened and adjourned within a week of the death and given fathers conviction for murder was not re-opened. 6. Engagement with Family Members  6.1 The Review Panel agreed that it was important to involve the members of the maternal family who have care of the children as well as the father. The Chair of the Serious Case Review and the Chair/Author of the Domestic Homicide Review met with family members to seek their contribution and questions. Very careful consideration was given to offering the children the opportunity to make a direct contribution to the Review, particularly Child 1. Ultimately it was 11  agreed that this decision was best placed with the maternal family members who had care of the children. The children have experienced trauma and are having to make major adjustments to their lives, they have lived with the uncertainty and unpredictability of criminal proceedings and only following this has any sense of respite from the dominance of this event been achieved. Ultimately, maternal family members believed that involving the children in a further process which looked back over what happened in this family could re-traumatise and trigger the depth of feelings they are beginning to manage and as such it was too risky to their emotional welfare.  6.2 Father was seen in prison post sentencing. He said that he is a man of strong principles, and that he was profoundly affected by his ex-wife stopping his contact with his first born child. He stated that he is exceptionally risk averse and felt that the fear of potential loss of his children was the single biggest factor that resulted in him killing mother, describing himself as going ‘ into an instant spiral of mental breakdown’.  6.3 Father stated that he became paranoid and, although he does not recognise other people’s general description of him as a controlling person, he does accept that he became ultra-controlling in some ways after he found out about mother’s affair. Father agreed that he did control spending and kept spreadsheets depicting intimate aspects of his life with the mother, but saw this as necessary to keep control or prove a point. Father stated that in the days leading up to the murder he was sleep deprived for up to eight days and lost a lot of weight.  6.4 Father said that as parents to Children 1, 2 and 3 out of himself and the mother he was the disciplinarian and that the mother had a more permissive approach. Father  reflected that he would “give them [the children] a forfeit” when they needed this; most of the which involved sitting down and discussing with the children what they had done wrong and how to make amends. On other occasions he agreed he would give them an actual forfeit such as taking their iPad off them, undertaking a domestic task or physical exercise or give them lines or a story to complete.   12  6.5 Father stated that his relationship with Child 1 had changed in the preceding two years, noting that Child 1 had become grumpier with him and apparently getting on much better with the mother. On occasions, as on the day of the murder, father found Child 1 to be disinterested in and dismissive towards him. 6.6 Father stated that if the Courts had not favoured his ex-wife’s custody of his first born child, then he believed that he would not have reacted as he did to the thought of losing his children and that mother would therefore still be alive today.  It should be noted that although residence was granted to the mother of his first child, the testimony of his ex-wife would suggest that contact between father and child continued but that the relationship deteriorated over time during adolescent years when the child found the father to be rigid and inflexible. In addition, father was dismissive about his role in the life of his second born child, simply stating that the mother of that child was solely responsible for that child.  6.7 The maternal family members described mother as a devoted mother, a warm and gentle person who could light up a room by her very presence. This sentiment is echoed by all who knew her. The family members were aware that the marriage was in crisis and that mother was having an extra-marital affair, and although they perceived father as ‘odd’ at times, socially inept and ‘hard’ on the children, they never envisaged the real danger that he posed to mother and the children. A family member had accompanied and supported mother to seek legal advice some weeks before the murder, as father had stated that he would get a low paid job and sell the house undervalue to ensure that mother was cut off from financial support and security. They also believed that father had approached a solicitor with a view to cutting mother and the children from his will.  6.8 The maternal family posed two specific questions that they wished the review to consider; firstly, why did the police officer advise them to stay away for one night and then not follow them up following a return the following day, and secondly, whether the counsellor from Relate could have been more pro-active in referring mother and the children directly to safeguarding services.  13  6.9 Words cannot express the trauma and devastation endured by this family, and the courage and determination that have they had to find to try to help the children rebuild their lives. They have co-operated in totality with all that has been asked of them whilst grieving and helping the children to cope day to day.  7. Overview of significant information known to Agencies between September 2013 and 2014.  Information known to agencies but significant to understanding how events unfolded is identified by italic script. 7.1  All three children attended school routinely and had no additional health needs beyond the common range of childhood illnesses. Each child was considered to be settled in school and content in their day to day life. In October 2013, the family faced an emotional crisis when the children’s maternal grandmother died unexpectedly. This came as a great shock and greatly affected mother who was particularly close to her mother. In order to ensure the children were well supported mother advised each school of what had occurred so they could be additionally vigilant with the children.  7.2 Mother worked in the home in a role that involved caring for children. Through this employment, mother was connected into a network of support and on occasions attended training and support meetings.   7.3 In March 2014 mother accidentally bumped into a man with whom, prior to her marriage to father, she had had a close and positive relationship.  In the following weeks and months, they rekindled a friendship which then became an intimate relationship.  7.4 Shortly after the family returned from a family holiday,  father  presented at a Cheshire Constabulary Police Station some ten miles from his home town and and requested to speak to a police officer.  Father told the police officer that he believed his wife was having an affair and that her new partner was planning to harm or kill him in order that his wife could inherit his assets. Father stated that he had lodged a ‘suspicion notice’ to this effect at his 14  solicitors and had notified his sister of his concerns, but that he had not spoken to the mother about his suspicions at this time. 7.5 The police officer established that father lived with the mother and their children Child 1, 2 and 3. It was noted that father  and mother  had been married for approximately 16 years and that the couple’s wedding anniversary was a few days later. The Police Officer recorded that father spoke highly of his family and stated that he thought they had been happily married up until recently and that he wished for the marriage to work.  Although  father  stated that he was in fear for his personal safety, the police officer established that he did not have any evidence of this and had not at any time been assaulted, threatened or approached in any way which could be construed as a threat to his safety. 7.6 Father told the police officer that he had installed a ‘spyware’ tracking device on mother’s mobile phone that had captured her in a compromising position. He also stated that he believed his wife was lying to him because her movements did not match up to the CCTV installed in the house. The police officer offered advice and stated that he would make a contact call to father over the next few days.   7.7 Two days later, at 4:37am, Greater Manchester Police (GMP) contacted the Cheshire Police Force Control Room to advise that  father  had attended at a (different) Police Station within their Force area, and a concern for his safety was raised as a result of what he said. Checks were completed by Cheshire Constabulary and it was established that there were no current incidents at the family home address, however, the presentation at a different Police Station two days earlier was noted and shared with GMP.  An officer from GMP forwarded an email to the police officer who responded to father two days earlier outlining the circumstances of this second visit by father.  GMP told Cheshire Constabulary that  father  had stated that he was scared to go to his home address because he believed that  mother  was having an affair and that her new partner was planning to kill him. GMP had contacted mother and she reported that she was concerned that father was having a breakdown and that she was concerned for the welfare of herself and Child 1, 2 and 3. The 15  GMP officer reported that father had left the police station as they had no powers to keep him there and a welfare visit was requested at the home address in light of both father and mother stating they were concerned for their safety. GMP advised mother to contact Cheshire Constabulary if and when father returned home and there were concerns regarding her safety or his welfare.  7.8       At 8:21 a.m. a Cheshire police officer attended the home address and spoke to both father and mother. The officer obtained details of all the people resident at the address, including the children’s maternal grandfather who was visiting. Father requested to speak with the police officer in private, and took the officer to the bottom of the garden out of sight of the CCTV attached to the outside of a summer house. Father informed the officer that he believed the mother was having an affair and that he feared that her new partner was going to kill him. Father told the officer that he had been out the previous evening and had seen a suspicious vehicle but nothing had happened after he had left mother alone in a public house some distance from their home because she had gone to the toilet and used her mobile phone. Mother was collected by her father, after father had rung his father-in-law to say that mother was having an affair. During this journey, mother confided to her father that she was having an affair.   7.9       Father told the police officer that he had installed a tracking device to mother’s mobile phone which was capable of recording video footage. He said that the device had been in place for approximately one week and for that period of time father had been able to monitor mother’s movements and had on one occasion recorded an intimate occurrence. Father confirmed to the police officer that no other person had been seen or heard in the footage and that he was now unable to view it because he believed that mother had deleted it from his phone. The police officer established from father that he had not received any physical threats to his wellbeing and that he had no substantial evidence of the suspected affair. 7.10 After concluding the conversation with father, the police officer spoke with  mother who confirmed that she was engaging in an affair but was not 16  prepared to tell  father  who that was with. Mother stated that no threats had been made to father and that she was not frightened of him.  After leaving the home the police officer submitted a Vulnerable Person Assessment (VPA) and Domestic Abuse Stalking and Harassment (DASH) Risk Assessment, in relation to father, graded as standard/low risk. 7.11 The police officer subsequently reflected on the fact that mother was not aware of the tracking device and sought further supervisory advice on this matter. The police officer made a second visit to the family home the following day and informed mother of the tracking device. Mother did not seem surprised by the actions of father and did not want to make a formal complaint. Mother said that she had not felt harassed but wished for the device be removed from her phone. The device was removed by father in the presence of the police officer. Mother said she did not wish for any further support from the police.  7.12 Nineteen days later the VPA and DASH Risk Assessment were reviewed by the Public Protection Referral Unit (PPRU) in Cheshire Constabulary who agreed with the standard/low risk assessment.      7.13 Four days after the police officer had attended the family home, father attended a GP consultation, and mother was present for the first half of the consultation. Father stated that he had confronted the mother the previous week about his suspicion that she was having an affair; he described how until the confrontation he had not been sleeping due to his worry that the person that the mother was having an affair with would assault him.  Father reported that he had not been sleeping since the confrontation and wanted to work on the marriage.  He told the GP that he had no concerns about work and no suicidal ideations. The GP noted that Father was coherent, had normal speech, good eye contact and no evidence of psychosis. The GP advised father to contact Relate to seek marriage guidance. 7.14 Eleven days later, father sought and attended a further GP appointment.  The GP noted that father was under much stress, had marital problems and was not sleeping. Father reported that he has lost one stone in weight and was 17  finding it difficult to concentrate, requesting a sick note for one week; he was advised to self-refer for counselling and was given a sleeping medication. 7.15 Eight days later, father did not attend a scheduled GP appointment. The GP contacted father who said that the medication to aid him to sleep was not helping for the full night. He was advised to double the dose and re-book the missed appointment.  7.16 That same day, father telephoned Relate to enquire about relationship counselling and booked and paid for an initial consultation session with a counsellor for himself and the mother the following day.  Father and mother attended the counselling session together; they told the counsellor that mother had had an affair and also disclosed some contact with the police. Father stated he wished to know who the affair was with and mother said she would not give him a name, fearing what he would do to the person as he had already told lies to the police.  It was agreed that the couple would each attend a further individual session, although father expressed a desire for counselling as a couple only.  Three days later father contacted Relate and booked and paid for an individual appointment for himself the following day and one for mother two days later.  7.17 Father attended the individual counselling session at Relate. During the session he disclosed that he had put a spy camera on the mother’s telephone and a microphone in her iPad. He also advised that he had been to the Police to ask them to record his fear that he would be killed by the man that  mother  was having an affair with. Father said that he had told the Police about the spying equipment he was using, and that they told him that this amounted to stalking and to remove it. He stated that the Police had asked mother if she wanted to press charges which she declined. Father told the counsellor that he was not sure that he could trust her (the counsellor) and the counsellor recorded that she felt genuinely frightened of him.  7.18 When mother attended the individual session with the counsellor she asked, on arrival, if she could leave her telephone at reception.  Mother told the counsellor that she thought father had bugged the house, her phone, the 18  computer, and possibly her father’s house as well.  Mother told the counsellor that she was frightened for her own safety and that of the children, as father had threatened to “self-combust” and had told her that she would never see the children again. Mother was not clear what father had meant by the term “self-combust” but said that she did not think that he would actually harm the children. Mother described an incident that had occurred on the night of their wedding anniversary approximately one month earlier when father had driven erratically because he believed a car full of men was following them. Mother  shared with the counsellor examples of father’s controlling behaviours which included:  Control over the family computer to such an extent that, if typing an email, a message would pop up from father stating ‘I can see what you are doing’ and this was disturbing to the children;  That father controlled all the family finances and she was concerned he would leave her without money for the children  That he had started filming her going about her job  That she had been scared to refuse intimacy             The counsellor encouraged mother to prioritise her safety and that of the children, urging her to contact the Police for further support; advising that she had been in a controlling relationship for years and that as she had started to challenge and move away from the relationship, there were risks to her safety and she could be in danger.  The counsellor indicated that father was unpredictable and she feared his reactions when she told him that counselling could not as he hoped save the marriage. The counsellor gave mother information about the domestic violence service provided in Warrington,  the Refuge Warrington Independent Domestic Violence and Abuse Service and encouraged her to talk to her father and the police again.  The counsellor asked mother for a telephone number for one of her trusted friends and she provided one. 7.19 The following day, the counsellor sought consultation with her supervisor about the case via e-mail copying in the Chief Executive. The decision was taken not to offer any counselling on the grounds of safety and it was agreed 19  that this would be explained to the clients at a short session to be attended by father and mother the following day.   The counsellor delivered a short session to the couple to close the case. Mother was advised to seek counselling over the loss of her mother, and father was advised to consult his GP about possible mental health issues.  7.20 During this first half term period of the new school year, neither school noted any issues of concern with the children. On one occasion Child 2 was noted as distracted and talking in class by a history teacher which prompted an email to the Head of Year.  7.21 Two days later, mother contacted Cheshire Constabulary and informed them that she and father had been to Relate and that their counsellor had advised her to make further contact with the police. Mother  stated that the counsellor had advised against a police visit, for fear that it might inflame the situation, but had given mother  the contact details of an agency which could support her to get away from father  as soon as possible. Mother stated that her father was staying with them, and that she would attend at Warrington Police Station at 22.00 that evening. The call handler obtained the following information from mother ;  that the counsellor had informed her that she was not in immediate danger but was more concerned about father’s mental health;  that the counsellor had said that mother was in a mentally abusive relationship;  that the counsellor wouldn’t see them again until they both sought help with father’s paranoia and mother’s grief at the death of her mother;   that father had been to see his doctor who had allegedly said he was ‘fine’ but he had not been sleeping well since finding out about the affair;  that mother and father had decided to end their relationship that day.           The previous Police records were reviewed and it was further noted that:  20   mother had refused to make a formal complaint about the tracking device installed on her mobile phone;  mother was reported to have said on more than one occasion that she was not scared of father but wanted the information noted.               The call handler noted that whilst on the phone to mother, father was constantly calling her mobile phone. 7.22 The Inspector acting as Force Incident Manager reviewed the information and made the decision that in light of the differing accounts provided by mother and father, a low key welfare check at the address should be undertaken by a specialist department such as the CID or Public Protection Unit (PPU). The requested departments were unable to attend due to other policing commitments.  Less than two hours later, at 19:02pm, a uniformed sergeant and a police constable attended the family home. Father was not present when they arrived and the officers spoke with mother who was surprised and shocked by the police attendance at her home. She presented as embarrassed by the situation and informed the officers that she had entered into an affair and it had had a profound impact on father. Mother was compassionate towards father but pragmatic and assertive in her decision making process that she did not want a reconciliation. Mother is recorded as repeatedly stating that she was not in fear of father and is reported to have almost laughed at the suggestion that father would be violent towards her.  7.23 Mother spoke at length with the sergeant about what had occurred within the marriage and confided that father had told the children about the affair in an attempt to embarrass her, but in fact Child 1 had been very supportive of her. Father had called mother derogatory names in front of Child 1. Mother advised that she was very worried though about leaving, partly because of the financial issues and the fact that the house was only in her husband’s name, and partly because of her commitment to her business which she ran from home. Whilst the conversation between the sergeant and mother was taking place, the police constable spoke with Child 1. Child 1 was observed to be at ease and confident, and talked to the officer indicating that mother’s affair was 21  known within the family but that it was not her fault because father  was not nice to mother. Child 1 said that father was unpredictable and that Child 1 did not trust him; he had never been violent to them but would shout and get frustrated. Child 1 believed that father had hidden cameras in the house and thought that he was spying on them. Child 1 did not indicate fear of father, and was accepting that a parental separation was appropriate. The Officer found Child 1 to be mature and intuitive.  7.24 Just as mother and the children were leaving the home address, father arrived home. He appeared shocked by the presence of the police at the home, asking what was going on and what was happening with his family. Father  continually requested to speak to mother on her own, stating to the officers that he had not done anything wrong and that it was mother who had entered into an affair with a ‘gangster’ and had refused to tell him the person’s name. He acknowledged that he had said some things regarding the children which he deeply regretted, but did not wish the marriage to end. The officers calmed father; he stated that he was at ‘rock bottom’ due to lack of sleep but did not have any suicidal thoughts. He also stated that he did not believe that mother was trying to harm or kill him and appeared embarrassed by having alleged such a thing.   7.25 The sergeant requested that mother notify Cheshire Constabulary of where she was staying that night and advised that there may be further contact from the PPU at a later date. Father was given advice to see his doctor and that it would be better if he went to his sister’s address so that he was not on his own. 7.26 In total, the police officers were at the family home for nearly two and a half hours. They submitted a VPA and DASH risk assessment graded as medium risk. It was also requested that a critical marker be placed on the address to provide information to other police officers who may have cause to attend. Intelligence checks and review of the VPA and DASH Risk Assessment was undertaken by the PPU sergeant.  The sergeant agreed with the medium risk assessment and made a referral to New Directions Adult Mental Health Service in connection with father’s mental health.     22  7.27 That same day the referral from the PPU was received by Adult Social Care Reception. The VPA was also sent onto Children’s Social Care when the screening revealed that three children were referenced in the household. The VPA was received by Children’s Social Care on the same day. It was misplaced into an information only folder prior to a decision being made about what action was required. It was subsequently discovered the day after the incident.  7.28 That same day, mother returned to the family home with the children, having changed her mind about leaving the home, because she remained concerned that she was letting down her clients and that the children needed to be back in school. Later that day mother rang the GP to request bereavement counselling and was given information about how to refer herself to the local Improving Access to Psychological Therapies Service. Mother also rang Relate and spoke to an administrator, asking to see the counsellor again because she was confused about her feelings. She told the administrator that, acting on the counsellor’s advice, she had contacted the police and had left the family home overnight; however father was persuading her to give the relationship another go. Concerned that her phone might be bugged the counsellor determined that it was unsafe to speak with mother, and consequently, the administrator was asked to briefly contact mother’s father and give him the details of the IDVA service. This took place thirteen days before mother was murdered.  7.29 The following day, father had a telephone consultation with the GP surgery.  Father discussed only a concern about his prostate and it was agreed that he would provide a urine sample and have a blood test to test for levels of prostate cells within the patient’s blood. Three days later, father had a face to face consultation with the GP. He told the GP that the counsellor from Relate had recommended individual counselling and he was given self-referral details. He stated that he was not sleeping but did not want anti-depressant medication and a repeat prescription for night sedation was given. The GP noted father was coherent with good eye contact. Father indicated that he had noticed a spot of blood in his motion and the doctor discussed carrying out a 23  blood test. Between the two consultations, the referral to New Directions was processed within Adult Social Care Services, and, in accordance with standard practice, a letter was sent to father, inviting him to make contact. 7.30 Five days after mother returned to the family home, father, mother and the children went away for the weekend on a planned trip with another family. Following this, mother, her father and the children went to stay with maternal family members for the children’s half term break. Upon returning home, mother and father spoke about their relationship. Those close to mother indicate that mother had concluded that the relationship was ending, whilst father states he remained hopeful that the marriage would survive.  7.31 The fatal incident occurred the following day, the day before the children were due back at school.  8. Analysis 8.1 Through the evidence exposed through a criminal investigation for the murder of mother, it is now know that Child 1, 2, and 3 lived in a family home that was dominated by father’s controlling behaviour, which impacted greatly on the mother and his relationship with the children.   Having read many of the statements gathered by the police during the investigation, it is clear that mother was a very warm and optimistic person who sheltered the children as far as possible from the excessive traits of her husband’s behaviour.  It is apparent that father used the strength of mother’s relationship with the children as a tool against her, evidenced by a family member recalling that on an occasion when mother asked to go out with friends, father responded by saying that if she did he would cut the children’s food allowance.  8.2 There is evidence that father was controlling and rigid in his style of parenting, and this was likely to have been a significant factor in why his relationship with his adolescent children became so difficult. His first born child found his attitudes and behaviour hard to tolerate and Child 1 indicated that he was ‘weird’, recognising his behaviour as different to that of other parents including mother. His need to exercise control resulted in the children experiencing 24  punitive punishments, such as writing lines and essays, physical exercise drills and withdrawal of communication.  8.3 The Domestic Homicide Review has identified that father had had a long history of controlling behaviour as evident in his first marriage and more recently history suggests that mother had become accustomed to behaviours that were indicative of his need to control. They lived in an affluent area, where high expectations of family life are considered to be the norm, according to professionals who work there. The area would not be typically targeted by community or welfare services, and potentially in an area where economic and employment status is significant, it may be highly stigmatising to seek outside help or support.  8.4 In conversations with the children’s schools, it is evident that the school knew the children and had regular contacts with mother. The children were perceived as happily settled in school and took advantage of school life with no obvious barriers to learning. Most parental contact was with mother who was noted to be a very attentive and warm parent.  The contacts with father tended to be on more formal occasions such as parents’ meetings where he was considered to be a ‘pushy parent’ who apportioned blame to the school if the children were not top of the class. The school never had occasion to be concerned about the children from a safeguarding perspective and had not known of the parents’ marital conflict. The children had friendship groups and were popular amongst peers. One can only conclude that the children’s resilience, given the stress of living with father, was a testament to the skilful parenting of mother and the quality of the relationships with their extended maternal family.  8.5 It is evident from Child 1’s statement to police that the child’s relationship with father had not been easy but had become much more strained during adolescence. Child 1 perceived father as nagging, irritating and overly controlling of mother. Child 1 considered that father restricted mother’s freedom and that she missed out on life because of this. As Child 1’s relationship deteriorated with father, it strengthened with mother so that when father told the children about their mother’s affair, expecting a sympathetic 25  reaction to him, Child 1 was supportive of mother and accepted and understood the context in which this had happened.  8.6 During the last few months of mother’s life, she appeared to have developed a dawning realisation that she was a victim of her husband’s controlling behaviour and that domestic abuse had a wider context than only acts of violence, which was reinforced by her contact with the counsellor from Relate.  In the last months of her life, mother, in common with many women in her situation, was struggling to make sense of what this meant for her and her children and trying to overcome the barriers to changing her circumstances. Commonly, women are highly vulnerable, feel a sense of shame and embarrassment believing themselves to be responsible for their husband’s behaviour, alongside a range of conflicting emotions and practical dilemmas. The overwhelming effect of all of these issues should never be overlooked by professionals, who need to take a supportive and empowering approach with a woman, but also have a responsibility to act independently if there is a belief that a woman or child is at risk of significant harm. The paragraphs below consider the single and multi-agency approach to three significant episodes of practice and what can be learnt from this to enhance safeguarding practice.  8.7 Response to father’s presentation at two Police Stations 8.7.1 Father presented at two separate police stations over a period of two days and on each occasion indicated that he believed himself to be at risk of harm from a person with whom his wife was having an affair. It is now known that one week prior to the first visit, suspicious that she was having an affair, Father had installed a spyware device on Mother’s mobile phone so that he could track her movements. The officer that spoke with father recalled that he was worked up about his concern that his wife was having an affair. The officer made intelligence checks which revealed no concerns about domestic abuse within the family home and having established that there was no evidential basis to his claims, concluded that he would undertake a follow up contact within one week. This officer did not complete a VPA because he considered this was not a report of a domestic incident, that father did not present as vulnerable and there were no identifiable child protection concerns. 26  In essence, the officer considered that father was seeking some ‘common sense’ advice to put things into perspective. The officer spent one and half hours with father and subsequently recorded the contact, tasking himself with a follow up contact.  8.7.2 The Police Management Report questions whether any offences had been committed at that time in relation to the reference to spyware device and whether reasonable consideration was given to the issue of stalking at this point. Ultimately, the report concluded that although there was no evidence of an actual offence and indeed no indication as to whether mother knew of this, the officer could have investigated further the circumstances surrounding the spyware device and the CCTV at the family home and issued a harassment notice in the form of a Police Information Notice (PIN). The reason this did not happen was because this officer did not consider an offence had been committed, indicating that tracking devices are not uncommonly used in such situations and that CCTV is a growing feature of many family homes.  8.7.3 Amendments were made to the Protection from Harassment Act 1996 in 2012 which introduced a new offence of stalking whereby ‘a person pursues a course of conduct in breach of S1 (1) of the 1997 Act (i.e. a course of conduct which amounts to harassment) and the course of conduct amounts to stalking’. There are a number of types of stalking including ‘monitoring the use by a person of the internet, email or any other form of electronic communication’ and ‘watching or spying on a person’. The Police note it is pertinent that an offence of stalking can only be committed where an offence of harassment has occurred, and this would mean having an understanding of whether the victim had been caused any alarm or distress, in this instance, this was not known or pursued. The officer did make a decision to follow up on father’s situation, however this did not happen before father presented at a second police station two days later. 8.7.4 The second presentation was at a Police station within the jurisdiction of a different Police force, Greater Manchester Police, and the information was shared across the Forces in an efficient and timely way.  It is now known that prior to presenting at this station father had confronted mother about his belief 27  that she was having an affair, loudly and publicly, in a restaurant. Father left the restaurant and mother called her father to collect her (see paragraph 7.8). The response by Cheshire Constabulary to undertake a visit to the home demonstrated an appropriate response to a second such presentation and was intended to check out the facts of the situation and establish that all was lawful. The police officer who attended recalled that father presented as lucid and coherent in his conversation but displayed a paranoia regarding his marriage. He spoke at length with father and mother, established that mother had as father suggested been having an affair and advised that father saw the GP about his lack of sleep.  8.7.5 The Police Officer reflected on the fact that father had told him he had used a tracking device and his discomfort that mother did not know this. The officer sought advice from a senior officer on the matter before making a second visit to address this information with both father and mother. Mother asked that the device was removed but stated that she did not wish to make a complaint about it; she was concerned for father and indicated that she did not feel harassed by him.  The police officer warned father about the use of such a device, he explained that stalking was a criminal offence that he could be arrested for.  The police officer could have issued a Police Information Notice (PIN). A PIN does not constitute any form of legal action, but is used to demonstrate that a suspect was aware that their behavior could count as harassment. This can be important because the offence of harassment occurs when ‘there has been a course of conduct (not a single event) and the perpetrator knows that their conduct amounts to harassment’. The use of a PIN would have been appropriate in the circumstances, however, because the police officer noted that mother was not fearful of father, this was not considered.  8.7.6 The evidence gathered for the criminal trial revealed that despite the verbal warning by the police officer, father continued to purchase and use covert surveillance such as a car tracker device and a tracing company to establish the whereabouts of the man with whom mother was involved. Whilst speculative, it is possible that the formality of a notice may have deterred 28  father from further use of technology for the purpose of stalking but this Review does demonstrate the challenges of predicting risk for a crime that has a higher rate of repeat victimization than any other crime.   8.7.7 The officer recalled that in speaking with mother, father and maternal grandfather all were calm and the atmosphere was comfortable. The officer did however complete a VPA and a DASH risk assessment in relation to father, but not in respect of mother. This was because father had stated he was at risk of harm, whilst mother had indicated that she was not in fear of her husband.  This omission indicates that controlling/stalking behaviour is not being responded to as would be physically abusive behavior.   8.8 Mother and father contacts with Relate 8.8.1  Five days after the visits from the police father attended the GP accompanied by mother with presentation of similar issues, that being father’s reaction to mother’s affair.  The family was living in a state of crisis. The GP suggested that Relate would be an organisation that could help them address their issues as a couple.  8.8.2 Relate charity is the parent organisation for a service that provides a counselling approach to support healthy relationships, which is delivered by local and individual Relate charities, each with its own Board of Trustees. It is the national body which develops the policies and procedures, including those for domestic abuse and child safeguarding, which are then used by the local services. The client group is self-referral and commonly this would occur when there is a problem or crisis in a relationship between a couple. The couple were allocated a counsellor who is a qualified practitioner who had completed organisational training in domestic abuse in 2007 and Child Safeguarding in 2015 post the injury to Child 1. The organisation is supported by a Domestic Violence/Abuse Policy and a Child Protection and Safeguarding Policy both written in 2013 and reviewed in 2016. The first session was attended by the couple together; this is a standard approach to assessment with the aim of establishing whether relationship counselling would be appropriate for the couple. Given the information that father had contacted the police because he believed himself to be at risk, the counsellor made a decision to undertake 29  Individual Structured Interviews (ISI), again a standardised approach to making a more detailed assessment as to whether counselling as a couple can be offered safely. The information gathered from the ISIs was discussed with a clinical supervisor and a decision was made and imparted to mother and father that counselling was not appropriate.  8.8.3 The Individual Management Report provided from Relate suggests that there are no lessons to be learnt from involvement with this Review, that all policies and procedures were provided appropriately, and that mother acted on advice to remove herself from potential harm. The Report cites as evidence of this that mother contacted Relate to inform them that she had successfully left the family home with police assistance.  This is however contradicted by the police statement taken from the counsellor which indicates that mother contacted the Relate office asking to speak to the counsellor because although she had left the family home the previous night, father was persuading her to give the relationship another chance.  Mother was not offered the opportunity to speak to the counsellor or a professional member of staff at Relate because it was considered too risky given that father had previously bugged her telephone. This was a very significant call from mother; she may have been seeking affirmation, reassurance, and a reminder of the reasons why this was necessary to enable her to carry through the action she had commenced. Instead her father was contacted with a telephone number of the IDVA service. Whilst there clearly was some risk present, arguably there was greater risk in not responding directly to her needs at that point in time and arranging a safe manner of contact.           The Domestic Violence/Abuse Policy states at 8.2:            ‘The victimised partner can also be invited to attend a short number of sessions to help them consider their own and their children’s safety and to access suitable external support’.  8.8.4 The counsellor at Relate had a firm understanding that mother was exposed to risk of harm and gave very specific advice that father was unpredictable and that mother and the children needed to be removed from that risk. The counsellor understood that a point of separation represents a hugely 30  increased risk in respect of domestic abuse and that this posed a threat to mother and the children.  When mother saw the counsellor individually, she reflected and articulated that she was a victim of domestic abuse, she shared how this manifested itself and the impact it had on her. Most significantly mother disclosed marital sexual violence. The counsellor was rightly extremely concerned by all that she heard, and advised mother to seek police assistance in moving out of the home. Whilst understanding that the counsellor wanted to support and empower mother to take control of her situation, I am firmly of the view, that because the counsellor did appreciate the risks for the children, that when mother indicated that she was vacillating in her decision a referral should have been made directly to the police and/or Children’s Social Care in respect of the children. The action of not seeing or speaking with her again, left her, as a victim, taking responsibility for her own protection and that of the children. Mother, in common with many victims, was not best placed to objectively assess the risk she and her children faced; professionals were. 8.8.5 Mother wanted to separate from father. She was, however, struggling to reconcile how she would practically manage this: what would happen to their home, how she would access financial resources, and how would she earn a living given that her job operated from home and that she would be letting down her clients.  There are many emotional barriers that prevent women from leaving abusive relationships, and this can be particularly so when a woman has been a victim of psychological abuse because it can be very hard to take back control. Varying research suggests that women will attempt to leave an abusive relationship between five and seven times before successfully doing so. 8.8.6 The Relate Domestic Violence/Abuse Policy makes the following connection with the safeguarding of children:              “5.1   In view of the interconnection between domestic abuse and child abuse, whenever Relate staff or volunteers receive information that gives cause for concern about an adult’s safety, they will bear in mind the increased possibility that there may also be a child at risk of direct abuse and they will 31  always ask for details about children and will make sensitive enquiry as to their safety.” “5.2 If there is cause for concern about a child they will act in accordance with Relates Child Protection & Safeguarding Policy”           “5.3 When responding to either of the situations in 5.1 or 5.2 above, Relate will seek to safeguard the vulnerable parent as an essential and integral part of safeguarding a child at risk.” There was no reason for the counsellor to believe that mother would intentionally place the children at risk. However, the counsellor, more than mother, understood that a decision to remain with father did place the children at risk of harm, and for this reason, I consider that a referral to Children’s Social Care was an appropriate course of action and should have been discussed with mother. It is also significant that mother cared for other children in her home and there was an additional responsibility to consider whether these children were also at risk.  8.8.7   The Child Protection and Safeguarding Policy is explicit that: “Paid and volunteer staff need to be aware of their responsibilities for safeguarding and promoting the welfare of children, how they should respond to child protection concerns and make a referral to local authority children’s social care or the police if necessary”.  The Individual Management Review does not indicate that specific consideration was given to whether there was a risk of harm to the children despite a view that father was unpredictable and presented a risk to mother.   8.8.8 There is considerable reflection and learning for Relate; the agency identified risk well, and did take steps to advise and encourage mother to achieve a safer environment for herself and the children. There was however limitation in the approach to safeguarding by not sharing information directly with those agencies that have a duty to assess and potentially act upon the risk identified. Relate’s course of action placed all safeguarding responsibility with mother, which missed a key opportunity to share the very sound knowledge of the counsellor with key professionals going forward.   32  8.9      Mother’s contact to Police  8.9.1 Mother’s contact to the Police was two days after the last meeting with Relate. Mother stated that she was following the advice of the counsellor that she needed support of Police to safely achieve a separation from father. When this contact was evaluated, in light of the previous contacts, a decision was made for an officer to visit the family home, the sergeant requested that a police constable accompany him in the knowledge that there were the children in the home, and they were briefed that the previous contact had been in relation to a marriage breakdown and the previous use of a tracking device.  8.9.2 The officers found mother to be an articulate and honest woman devoted to her children. She indicated that she did not really want the police involved as she thought the situation had been ‘blown out of all proportion’.  On reflection, both officers recalled that mother was embarrassed by their presence and worried about what the children would think and also how it would appear to the neighbours.  Mother did not indicate that she was in fear of father; she was assertive in stating that their marriage was over, whilst at the same time showing concern and care for father.  The Sergeant spoke with maternal grandfather who was staying with the family and the police constable spoke in some depth with Child 1, and briefly with Child 2 and 3. Child 1 spoke disparagingly of father, how he controlled mother and that if they left the address they would ‘lose everything’. Child 1 did say [the child] was scared of ‘what he’ll do to mum’, this was understood to be in the context of making her life difficult through refusing an amicable separation. Child 1 questioned whether father was also tracking their movements.  8.9.3 The officers did not identify any child protection concerns, other than a strained relationship between father and Child 1, and concluded that mother was not fearful of father, more that this was a couple and family struggling to achieve an amicable way forward when mother wanted a separation and father did not. The sergeant understood that marital breakdown is a high risk factor in domestic abuse and this, coupled with the tracking device and the information that mother shared from Relate, led him to make a judgement that a safeguarding approach should be taken and he suggested and reached agreement that mother would leave the family home with the children and her 33  father that evening. This action was intended to negate any flashpoint which could potentially occur once father returned to the family home and to provide mother with an opportunity to make a clean split, giving mother the independence to go where she wanted without the knowledge of father. The Sergeant asked mother to let them know where she went later that evening, this was in order to complete the task of helping her to leave safely and to demonstrate concern for their welfare as they made this move.  8.9.4 In the event, father returned to the family home as the family were preparing to leave. The officers remained throughout and suggested to father that he consider staying with a family member that night as he was clearly distressed by the turn of events. The officers assessed that father was upset but at no time unpredictable or volatile.  He was advised to see his GP because of concerns that he was not eating and sleeping.  8.9.5 The officers completed and submitted a VPA and DASH risk assessment. The DASH risk assessment was completed with mother and she answered no to most of the standard questions, which led to the following results in respect of father:  He had never been violent or tried to hurt her or the children  He had never hurt a family pet  He had never threatened to hurt her or the children  He had never stated that he was going to harm himself  He was not addicted to alcohol or drugs  He had never tried to suffocate or drown her  He had never said anything of a sexual nature which made her feel bad about herself  He had only ever used lawful chastisement on the children and this was never excessive What is less apparent from this assessment is the extent to which he used psychological measures to control mother and that he had a high level understanding of technology to aid this. Additionally, it is now known that mother did disclose sexual violence to the counsellor, however, this did not appear to be specifically identified as a very specific matter for concern.  The 34  level of risk was assessed as medium and this was appropriate to the application of the tool.  The officers attending that night took a robust approach and met the objective of helping mother safely achieve a physical separation from father.   8.9.5 The VPA and DASH risk assessment were screened by the PPRU the following day. As stated, the risk assessment was appropriate to the information known; however, this also raises one very pertinent question, that being why it was that the counsellor had indicated that mother needed to place herself out of danger swiftly. Inherent in the limitations of understanding the whole picture of risk for mother was the fact that there was no communication between the counsellor and the Police. Had this occurred, then the likelihood is that the much more concerning information shared by mother in a one to one situation with the counsellor would have been shared with the police. I am of the opinion that this would have elevated the risk assessment for mother and the children. The PPRU officer did consider forwarding the information through to the Independent Domestic Violence Advocacy (IDVA) service but she did not do so because she believed that Relate were already providing a service. Significantly, Relate had provided mother with a contact number for the IDVA service but had made no direct referral. The absence of direct communication between the Police and Relate had an impact on the quality of information known to the Police, which in turn impacted on the risk assessment which did not refer the mother or the children to further services.  8.9.6 Mother’s decision to return to the family home did not appear to have been considered as a possibility. It was a very significant decision, and one commonly taken by women struggling to separate from men who have long standing power over them. Had this possibility had been considered, a follow up response from PPRU or indeed the counsellor following mother’s request could have helped mother to maintain the separation until she was in a stronger position emotionally. The value of information sharing across professionals directly is a consistent theme in Serious Case Reviews. Although mother was an articulate woman and capable parent, indeed 35  descriptions of her murder reflect that she was focussed on protecting Child 1 until her dying breath, she was also the victim of long standing psychological abuse who needed significant support to keep herself and her children safe. The IDVA service was the most appropriate service to offer the level of support that mother needed and had referrals been made directly by professionals, this service would have been best placed to respond appropriately.   8.9.7 The PPRU officer in reviewing the VPA noted that this was a second referral surrounding the situation, which now raises concern about father’s mental health and accordingly made a referral to New Directions through Adult Services in relation to father.  The standard response to such a referral was to write to the person inviting a contact; father did not respond to this. The screening in adult services resulted in the referral also being shared with Children’s Social Care, as stated this was misplaced and not screened prior to the incident. The Individual Management Report from Children’s Social Care indicates that had this contact been screened, it is likely it would have been progressed to a referral and that checks with other agencies would have been completed. Standard checks with school and health services would not have revealed any issues of concern for the children and in all likelihood that would have led to a letter advising of support services being sent to the family.   8.9.10 The significant points of missed opportunity for communication lay between Relate and the Police, and the absence of either agency making and initiating a contact with the other, specifically in relation to mother’s need for support and protection led to additional vulnerability for the children.   9. Learning Outcomes    9.1 The children of this family have experienced trauma beyond what is imaginable. Two of the children witnessed the horrific murder of their mother by their father, and all three children have lost both parental figures. The effects on their lives are profound and lifelong.  The maternal family, themselves grief stricken, have followed the lead of the mother and care for 36  the children with stability, love and nurture to help them to continue their lives. This is a tragedy that no family should have to endure.  The appraisal of professional practice in no way seeks to apportion blame to professionals who were responding to an unfolding series of events. It is the father alone who is responsible for what happened and the impact on the children. The outcomes do however seek to understand what can be learnt in order to better assist the future safeguarding of children.   9.2     Children who live with Domestic Abuse in the home may face challenges and risks that can be life - long and should be considered as Children in Need under the Children Act 1989.  Children are often described as the hidden victims of domestic abuse. The last fifteen years has seen a growing recognition and understanding that living in a home where there is domestic abuse is harmful to children. Whilst there is the obvious risk of becoming physically hurt in a violent relationship, children also suffer long-term emotional effects as a result of living with domestic abuse. The Adoption and Children Act 2002 extended the definition of significant harm from The Children Act 1989 to include ‘impairment suffered from seeing or hearing the ill-treatment of another’. When there is a known risk of harm, it is appropriate for professionals to make referrals to Children’s Social Care who have a primary duty to undertake an assessment of a child’s needs in accordance with  Section 17 and 47 Children Act 1989. To this end, the Relate Child Protection and Safeguarding Policy should be reviewed, using the case as an instructive case scenario, to ensure that clear local advice and guidance is available to practitioners to support the need for referral about risk to children. This guidance should be consistent with the local area threshold criteria for access to children’s services.   9.3 A point of separation represents increased risk harm to a victim of domestic abuse as well as any children within that relationship.  Successive enquiries and research have shown that there is a strong relationship between victims who attempt to end an abusive relationship and partner homicide. The ending of an abusive relationship must serve as an 37  indicator to professionals supporting victims and assessing risk that additional services should be accessed for both support and expertise. It is professionally naive to consider that separation will be achieved on the first attempt or that it is the end a problem when in reality it is simply the beginning of the next chapter.   9.4  Stalking behaviour in the context of Domestic Abuse is an indicator of high risk and is significantly associated with dangerous acts.  Although there is no UK comparable data, studies an America reveal that 76% of women murdered by an ex-partner were stalked in the lead up to their death. It is a fact that with relative ease and limited knowledge, a perpetrator can use technology to track their victim’s whereabouts through tracking/locators on mobile telephones and cars. It is believed that the father, who had a high level of knowledge of technology, was able to record mother’s private conversations and observe her movements through remote access to the household CCTV. From 2012, two criminal offences specifically relating to stalking have been introduced, the Suzy Lamplugh Trust points out that stalking differs from harassment because of the ‘obsessive fixation’ of the stalker, and the element of fixation which means that stalking that can escalate very quickly and dangerously.    The use of PIN notices, whilst having no legal status in itself, serves as an indisputable warning to the perpetrator, the naming of the behaviour, and an indicator of concern for the victim.   Given the undoubted risk of stalking, their use should be firm and consistent.   9.5     The sharing of good quality information directly between professional agencies is critical to ensuring robust risk assessments and responses are achieved.  A key limiting factor in assessing risk to children is poor quality of information and for this reason structures that support good quality information sharing are critical to safeguarding children. The point is already made that review of guidance by Relate would benefit practitioners seeking guidance about how and when to share information, and it equally important for Officer in Public 38  Protection undertaking quality assurance to be wholly satisfied that they have relevant source information and have made no assumptions that other agencies are providing services.    The Domestic Homicide Report considers in some detail the model of the DASH risk assessment. It notes that national research recognises that it is easier for police officers to recognise Domestic Violence than wider issues of coercion and control within relationships and the current DASH risk assessment was not felt to support officers to develop this approach.  A revision of the model, with a greater focus in issues of coercion and control, is to be piloted in a small number of police force areas with the intention of rolling it out nationally once it has been fully evaluated. This is a positive development; however, there remains a local need to ensure immediate learning and refocus. The police officer attending the Panel meeting clearly articulated the need to be mindful that DASH is a tool that should never be used to replace professional judgement and intuition.   9.6 IDVA services play a critical role in supporting victims of domestic abuse and co-ordinating multi-agency risk assessment for victims and children and rely on partner agencies to facilitate contacts with this that need help.   The Independent Domestic Violence Advocacy service is provided by Refuge in Warrington. It is structured in such a way to be responsive to crisis and readily available to victims in need. It provides an expertise of the legal systems that victims are often intimidated by, and safety planning as well as access and support to find practical solutions to the very real issues faced by victims leaving a partner. Although mother was provided with the contact details for this service by the counsellor, the service was never made aware of the mother and the risks presented to her family. Given the mother’s wish to separate, but confusion that she felt in being able to achieve this, the IDVA service would have been ideally placed to offer the support that was needed.   39  9.7 For some children, Domestic Abuse is causing hidden harm.  Systems that help children be aware of, and talk about Domestic Abuse, will help to identify and support children to remain safe.   The children of the family, in particular Child 1 as the eldest, were all aware that their father used controlling behaviour toward them and their mother. There is no indication that, other than when asked by the police officer, Child 1 spoke about this outside of the family. The children’s schools had no knowledge of the police visits to the children’s home, and no evident reason to be concerned for their welfare. The school attended by Child 1 is currently taking part in Operation Encompass, an initiative between the Local Safeguarding Children Board, school and Cheshire Police. This operation aims to ensure that schools are made aware in a timely fashion of all police responses to domestic abuse where a child is present and attends their school. This will enable school staff to offer support to ensure that children feel consulted and safe and promote the awareness of the all parents that domestic abuse impacts on children.    The Domestic Homicide Review has given particular consideration to the accessibility of information about domestic abuse within the profile of the community where this family lived and has made recommendations to the Community Safety Partnership about how this can be enhanced.   10. Recommendations   1. That WSCB publicises and promotes the role for Independent Domestic Violence Advocates amongst professionals within constituent agencies;  2. The WSCB seeks assurance from Relate that their Child Protection  and Safeguarding Policy specifically direct practitioners and manager to the  action that should be taken when there is a known risk of harm to a child in accordance with local threshold criteria; 3. The WSCB seeks assurance from Cheshire Constabulary that Public Information Notices are utilised to maximise the impact of warnings in cases of stalking, and that the issuing of such notices in matters of 40  domestic abuse where is a child is present is shared with Children’s Social Care colleagues through the Multi Agency Safeguarding Hub; 4. That the WSCB supports and develops early help initiatives to help children talk about domestic abuse.          