Death of 10-year-old and 7-year-old boys and their mother and father in March 2018. The children, Luis and Carlos, and their father, Juan, were found dead at the foot of cliffs in Sussex; their mother, Maria, was found dead at the family home in London. The coroner certified that Luis, Carlos and Maria were unlawfully killed, and that Juan had committed suicide. The family emigrated from Venezuela to the UK in 2016. Prior to the deaths, Juan wrote a document in which he claimed that Luis and Carlos had been sexually and physically abused while at school in Venezuela. The family did not come to the attention of agencies while in the UK, and the review panel were unable to find sources to support the claims of abuse. The review panel concluded that financial issues were a potential motivation for the murders and suicide. The family were Venezuelan with Portuguese heritage. Learning includes: consideration of the financial and homelessness support available to migrant families; and ensuring the link between financial difficulty and suicide is incorporated into safeguarding adults and suicide prevention. Recommends that: the London Borough of Richmond upon Thames addresses issues of financial and homelessness difficulties for all communities; links to domestic abuse are addressed in the development of the borough's violence against women and girls strategy; the borough ensures that issues of financial difficulty and links to suicide are incorporated into public health and suicide prevention work.
      
 Title:  Joint domestic homicide review and serious case review: overview report: Maria aged 47: Luis aged 10: Carlos aged 7: found murdered by Juan aged 57 who also took his own life. LSCB: London Borough of Richmond Upon Thames Community Safety Partnership Author: Bill Griffiths Date of publication: 2021  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.                          Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   1 Official    LONDON BOROUGH OF RICHMOND UPON THAMES COMMUNITY SAFETY PARTNERSHIP  JOINT DOMESTIC HOMICIDE REVIEW AND SERIOUS CASE REVIEW  OVERVIEW REPORT   MARIA AGED 47 LUIS AGED 10 CARLOS AGED 7  FOUND MURDERED BY JUAN AGED 57 WHO ALSO TOOK HIS OWN LIFE  MARCH 2018 IN RICHMOND AND SUSSEX   REVIEW PANEL CHAIR AND REPORT AUTHOR BILL GRIFFITHS CBE BEM QPM 25 AUGUST 2020  Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   2 Official LIST OF CONTENTS    Paragraph No    Page No Introduction               1 - 7        3 Timescales              9 – 10        4 Confidentiality            11 – 13        4 Terms of Reference                14        5 Methodology            15 – 17        5 Involvement of family, friends and others        18 – 20        5 Contributors to the review          21 – 22        6 Review panel members               23        7 Author of the overview report               24        8 Parallel reviews                25        8 Equality and diversity                26        8 Dissemination                 27        8  Background information (The Facts)        28 – 84        9 Discovery of the fatal incidents         28 – 30         9 Family background           31 – 35        9 Living in Lindon           36 – 61      10 Pen pictures of Luis and Carlos         62 – 64      15 The fatal incidents           65 – 84      15  Analysis            85 – 93      19  Conclusions and lessons learned         94 – 98       21   Recommendations           99 – 101       22      Glossary                     23 Distribution List              24  Appendices        Appendix 1 – Terms of Reference for review           25  Appendix 2 – Independence statements                29 Appendix 3 – Action plan             30    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   3 Official  INTRODUCTION  1. This report of a joint Domestic Homicide Review (DHR) and Serious Case Review (SCR) examines agency responses and support given to Maria (aged 47), her children Luis (aged 10) and Carlos (aged 7) residents of the London Borough of Richmond Upon Thames (LBRuT) prior to the discovery in March 2018 of her death at home and her children’s death in Sussex, all at the hands of Juan (aged 57) who took his own life.  2. In addition to agency involvement the review will also examine the past to identify any relevant background or trail of abuse before the homicides, whether support was accessed within the community and whether there were any barriers to accessing support.  By taking a holistic approach the review seeks to identify appropriate solutions to make the future safer.  3. On a Monday in early March 2018, police received a message from Mateo, who resides in Australia, that he had received an email from his father, Juan, declaring his intention to take his own life.  Police attended the house in Richmond and found Maria deceased with multiple stab wounds.  Further enquiries made the link with the discovery that same afternoon at the foot of cliffs in Sussex, of the bodies of Juan and their sons.  4. The family are Venezuelan with Portuguese heritage through Juan and entered the UK via Spain in January 2016, with the sons attending school locally in Richmond.  Written material found at the scene supports an initial hypothesis that Juan murdered his wife and then drove his sons to Sussex where he took their lives at the time of taking his own life.  5. At the subsequent joint Inquest hearing in May 2019, the Coroner pronounced that Maria, Luis and Carlos had been murdered by Juan, who then committed suicide.  There is no evidence of third-party involvement.  6. The review will consider agencies contact/involvement with the family from January 2016 to the day of the fatal incidents in March 2018.  Any relevant fact from their earlier life will be included in background information.  7. The key purpose for undertaking DHRs and SCRs is to enable lessons to be learned from homicides where a person is killed because of domestic violence and abuse.  For these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change to reduce the risk of such tragedies happening in the future.  8. One of the operating principles for the review has been to be guided by humanity, compassion and empathy, with Maria’s and her children’s ‘voices’ at the heart of the process    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   4 Official TIMESCALES  9. The review began with a Panel meeting on 2 July 2018 when Terms of Reference were agreed, and Chronology reports commissioned from all identifiable public and voluntary bodies that may have had contact with the family.  At the second meeting on 13 August, Chronologies were reviewed, and it was agreed that the absence of relevant contact with the family from any source meant there would be no further information to be gained from Individual Management Reviews (IMR).  The Metropolitan Police provided a letter that set out relevant discoveries from the homicide investigation.  10. It was apparent that the only other source of insight on what had happened, and why, lay with family and friends, however, the family were living in Australia and Mexico and their engagement was limited.  Following the second meeting, the process was put on hold pending forensic examination of telephones and a family computer for relevant information that might shed light on what happened and why.  The Inquests were held in May 2019 at West London Coroner’s Court.  An initial draft overview of the facts was considered by the Panel on 13 June and a third version at the meeting on 21 August.  A fourth version was presented to the Community Safety Partnership on 30 September 2019 and agreed subject to discussion points from the meeting leading to the final version on 24 October 2019.  CONFIDENTIALITY  11. The chronologies are confidential.  Information is available only to participating officers/professionals and their line managers.  12. For ease of reference, all terms suitable for acronym will appear once in full and there is also a glossary at the end of the report.  Family and friends that feature in the review are included in the glossary and below for reference. Maria  Subject of DHR Luis  Eldest son of Maria and Juan, aged 10, subject of SCR Carlos  Their youngest son, aged 7, subject of SCR Juan  Husband, father and perpetrator Mateo  Eldest son of Juan from an earlier marriage, living in Australia Antonio Brother of Maria, living in Mexico Lucia  London-based friend of Maria Rose  Parent at local primary school Sheila  Parent at school Tania  Parent at school  13. The Government Protective Marking Scheme (GPMS) was adopted throughout with a rating of ‘Official-Sensitive’ for shared material.  Either secure networks were in place (gsi, pnn) and adopted (cjsm) or papers shared with password protection.  An integrated chronology was provided to all Panel members for review and discussion.    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   5 Official TERMS OF REFERENCE  14. Following discussion of a draft in the first Panel meeting, Terms of Reference (ToR) were issued on the same day (appendix 1) with a chronology template for completion by agencies reporting contact with the family.  METHODOLOGY  15. Under s9 Domestic Violence, Crime and Victims Act 2004, a Domestic Violence Homicide Review (DVHR) was commissioned by Richmond Upon Thames Community Safety Partnership and, on 24 April 2018, Bill Griffiths CBE BEM QPM was appointed Independent Chair of the joint DHR/SCR Panel.  Tony Hester supported him throughout in the role of Secretary to the Panel.    16. This review was commissioned under Home Office Guidance issued in December 2016.   Close attention was paid to the cross-government definition of domestic violence and abuse and is included in the Terms of Reference (appendix 1).  The following policies and initiatives have also been scrutinised and considered: • HM Government strategy for Ending Violence against Women and Girls 2016-2020 • Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews published by the Home Office December 2016 • Domestic Homicide Reviews: Key Findings from analysis of domestic homicide reviews published by Home Office December 2016 • HMIC (Her Majesty’s Inspectorate of Constabulary) Reports: ‘Everyone’s business: Improving the police response to domestic abuse’ 2014 and ‘The Metropolitan Police Service’s approach to tackling domestic abuse’ 2014 • London Borough of Richmond upon Thames Council website: ‘Domestic Abuse’: https://www.richmond.gov.uk/services/community_safety/domestic_abuse  17. There are no prior DHR reports in the LB Richmond upon Thames.  In the last five years there have been two SCRs published and one related to a 14-year old boy.  There are no similarities or repeat learning for this review.    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   6 Official INVOLVEMENT OF FAMILY, FRIENDS, WORK COLLEAGUES, NEIGHBOURS AND WIDER COMMUNITY  18. With the assistance of the police family liaison officer, contact by email was made with Antonio who has indicated that a family meeting will be held to share their reflective thoughts on why this tragedy happened.  Mateo has also been contacted and he did not respond.  The family was provided via email with a draft of the overview report for comment in August 2019 but did not respond.  19. Maria’s London friend Lucia has indicated to the police her willingness to participate and did so through her husband who spoke to the Chair.  The Chair has been provided with witness statements and has also conducted three telephone interviews with parents who knew the family through the school attended by the children.  20. This was an unimaginable and appalling tragedy for Maria’s family, and the Panel offer their heartfelt condolences upon their loss.  For the family of the perpetrator, news of Juan’s actions must have been profoundly shocking, as well as inexplicable, and they also have endured loss, for which deepest sympathy is also offered.  CONTRIBUTORS TO THE REVIEW  21. A review report would normally consist of an anthology of information and facts from the organisations represented on the Panel, most of which were potential support agencies for the family listed below.   The main source of information derives from the police investigation into the deaths. Local GP Practice for the family Local Primary School Metropolitan Police Service  22. Records have been searched by all possible statutory and voluntary services in the London Borough of Richmond upon Thames without trace of any family member.  The homicide investigation team considered research with the authorities in Venezuela regarding a reference to alleged child abuse by third parties in Caracas prior to the family departing to reside in the UK but due to the political situation that has not been feasible.    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   7 Official THE REVIEW PANEL MEMBERS  23. Table 1 – Review Panel Members  Name   Agency/Role  Michael Allen [up to January 2019]   Lead for Violence Against Women and Girls LBRuT    Mark Wolski [from June 2019]   Lead for Violence Against Women and Girls LBRuT  Robyn Thomas  Head of Community Safety LBRuT   Chris Robson   LSCB Chair / KRSCP Independent Scrutineer  Elizabeth Major  KRSCP Professional Adviser    Tracey Welding   KRSCP Board Manager  Sean Maguire  Achieving for Children LBRuT   Mandy Harper   Named Nurse Safeguarding Children LBRuT  Ian Hutchings   LBRuT Education  Julia Dwyer   Refuge  Marcela Beneditti   Refuge – Latin American Liaison  Peter Timms  MPS Specialist Crime Review Group   Bill Griffiths   Independent Chair  Tony Hester  Independent Manager and Panel Secretary   Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   8 Official AUTHOR OF THE OVERVIEW REPORT  24. Set out in appendix 2 are the respective background and ‘independence statements’ for Bill Griffiths as Chair and author and Tony Hester who managed the review process and liaison with the CSP and Panel.  PARALLEL REVIEWS  25. The Chair set up liaison with the Case Officer and the Coroner.  An Inquest into all four deaths was concluded in May 2019, the Chair applied for ‘Interested Party’ status and was provided with a copy of some Inquest documents.  There will be no criminal or misconduct proceedings arising from the deaths.  EQUALITY AND DIVERSITY  26. Consideration has been given to the nine protected characteristics under the Equality Act in evaluating the various services provided.  All concerned are White with Latin American heritage, Maria is female, and the children are male.  It is believed they were of Catholic Faith but there is no record of church attendance in this country.  The family had emigrated from Venezuela to the UK in November 2015 with Portuguese EU citizenship (apart from Maria who was admitted as Juan’s family).  The children settled well into education, including developing English as their second language.  They had sufficient capital for a comfortable lifestyle but with no new income generated, they had by March 2018, run out of money and faced homelessness with no recourse to public funds.  This situation was not known to the school, GP or any other agency.  There is no evidence of differential service from any public body for any of the deceased.  DISSEMINATION  27. The intended recipients of copies of this report, once approved by the Home Office Quality Assurance Panel, are listed at the end of the review after the glossary.   Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   9 Official BACKGROUND INFORMATION (THE FACTS)  Discovery of the fatal incidents  28. At about 17:00 on the afternoon of a Monday in early March 2018, Sussex Police were alerted by the coastguard to the discovery of three bodies at the bottom of a cliff near to Beachy Head.  Documents in their possession and in a parked car, identified them as Juan and his two sons.  Subsequent enquiries identified a witness who had noticed a man with two children walking across fields from the direction of the car park at about 15:45. The children’s hands were being held and they are described as looking “reluctant or tired”.  29. Later that day, at about 18:00, the Metropolitan Police were contacted by Juan’s son who lives in Australia, to report that he had received an email from his father with the heading “Farewell” in Spanish and setting out an intention to take his own life and take the lives of his sons.  Officers attended a rented property in Richmond, forced entry and discovered Maria’s body in the master bedroom.  Numerous stab wounds had been inflicted.  30. Typed notes clearly indicating suicidal and murderous intention were found clearly on display to be noticed.  The two incidents were soon linked when Sussex Police made their enquiries and it was agreed that all four deaths would be investigated by the Metropolitan Police and referred to the West London Coroner for Inquest.  Family background  31. Maria was Venezuelan, the youngest of one brother, Antonio, and four sisters, and was brought up in Caracas.  Juan and Maria met in 2004 and were married in 2008.  Luis was born in 2007 and Carlos in 2010.  Juan had been married twice before and had a son, Mateo, with his first wife and a daughter with his second.  The daughter is estranged from her father, having not had contact with him for more than 20 years.    32. Juan ran his own construction business and this is verified by examination of a computer recovered from the crime scene that contained invoice records.  Maria had trained as a journalist and had held a senior position in a communications company.  33. Venezuela is a country that has experienced severe financial inflation and civil unrest.  As a result, many of its citizens have emigrated, including Antonio who left for Mexico in 2008 and Mateo living in Australia since 2009.  In the email that alerted Mateo to Juan’s intentions, there is a reference to child abuse in Caracas and Lima that contributed to their decision to emigrate.  This email is the only known reference to such abuse.  Given the breakdown of law and order in Venezuela it has not been possible to seek inquiries by the authorities there via Interpol.  The allegation will be examined in the section that sets out the evidence from the crime scene.  34. Juan had Portuguese nationality through his parents and held a Portuguese passport.  Portuguese Identity Cards for the children were applied for from Venezuela and issued in Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   10 Official 2013.  Maria’s Venezuelan passport shows that she entered the UK in November 2015 as a family member of Juan.  It is believed the family had flown from Caracas to Madrid before making their way to London.  35. Mateo knew that his family had been looking at opportunities to leave Venezuela for some time due to concerns about the quality of life there, including the safety of the children, a common theme.  He understood they settled on England as a destination because of the access to Portuguese nationality providing membership of the European Union plus the potential benefit to the children of learning the English language.  Living in London  36. On arrival, Juan made use of the North London address of a friend, Lucia, whom they had visited for a holiday in 2012 for the purpose of opening bank accounts and as a billing address.  In November 2015, Juan signed a contract for rental at a house in, South West London.  Customs and Excise registered the import of personal possessions from Venezuela there in March 2016.  37. The family registered with a local Health Centre from January 2016 and remained so throughout their house moves.  The contacts with the Practice were unremarkable and there is nothing to indicate domestic or child abuse.  Maria was seen for a health check in July 2016 and for a chest infection in November 2017 for which antibiotics were prescribed.  Luis attended with Juan in August 2016 with an eye injury from a Frisbee, then four times in 2017 for a rash and chest infections.  Carlos was seen four times in 2017 for an ear infection and chest infections and once in February 2018 when referred for an audiology assessment.  Juan was treated for shingles in June 2017.  38. In September 2016, the family moved to another house in Richmond and Juan registered the lease purchase of a Mercedes car in November.  In May 2017, he signed a contract for the rent of their final house in Richmond, paying ten months’ rent in advance.  This may be significant because renewal of the contract was due on a Monday in March 2018, the day of the homicides.  The estate agent involved had been informed that Juan intended to renew for a further 12 months and this would have required a substantial amount of money.  39. One neighbour informed the investigation that Juan had described himself as involved in the import/export business.  There is no evidence that he had such a business or that he had any employment at all.  Maria did not work.  They appeared to be living from money that had been transferred from a Santander Bank in Portugal during 2018 to a joint Santander Bank account in the UK that had also been credited with cash deposits in branch.  Another joint bank account was held with Lloyds and this was credited with transfers from the Santander account.  40. It would appear that Maria had the means to make independent purchases.  She had credit cards (Visa and Mastercard) in her own name and Visa Debit cards for both bank accounts were retrieved from her purse.  She also had a Marks and Spencer account.  Cards in Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   11 Official Juan’s name were found in his wallet.  It appears that Juan made exclusive use of the Lloyds bank card.  However, it has not been possible from the bank data provided to identify which card holder used the Santander bank card.   41. The balance in each account at the time of the homicides in March was under ten pounds.  Two junior ISA accounts at Lloyds in the names of the children had been opened with £500 each in February 2016.  It is understood that these accounts had also been depleted to a negligible amount.  There was no cash of any significance found at either murder scene.  What may be worthy of note is that evidence from the bank production orders show 23 online payments from the Lloyds Bank account to the National Lottery between early January and early March amounting to £491.  Based on the pattern of spending on this account, it is highly likely these payments were by Juan.  42. Enquiries with neighbours at both the addresses reveal that the family were perceived to be warm and friendly, yet private in nature.  One had formed the impression that Juan was suffering from “some form of depression”.    43. The children attended a local Primary School from June 2016.  Their headteacher reported that the children were doing well at school, albeit Spanish was their first language, and at no time expressed any worries or concerns connected with their home in the UK or from their time in Venezuela.  When attending the inception familiarisation, the parents did refer to the security and corruption situation in Venezuela as their reason for moving to Europe.  They did not feel safe in Venezuela.  The boys made good progress with English and were soon integrated with school life.  They last attended the school on the Friday before the homicides and were collected by Juan who had mainly carried out this duty.  44. With the assistance of the headteacher, the Chair conducted telephone interviews with three parents who had the most contact with the family.  Rose has two children who, coincidentally, were in the same classes as Luis and Carlos when they joined the school in 2016.  Maria did not drive; therefore, they saw more of Juan on the school run.  When Rose did meet Maria, for example, at school events or a pupil’s birthday party, Maria was generally chatty with a ready smile.  45. Rose wanted to improve her Spanish and Maria lacked confidence in her English (which was actually “very impressive”) and they discussed practicing for mutual benefit.  It did not happen because Maria would say she was busy “working on articles” as a journalist.  Maria did talk about their time in Venezuela and that it was too dangerous for the boys to attend school, so she had home-schooled them.  46. The boys were well-mannered, well-behaved and popular.  However, they were also naïve.  On a field trip, Luis kept wandering off from the group.  It was then ascertained that he had never been on a field trip before so was not aware of basic safety advice.  Their parents were very generous: gifts for everyone in the class at Christmas and the whole class of 30 invited to an activity such as go-karting at a son’s birthday event.  Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   12 Official 47. Sheila met the family when her son was being given extra tuition and Luis joined him due to his lack of English.  The boys bonded as a result and remained firm friends throughout.  Luis’s English rapidly developed.  There was an end of academic year gathering of parents for drinks and Sheila’s husband had a conversation with Juan.  He disclosed that they had left Venezuela due to the security and corruption situation.  He was planning to set up a business, perhaps a shop, but wanted to see the boys settled in first.  48. That summer of 2016, the two mothers and children twice met for a picnic on the common and their children played happily together.  Maria expressed embarrassment at her English but did describe something of their life in Venezuela.  She remarked on the freedom to sit in the open air compared with the oppressive feeling from living in a gated community in constant fear of kidnap.  When they moved house, Sheila saw less of Maria because Juan would drive the boys to and from school.  Maria did attend school events and was at the Christmas show in December 2017, the last time Sheila saw her.  49. Sheila would regularly see Juan dropping off and collecting his sons and they would run up to their father every day to hug him, always happy and smiling.  This was also noted by the headteacher.  Juan seemed a very proud man and was immaculately dressed, as were the boys whom Sheila noted had the full set of school uniform.  She had the impression they were a wealthy family.  50. On reflection, the only points of concern Sheila had been that Maria appeared with her arm in a sling1 during the summer of 2017.  She brushed it off as nothing when asked how she was.  Second, was that the school had a toy pet, ‘Oscar the Owl’.  Children would take it home for the weekend and would add to a continuous picture diary.  Sheila noticed that, typically, the diary would contain pictures of the owl and family members engaged on ‘adventures’.  Carlos’s contribution contained only pictures of the owl around the house with no family depicted.  Then in November Carlos did not attend a birthday party and Juan delivered a present the next day, saying: something had come up.  On the Saturday before the fatal incident, Carlos did not attend another party to which he had been invited.  51. Tania became friends with Maria because she was also from South America and had a child in the same class as Carlos.  With Spanish as her first language, she was able to explain how things worked at the school as well as in the UK.  She gathered that Juan had his own construction business in Venezuela and Maria had held a senior position in a communications company.  The impression was gained that they were very wealthy.  This made them a kidnap target for “the rebels” which led to Maria home-schooling the children for two years.  52. They were “very happy” to be in the UK and particularly enjoyed the freedom of open spaces.  Juan spoke of starting a business in the UK, such as a specialist coffee shop.  Maria had not worked for three years and wanted to find work.  Tania offered help with her CV which was not taken up; in hindsight, a point of concern.  They were “full on” with their  1 No record of injury in GP chronology Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   13 Official children and the family were clearly devoted to one another.  Over the winter, Tania could see that Maria was depressed.  She complained about the weather and kept harking back to what their lifestyle had become in Venezuela.  Tania suggested she needed help to disconnect from those bad memories.  She, too, observed how well-mannered and behaved the children were and Juan seemed like the perfect father.  There was no hint of abuse in the UK or historically in Venezuela.  53. Juan’s son Mateo had spoken to the family by telephone about once a month.  He gained the general impression that life in the UK was: working out OK for the family.  He had a slight concern that his father was trying to start a business and it was taking some time.  He was not sure if they had enough funds.  Along with this, they all seemed sick or unwell with respiratory issues which he assumed was due to the change in climate for them.  As far as he knew, the boys were happy at school and engaging in activities.  Neither Juan or Maria expressed any concerns or worries to him.  54. Maria’s older brother, Antonio, had a good relationship with her and Juan and was godfather to Luis.  He would see the family about once a month but, in 2009, emigrated to Mexico.  He understands that his sister’s family took the decision to leave Venezuela and emigrate to the UK in 2016 because they had: concerns for the safety of the boys – it can be a dangerous place.  Antonio spoke to Maria by telephone about twice a week, to the boys occasionally, but to Juan briefly only once.  55. Antonio believed Maria was happier living in London and he understood the boys were happy, enjoyed school and had friends.  He did not ascertain anything about their employment or financial situation and was not concerned.  His last conversation with Maria was on the Saturday, two days before the homicides.  They had a general conversation about politics and made jokes.  Maria revealed it was snowing in London which she liked even though it made her feel ill.  56. The telephone used by Juan was damaged in the fall at Birling Gap and data could not be recovered from it.  The telephone used by Maria and a computer that appeared to be a family resource were examined successfully, the latter using key word searches.  There are a number of personal records such as passport visas, residency documents, school information, copies of the tenancy agreements for both addresses along with utilities and bank statements. There are a number of family photos on the hard drive which all appear to be dated before the family arrived in the UK.  There are Excel spreadsheets with invoices relating to construction work in Venezuela.  There is nothing logged that indicates that Maria carried on with work as a journalist.  57. The friend, Ana, that lived in North London and facilitated the family’s entry to the UK by providing an address for opening bank accounts, maintained contact with Maria.  They met for lunch shortly after the family’s arrival and Maria relayed an account of the reason for emigrating, that Lucia has summarised thus: “She [Maria] explained that when the children went to school they would start to behave “weird”. The children were told that Maria was not their mum. The children Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   14 Official would then complain that they were not their parents. Maria and Juan hired a detective and it was established that the Mafia were trying to brain wash the children, they were showing pictures and telling the children that the parents they had at home were not theirs…Maria was depressed. It was established that “everyone” was in on it even a family cleaner, their family food was poisoned, they were being watched. Maria decided to home school and she did this for about 2 years. In Venezuela they stopped going out, Juan was the only one to go out.”  58. Lucia was empathetic and the friends: cried a lot during the conversation.  Maria said that she felt unsupported by her family who were sceptical about the account, whereas, Juan’s family were supportive.  59. Maria and Lucia kept in touch via the WhatsApp facility and would meet occasionally, including as couples with her partner.  Lucia described Juan as: a quiet man who never got a word in as Maria did all the talking.  Lucia was aware that Maria had a positive relationship with Juan’s son, Mateo, albeit he was living in Australia.  He had been ‘Best Man’ at her wedding with Juan and had briefly worked in his father’s construction business.  The last time Lucia met Maria was just before Christmas 2017 and nothing seemed amiss.  60. At the beginning of March, about five days before the fatal incident, the family received notification of the secondary school placing for Luis2.  He had been allocated their third choice school in the six they had listed in order of preference.  Luis was 107th on the waiting list for their first choice and 66th for their second choice.  They had yet to respond to the notification.  The head teacher considers the secondary school allocation an unlikely driving factor in the later events.  The parents were very intelligent and able to understand the school admissions system.  They had thoroughly researched the primary school prior to choosing a small rental property close to the school to facilitate original entry when they first came to the UK.  Three months after Luis and Carlos were allocated places at that school, the family rented a larger house more than walking distance away.  It is felt that if they were similarly concerned about secondary transfer they could and maybe would have chosen a property closer to their first choice to help guarantee a place.  61.  The last WhatsApp communication between Maria and Lucia was between about 3.30pm on the Thursday before the homicides and 10pm on the Saturday.  The ‘conversations’ in Spanish contained nothing contentious; comprising references to the weather (it had been snowing) and general health (Maria was recovering from influenza).  It has been established that Maria last looked at her WhatsApp facility at about 8.45pm on the Sunday, a day before the homicides.     2 Secondary school placement as a potential issue was brought to attention after the Panel’s deliberations Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   15 Official Pen pictures Luis and Carlos  62. The narrative of the family life in London sets out what happened in that two and a half years and what was observed by relatives, friends, staff and other parents at the school attended by Luis and Carlos.  The headteacher has provided a further insight into the personalities of the children by a pen picture of each boy.  63. Luis, aged 10, was an inquisitive, funny, friendly boy who was passionate about everything he did. His enthusiasm for learning was infectious and he was always asking questions and wanting to know more about the world. In class, he would desperately want to be chosen to answer every question and would be very disappointed if he wasn’t. He loved dinosaurs and presented an incredible PowerPoint and detailed explanation of pre-historic life, despite having spoken English for less than two years. He engaged every single member of his class….including his teacher. Luis loved reading and was often seen with a book in his hand – he loved ‘Diary of a Wimpy Kid’. He was very imaginative and loved making up stories. He would often be found re-enacting a made-up story in the playground – sometimes with his friends but sometimes because he just loved doing this on his own. Luis was a popular (if sometimes over-enthusiastic) boy and was curious about everything around him. He was a loving boy who looked out for his brother and who loved his family.  64. Carlos, aged 7, was a quieter version of his older brother. He was bright, funny and his sunny disposition was a delight. Carlos, despite his tender years, was nurturing towards younger children, ensuring that they weren’t left out of any games. He was passionate about football and was the peacemaker on the pitch. He had a special way of telling everyone what to do and everyone respected that and listened to him. In fact, after he died, the children commented on who would sort things out on the football pitch. He was a very fair player and everyone loved having him on their team. In class, despite having spoken English for a relatively short time, Carlos was hard working and very focused. He loved literature and a particular favourite of his was ‘The Day the Crayons Quit’ – he loved the different personalities of the characters. Like his brother, he loved dinosaurs and his last party had a Jurassic crazy golf theme but also included a hint of his culture with a piñata being a particular success. Carlos is still very much missed by his class who often talk about him.  The fatal incidents  65. On a Monday in early March 2018, Mateo received an email from Juan headed “Desbedida”, the Spanish for “Farewell”.  There was an attachment and Juan had written: Hi Mateo, sorry to write this but when you read this we won’t be in this world.  Please read the attachment.  Nothing will make you understand.  I’m sorry I won’t meet your son [aged 3 months] and sorry for the pain and troubles.  66. Mateo did not open the Word document immediately, but tried to contact his father and family, without success.  It was 05:00 in Australia and he eventually found an international contact for the Metropolitan Police to report his concerns.  He stayed on the line and was Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   16 Official informed that entry had been forced and Maria found with neck injuries.  His father and brothers were not present, and he learned what had happened to them a day later.  He also established that other family members, for example, Maria’s brother Antonio, had been sent the same attachment.  67.  The English translation of the document is more than 1500 words.  Essentially, it is Juan’s justification for the actions he intended: to destroy his family and himself.  It is not supported by any other information but its inclusion here is important, not only as evidence of planning but also as it could be illustrative of Juan’s controlling behaviour, in this instance by trying to influence the post facto judgement of his actions.  The salient relevant features and direct quotes [italics] are set out below: Luis and Carlos were abused physically and sexually for almost two years at [a pre-school] in Caracas. They were being taken from school and taken to parties and orgies, they were being filmed and they were being sexually abused. They were manipulated and told to not say anything to their parents, because if they did we would die. The school organization and their employees, families with children at this school and some acquaintances of ours were involved in this.  68. Juan then wrote that they had visited Lima to see if they could emigrate there and visited a school to find a placement for Luis.  They left him there for a few hours for an assessment.  Subsequently, Luis disclosed he had been taken to a party with adults where he was abused.  They did not realise what was happening until it was too late.  Maria started to connect the dots and the boys were removed from the school.  They did not report the situation because, considering the unsafe conditions in Venezuela, our lives were at risk.  69. Carlos was told that Maria was not his mum, and for almost a year, he would wake up screaming and be more disturbed if she approached, meaning only Juan could calm him.  This resulted in: Maria fell into a very deep depression, filled with a feeling of grief and guilt. Very slowly we were able to get over this situation, but we couldn’t leave it behind.  Maria is constantly living in pain and her guilt is too much. She has made a huge effort but it is more powerful than her.  70. Juan then writes in a philosophical style: For years I have been trying to find the answer to life. After what happened to us with the kids, it became much more intense.  About fifteen years ago I read [a popular spiritual text] and having read many things from different religions, I managed to find in it the only sensible explanation to the world we see.  Some people have suggested that this world isn’t anything more than a simulation, created by a far more advanced civilisation. I also remember a writer who said that life was nothing but a sequence of good and bad luck events.  71. He expands on this point, wondering about the origins of life, the explanations of different religions and questioning why God created and tolerates human imperfection while allowing wars and situations, such as in Venezuela.  He challenges the concept of ‘free will’, writing Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   17 Official that he would never have chosen to be born.  Returning to his reading of [the popular spiritual text], Juan writes that its message of hope and the certainty that God will provide the answer you are looking for has not led him to find the Truth, but that fear and grief are still drowning his spirit.  He then expresses what might be considered suicidal ideation: Actually, it is difficult to live.   In this world full of grief, suffering, uncertainty, hopelessness, sickness and death.  How can one be happy in this world if there are so many people unhappy, suffering and with no hope at all?  How can one be happy thinking about hard and bitter work, the suffering and grief of all the others who preceded us?  72. The next passage refers to his children: Maybe children have a more truthful perception of things.  I remember that [Carlos] asked me in more than one occasion why God invented sickness and death.  He wonders why God doesn’t make things that are perfect.  Lately, [Carlos], who only complains when the pain is really bad, has been having earache3 and, upset and with terrible grief in his face asks me why it has to hurt so much and why God doesn’t help him.  [Luis] wonders, rightly so, why things have to be so difficult, why so much effort is required for everything, and says, rightly so, that we should just live and be happy.  That life should be about that. That belief makes him suffer and makes it difficult for him to face certain things.  73. Juan then states that they are both “wonderful kids, good-natured, generous and kind” but that he cannot stand seeing them in pain anymore and “above all, thinking about the pain they are yet to experience”.  He refers back to the concept that the world is a simulation and leaving it is the “right decision”.  If that comment referred his plan to take his own life, the final passage makes clear his decision also to end their lives: If life is nothing but the product of fate, if we don’t transcend after life, then leaving it is the right decision.  If this world is nothing but an illusion and in reality we are still One with God, there will be no consequences for abandoning it.  But if life is what religions profess, at least I will have given my children a ruthless and strict judgement by a vengeful and blood-and-death-insatiable God.  I love them all4 and I ask for forgiveness for the grief this causes you.  74. Computer records show that Juan created the note at about 17:30 on the Sunday and last accessed it at 02:00 on Monday morning.  The time it was sent, attached to the email, is logged at about 08:30 GMT.  75. Searches of the internet made between 01:13 and 01:34 hours that same morning, included: Beachy head suicide Facebook – what are the most popular suicide spots in the world A route from [address 2] to Beachy Head, along with a weather forecast  3 Carlos was treated by the GP Practice for an ear infection in February 2018 4 By using ‘all’ instead of ‘both’, this may be a reference to Maria as well Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   18 Official Blogs / opinions on [the title of the spiritual text referred to in the note].  76. The forensic examination of the computer and Maria’s telephone did not reveal any correspondence or other evidence relevant to the relationship between Maria and Juan, nor any reference to the alleged abuse of the children.  77. This finding may be challenged because Lucia originally contacted police to report that her friend and niece to Maria who lives in Spain, had contacted her when the family received the message from Juan.  Maria’s niece and her mother had been sending emails5 to them saying that: The family had had bad things happen to them and they didn’t want to live anymore.  The last email had been sent on the Sunday.  Lucia had responded with the outcome of the WhatsApp communication she had with Maria up to the day before.  78. Examination of the crime scene found Maria in bed dressed in nightclothes.  Her mobile telephone which was switched off was found under her body.  The pathologist who examined her found more than 60 stab wounds on her upper body, some of them defence type injuries to her arms and hands.  She died from multiple incised wounds.  Toxicology found a therapeutic concentration of zopiclone6 which has sedative properties.  She had also taken diphenhydramine and pholcodine, possibly as part of a combined cough remedy, that also has sedative properties.  There was no trace of alcohol.  79. The kitchen knife used to inflict these wounds was found in the dish washer.  Aside from the blood traces associated with the attack on Maria, a bloody handprint was found on the bedclothes in the children’s bedroom, indicating that Juan had placed his hand on the bed shortly after the murder, perhaps to check that his sons were asleep.  80. On a table were found a school bag with a computer-generated note, printed in capitals: Please send to [the] Primary School.  Another note read: Please cremate the bodies and throw it anywhere.  A third note stapled to a printed copy of the attachment sent to family, reads: I am so sorry, but I cannot let my children live anymore in a world of despair, emptiness, pain, suffering and uncertainty.  There is no hope in this life.  I cannot find God to get faith and hope  81.  The car registered to Juan was picked up by static ANPR between 12:42 and 13:39 hours travelling via the M23 and Brighton in the direction of Beachy Head.  The remains of crisps and yoghurts consumption were found in the car.  82. Juan and the children each died from multiple injuries consistent with a fall from the cliff.  Toxicology concluded that Juan would not have been affected by alcohol or any of the drugs or medicines that were tested for, at the time he died.  There was no sign of brain  5 None were discovered by examination of Maria’s computer and phone 6 A hypnotic drug prescribed for the short-term treatment of insomnia in adults. Not GP prescribed, but there is a payment to an online pharmaceutical company on 13 February that could be the source – not verifiable Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   19 Official disease.  Both children had ingested zopiclone in a therapeutic concentration found in the blood.  Zopiclone has sedative properties and should only be prescribed for adults.   83.  Inquests were concluded at West London Coroners Court in May 2019 and, under s5(2) of the Coroners and Justice Act 2009, the Coroner formally certified the circumstances by which each had come by their deaths, as follows: Maria – the deceased was found at her home address in March 2018.  Police were alerted by her stepson who lives in Australia, who woke to find an email from her husband and his father describing an ongoing suicide pact.  She was stabbed in excess of 60 times to the face, neck, upper body and limbs.  Conclusion Unlawful Killing Luis and Carlos – [each] deceased died at the foot of cliffs near Eastbourne on the [same date].  He had been sedated at some point in the 12 to 14 hours preceding death.  He was forced off the upper edge of the cliff by his father and died along with his father and [younger/older] brother.  Conclusion [each] Unlawful Killing Juan – the deceased died at the foot of cliffs near Eastbourne on the [same date].  He had in the preceding 12 to 24 hours murdered his wife at their home by stabbing.  He had researched suicide methods and places7.  He had written emails to family members indicating clear intention.  He left the top of the cliff along with his two sons killing all three.  Conclusion Suicide  84. The reference to a suicide pact between Juan and Maria may be contained in the original accounts from Maria’s friend, Ana.  There is her initial report to police in paragraph 77 above.  In her witness statement it is recorded that, a few days after the discovery of the deaths, she had been told by a relative of Maria’s that, about two years before, Maria had said that: Someday they might receive a letter from them [Juan and Maria].  There is a reference in Juan’s suicide note to Maria’s depression. The Coroner considered, and ruled out, that Maria’s murder was part of a suicide pact between her and Juan.  ANALYSIS  85. There were no outward signs of domestic abuse or child abuse within the family.  On the contrary, they appeared to have settled well and observers gained the impression of a contended and comfortably off family.  The Panel did explore and discuss the available information for indicators of coercive and controlling behaviour by Juan.  Maria was unable to drive, attended school events only rarely and did not work, albeit she had spoken to other parents at the school about doing so.  Her social contact over the 2017/18 winter had been limited to phone calls with family and messaging with her friend Lucia.  She could well have felt isolated and may well have been isolated under coercion and control exercised by Juan, however, other than complaining about the cold and the effects of influenza, Maria did not disclose anything to her brother or Lucia in the contacts she had with them over the weekend prior to the fatal incident.   7 There is no other evidence of such research prior to that described in paragraph 71 Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   20 Official 86. It is beyond doubt that Maria and her children were murdered by Juan who also took his own life.  The main unresolved question is ‘why?’.  One hypothesis is contained in Juan’s suicide note in which he sets out his version of what happened to the family in Venezuela prior to their emigration to the UK, specifically that the children were being taken out of school and physically and sexually abused.  That there were concerns for the safety of the children is corroborated by Antonio, although he was not aware of the details.  Maria’s disclosure to Lucia shortly after arrival in the UK confirms that she had concerns about the children being “brainwashed” which led to her home-schooling them for two years.  However, she did not disclose to Lucia that there had been child sexual abuse (CSA).  87. There is no evidence available that CSA was an ongoing concern during the two years living in London until Juan’s suicide note was written.  In none of the conversations with teachers and friends during that time was reference made to CSA.  Being subject of CSA is known to be detrimental to long-term mental health and general well-being and symptoms can often been observed by professionals, such as teachers and clinicians.  In fact, the children settled remarkably well into their school; had rapidly developed their language ability, fully engaged in school activities and made friends.  They were observed to be happy and affectionate at all times.  88. The family had regularly attended the GP Practice, mainly with respiratory infections, and no historical concerns were raised.  There was no trigger for ‘professional curiosity’.  Antonio, Mateo and Lucia were in regular contact with Maria, including in the days immediately preceding the fatal incidents.  The pressure she was apparently feeling over the historical CSA issue, that Juan was writing about in such graphic terms, was not mentioned by her.  89. The second theory for Juan’s drastic actions is that the family had run out of money and faced eviction on the day of the fatal incident.  Again, Maria did not mention the severe financial pressures that Juan was dealing with to her friend or brother during contact that weekend.  She may have felt that it was a private matter; on the other hand, Juan may not have shared with her just how critical was the situation.  What cannot be ruled out is the likelihood that Juan was exerting financial control in the relationship.  The fact that Maria had possession of credit and debit cards in her own name8 does not eliminate the possibility that she was subject of economic control as a form of domestic abuse.  90. The family had no visible means of financial support yet behaved as if they were wealthy and acted with largess at times, such as their children’s birthday treats for classmates.  The renewal of their rental contract was due on the day of the homicides.  Juan made no reference to financial issues in his suicide note and, for reasons that cannot be established, set out a different rationale.   8 The banks were not able to identify the various users within the record of transactions Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   21 Official 91. There is substantive research9 available that relationship-based homicides are rarely spontaneous and the: ‘He just snapped’ explanation, which suggests an immediate proximal provocation, is not supported.  Schlesinger describes ‘catathymic homicides’ as occurring when: There is a change in thinking whereby the offender comes to believe that he can resolve his inner conflict by committing an act of extreme violence against someone to whom he feels emotionally bonded.  92. The so-called ‘journey to homicide’ suggests planning and decision making.  Juan initiated his suicide note on Sunday afternoon when the children were probably awake and did not finish it until the early hours of Monday when they would have been asleep.  The attack on Maria was sustained and substantial and, given there are defence wounds, she would have been conscious and capable of crying out.  The bloody handprint on the boys’ bedclothes indicates they slept through the attack on their mother, possibly having been drugged with the zopiclone found in their bodies.  There may then have been a change of his plan [originally to kill them and himself in the house], because Juan initiated his internet searches for suicide locations from early on the Monday, just prior to completing the note that clearly states his intention to take their lives.  93. A more recent study10 identified ‘The Homicide Triad’, and the coincidence of three groups of characteristics, namely, the offender’s emotional or psychological state, the presence of acknowledged high risk markers and the triggers which create escalation.  This prompts further speculation that Juan: 1. Had become psychologically obsessed11 with his perception of CSA inflicted on his sons and his interpretation of a popular spiritual text 2. Was simultaneously facing the triggers of financial ruin and cultural embarrassment 3. Had then escalated his use of weapons and extreme violence to complete his ‘journey to homicide’  CONCLUSIONS AND LESSONS LEARNED  94. The Panel conclude that the date a large sum of money was required to continue the rental on the house, along with an overall picture of financial destitution for the family is significant and it is more than a coincidence that it is the same day of the fatal incidents.  It may also be relevant that Juan gambled 23 times on the National Lottery (on-line, using the Lloyds bank card that only he used) in the eight weeks prior and that was the second highest outgoing in that period.  The story of CSA in Venezuela that Juan cites as the reason for killing his sons is not supported by any other source.  95. The family did not come to the attention of any agency or organisation connected with safeguarding during their time in the UK.  None of the clinicians, teaching staff or parents  9 Schlesinger 2002, Adams 2007, Monckton Smith 2012 10 ‘Exploring the relationship between stalking and homicide’, Monckton Smith, Szymanska, Haile 2017 11 Webster dictionary: a persistent disturbing preoccupation with an, often unreasonable, idea or feeling; an idea or thought that continually preoccupies or intrudes on a person’s mind Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   22 Official who met the family through the school or their close family members resident around the world had any reason to be concerned and their lifestyle gave no hint of financial pressure.  96. Thus, one strategic learning point for this review is to ascertain how a migrant family in such financial stress could have sought and found assistance.  It is believed they could have had some recourse to public funds.  Had this family decided to seek financial or homelessness support in the London Borough of Richmond upon Thames prior to the fatal incident, what resources would have been available?  The Panel explored the accessibility of information in respect of financial difficulty and homelessness and concluded that the family would have been capable of identifying where to approach for support and advice.  97. The unknown factor is what inhibited Juan in particular from seeking help.  One possibility is that Juan felt culturally pressured to provide for his family through what might be described as ‘Machismo’.  The largesse witnessed by parents at the school and the fact that Maria apparently knew nothing of the looming financial crisis tend to support this supposition.  However, the Panel felt there was insufficient data to confirm this hypothesis.  98. The second strategic learning point is the need to ensure the link between financial difficulty and suicide is incorporated into the work of Safeguarding Adults and suicide prevention.  RECOMMENDATIONS    99. It is recommended that the London Borough of Richmond upon Thames ensures that the issue of financial and homelessness difficulties for all communities and the link to Domestic Abuse is addressed within the development of its VAWG (Violence Against Women and Girls) strategy 2020-2023.  100. It is recommended that the London Borough of Richmond upon Thames ensures that the issue of financial difficulty and the link to suicide is incorporated into the work of Public Health and suicide prevention.  101. An action plan has been developed in appendix 3.  Author  Bill Griffiths CBE BEM QPM  25 August 2020    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   23 Official Glossary  ANPR  Automatic Number Plate Recognition CCG  Clinical Commissioning Group cjsm  Criminal Justice Secure eMail DA  Domestic Abuse DV  Domestic Violence DHR  Domestic Homicide Review GP  General Medical Practitioner gsi  Government Secure Internet HMIC  Her Majesty’s Inspector of Constabulary IMR  Individual Management Review LBRuT  London Borough of Richmond upon Thames MAPPA Multi Agency Public Protection Arrangements MARAC Multi Agency Risk Assessment Conference MPS  Metropolitan Police Service NHS  National Health Service pnn  Police National Network SCR  Serious Case Review ToR  Terms of Reference VAWG  Violence Against Women and Girls  Name references used  Maria  Subject of DHR Luis  Eldest son of Maria and Juan, aged 10, subject of SCR Carlos  Their youngest son, aged 7, subject of SCR Juan  Husband, father and perpetrator Mateo  Eldest son of Juan from an earlier marriage, living in Australia Antonio Brother of Maria, living in Mexico Lucia  London-based friend of Maria Rose  Parent at local primary school Sheila  Parent at school Tania  Parent at school     Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   24 Official Distribution List  Name   Agency Position/ Title  Paul Martin London Borough of Richmond Upon Thames Chief Executive  Cllr Gareth Roberts LB Richmond Upon Thames Councillor for Community Safety; lead on domestic abuse Cllr Penelope Frost  LB Richmond Upon Thames Cabinet Member for Children’s Services Liz Bruce LB Richmond Upon Thames Director of Adult Social Services  James Thomas Achieving for Children Interim Director of Children’s Services Vacant Richmond CCG CCG Designated GP Adult Safeguarding Vanessa Impey Richmond CCG CCG Designated GP Children’s Safeguarding Sarah Loades Richmond CCG CCG Designated Nurse Adult Safeguarding Sian Thomas Richmond CCG CCG Designated Nurse Children’s Safeguarding  Brian Reilly LB Richmond Upon Thames Director of Housing and Regeneration Angela Middleton NHS England Patient Safety Projects Manager (London Region) Sally Benatar  Metropolitan Police South West BOCU Commander Peter Timms  Metropolitan Police Detective Sergeant Specialist Crime Review Group Bill Griffiths Independent Chair Independent Chair/Author of the Domestic Homicide Review  Tony Hester Director Sancus Solutions Ltd Independent Administrator and Panel Secretary Quality Assurance Panel  Home Office - Cressida Dick  Metropolitan Police Service Commissioner Sophie Linden  Mayor’s Office for Crime and Policing Deputy Mayor Baljit Ubhey  Crown Prosecution Service London Chief Crown Prosecutor     Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   25 Official Appendix 1  Context  On 5 March 2018, police received a message from Mateo, who resides in Australia, that he had received an email from his father, Juan, declaring his intention to take his own life.  Police attended the house in Richmond and found Maria deceased with multiple stab wounds.  Further enquiries made the link with the discovery that same afternoon at the foot of cliffs in Sussex, of the bodies of Juan and his sons, Luis and Carlos.  The family are Venezuelan and entered the UK via Portugal (thus, they are EU citizens) some time before June 2016, with the boys attending school locally in Richmond Borough.  Written material found at the scene supports an initial hypothesis that Juan murdered his wife and then drove his sons to Sussex where he took their lives at the time of taking his own life.  People involved 1. The first murder victim: Maria aged 47 at the time of the fatal incident (b.1970) 2. The second murder victim: Luis then aged 9 (b. 2007) 3. The third murder victim: Carlos then aged 7 (b. 2010) 4. The perpetrator: Juan then aged 57 (b.1960) 5. The eldest son: Mateo age not known and residing in Australia  Addresses 1. Home for 1-4 above: Address 1 2. Previous address Address 2 3. An address as yet unknown provided to a car leasing company  Purpose of review  1. Conduct effective analysis and draw sound conclusions from the information related to the case, according to best practice.  2. Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and support victims of domestic violence, including their dependent children.   3. Identify clearly what lessons are both within and between those agencies. Identifying timescales within which they will be acted upon and what is expected to change as a result.   4. Apply these lessons to service responses including changes to policies and procedures as appropriate; and   5. Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.  6. Highlight any fast track lessons that can be learned ahead of the report publication to ensure better service provision or prevent loss of life.    Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   26 Official  Terms of Reference for Review  1. To identify the best method for obtaining and analysing relevant information, and over what period [Note: agreed at 1st Panel meeting to commence from 1 January 2016] prior to the fatal incidents to understand the most important issues to address in this review and ensure the learning from this specific fatal incident and surrounding circumstances is understood and systemic changes implemented.  Whilst checking records, any other significant individuals who may be able to help the review by providing information will be identified.  2. To identify the agencies and professionals that should constitute this Panel and those that should submit chronologies [Note: agreed at 1st Panel meeting that MPS, family GP and children’s school would submit chronologies by 06/08/18] and Individual Management Reviews (IMR) and agree a timescale for completion [to be agreed at the 2nd Panel meeting on 13/08/18].  3. To understand and comply with the requirements of the criminal investigation, any misconduct investigation and the Inquest processes [Note: the criminal investigation is ongoing until a report is provided to the Coroner; there are no known misconduct issues] and identify any disclosure issues and how they shall be addressed, including arising from the publication of a report from this Panel.  4. To identify any relevant equality and diversity considerations arising from this case and, if so, what specialist advice or assistance may be required [awaits conclusion of criminal investigation].  5. To identify whether the victims or perpetrator were subject to a Multi-Agency Risk Assessment Conference (MARAC) and whether perpetrator was subject to Multi-Agency Public Protection Arrangements (MAPPA) or a Domestic Violence Perpetrator Programme (DVPP) and, if so, identify the terms of a Memorandum of Understanding with respect to disclosure of the minutes of meetings [initial scope has not revealed any such processes in place].  6. To determine whether this case meets the criteria for a Serious Case Review, as defined in Working Together to Safeguard the Child 2013, if so, how it could be best managed within this review [Note: The Richmond Children’s Safeguarding Board have determined that the deaths of Luis and Carlos do not meet the criteria for a Serious Case Review, an issue that will be kept under review by the RCSB Chair who is a member of the DHR Panel].  7. To determine whether this case meets the criteria for an Adult Case Review, within the provisions of s44 Care Act 2014, if so, how it could be best managed within this review and whether either victim or perpetrator was ‘an adult with care and support needs’ [awaits conclusion of criminal investigation].  8. To establish whether family, friends or colleagues want to participate in the review. If so, ascertain whether they were aware of any abusive behaviour to the victim or her children, prior to the fatal incident (any disclosure; not time limited).  In relation to the family members, whether they were aware if any abuse and of any barriers experienced in reporting abuse, or best practice that facilitated reporting it [awaits conclusion of criminal investigation and situation with family overseas].  Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   27 Official 9. To identify how the review should take account of previous lessons learned in the LB Richmond Upon Thames and from relevant agencies and professionals working in other Local Authority areas.  10. To identify how people in the LB of Richmond Upon Thames gain access to advice on sexual and domestic abuse whether themselves subject of abuse or known to be happening to a friend, relative or work colleague.  11. To keep these terms of reference under review to take advantage of any, as yet unidentified, sources of information or relevant individuals or organisations.  Panel considerations   1. Could improvement in any of the following have led to a different outcome for Maria, Luis and Carlos, considering: a) Communication and information sharing between services with regard to the safeguarding of children and adults b) Communication within services c) Communication and publicity to the general public and non-specialist services about the nature and prevalence of domestic abuse, and available local specialist services.  2. Whether the work undertaken by services in this case are consistent with each organisation’s: a) Professional standards  b) Domestic abuse policy, procedures and protocols .  3. The response of the relevant agencies to any referrals relating to Maria, Luis and Carlos concerning domestic abuse or other significant harm from [a date to be agreed].  It will seek to understand what decisions were taken and what actions were or were not carried out, or not, and establish the reasons.  In particular, the following areas will be explored:  a) Identification of the key opportunities for assessment, decision making and effective intervention in this case from the point of any first contact onwards with victim, perpetrator or their children b) Whether any actions taken were in accordance with assessments and decisions made and whether those interventions were timely and effective. c) Whether appropriate services were offered/provided, and/or relevant enquiries made in the light of any assessments made. d) The quality of any risk assessments undertaken by each agency in respect of Maria, Luis and Carlos or the perpetrator.  4. Whether organisational thresholds for levels of intervention were set appropriately and/or applied correctly, in this case.   5. Whether practices by all agencies were sensitive to the ethnic, cultural, linguistic and religious identity of the respective individuals and whether any specialist needs on the part of the subjects were explored, shared appropriately and recorded.   6. Whether issues were escalated to senior management or other organisations and professionals, if appropriate, and completed in a timely manner.   7. Whether, any training or awareness raising requirements are identified to ensure a greater knowledge and understanding of domestic abuse processes and/or services.  Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   28 Official 8. Identify how the resulting information and report should be managed prior to publication with family and friends and after the publication in the media.  Operating Principles  a. The aim of this review is to identify and learn lessons as well as identify good practice so that future safeguarding services improve their systems and practice for increased safety of potential and actual victims of domestic abuse (as defined by the Government in 2013 – see below)  b. The aim is not to apportion blame to individuals or organisations, rather, it is to use the study of this case to provide a window on the system  c. A forensic and non-judgmental appraisal of the system will aid understanding of what happened, the context and contributory factors and what lessons may be learned  d. The review findings will be independent, objective, insightful and based on evidence while avoiding ‘hindsight bias’ and ‘outcome bias’ as influences  e. The review will be guided by humanity, compassion and empathy with the ‘voices’ of Maria, Luis and Carlos at the heart of the process  f. It will take account of the protected characteristics listed in the Equality Act 2010  g. All material will be handled within Government Security Classifications at ‘Official - Sensitive’ level.  Definition of Domestic Abuse  Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: • psychological • physical • sexual • financial • emotional.  Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.  Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.   Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   29 Official Appendix 2  Independence statements  Chair of Panel  Bill Griffiths CBE BEM QPM was appointed by the London Borough of Richmond Upon Thames CSP as Independent Chair of a joint DHR and SCR Panel and is the author of the report.  He is a former Metropolitan police officer with 38 years operational service and an additional five years as police staff in the role of Director of Leadership Development, retiring in March 2010.  He served mainly as a detective in both specialist and generalist investigation roles at New Scotland Yard and in the Boroughs of Westminster, Greenwich, Southwark, Lambeth and Newham.  As a Deputy Assistant Commissioner, he implemented the Crime and Disorder Act for the MPS, leading to the Borough based policing model, and developed the critical incident response and homicide investigation changes arising from the Stephen Lawrence Inquiry.  For the last five years of police service, as Director of Serious Crime Operations, he was responsible for the work of some 3000 operational detectives on all serious and specialist crime investigations and operations in London (except for terrorism) including homicide, armed robbery, kidnap, fraud and child abuse.  Bill has since set up his own company to provide consultancy, coaching and speaking services specialising in critical incident management, leadership development and strategic advice/review within the public sector.  During and since his MPS service he has had no personal or operational involvement within the LB Richmond Upon Thames, nor direct management of any MPS employee.  Secretary to Panel  Tony Hester has over 30 year’s Metropolitan police experience in both Uniform and CID roles that involved Borough policing and Specialist Crime investigation in addition to major crime and critical incidents as a Senior Investigating Officer (SIO). This period included the management of murder and serious crime investigation.  Upon retirement in 2007, Tony entered the commercial sector as Director of Training for a large recruitment company.  He now owns and manages an Investigations and Training company.  His involvement in this DVHR has been one of administration and support to the Independent Chair, his remit being to record the minutes of meetings and circulate documents securely as well as to act as the review liaison point for the Chair.  Other than through this and two other reviews, Tony has no personal or business relationship or direct management of anyone else involved.      Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   30 Official  Appendix 3 ACTION PLAN     Learning Point 1: to ascertain how a migrant family in such financial stress could have sought and found assistance    Recommendation Scope of recommendation i.e. local or regional   Action to take   Lead Agency Key milestones achieved in enacting recommendation   Target Date   Completion Date and Outcome    1 It is recommended that the London Borough of Richmond upon Thames ensures that the issue of financial difficulties for all communities and the link to Domestic Abuse is addressed within the development of its VAWG (Violence Against Women and Girls) strategy 2020-2023.  Local   1.1 Ensure that financial hardship and economic abuse is cited as a factor when considering Domestic Abuse within an overall Needs Assessment  1.2 Ensure that the learning of this DHR and the potential link of financial hardship and economic abuse and DA is cited within the borough’s new VAWG strategy and any planned activity to raise  LB Richmond upon Thames Community Safety Partnership    LB Richmond upon Thames Community Safety Partnership      Completion of Needs Assessment       Publication of VAWG Strategy       October 2019      January 2020       Needs assessment presented to strategic group in July 2020     Wandsworth and Richmond strategic group met in July 2020, next meeting September and to be finalised in December 2020 Joint Domestic Homicide Review and Serious Case Review – LB Richmond Upon Thames Maria found murdered March 2018 in Richmond and Luis, aged 10, and Carlos, aged 7, found dead in Sussex  Bill Griffiths Final v7R 25/08/20   31 Official awareness of DA in the professional environment and communities  1.3 Ensure there are clear and accessible pathways of support for those suffering financial hardship or economic abuse.      LB Richmond upon Thames Community Safety Partnership        Assessment of revised accessible support pathways     March 2020     Presented and discussed March 2020 and integrated Into local MARAC processes    Learning Point 2: to ensure the link between financial difficulty and suicide is incorporated into the work of Safeguarding Adults and Suicide Prevention   2 It is recommended that the London Borough of Richmond upon Thames ensures that the issue of financial difficulty and the link to suicide is incorporated into the work of Public Health and suicide prevention  Local  2.1 Ensure that the learning from this review is presented to Richmond Health and Well-Being Board (HWB)  2.2  Ensure that the learning from this review is embedded into the newly commissioned ‘Richmond Trailblazer Project (RTP)’ for Suicide Prevention.  Public Health for Richmond and Wandsworth   Public Health for Richmond and Wandsworth   Presentation of DHR to the HWB    Presentation of DHR to Partnership Project Board for RTP  January 2020    January 2021  Will be presented in October 2020    Will be presented in January 2021  Completion expected January 2021      