It’s been almost two months since I last posted anything. I’m glad to say that’s because I’ve been busy, beginning my PhD at Sussex University, along with my continuing independent consultancy work. But although I may be blogging less regularly, blog I shall.
In my last blog, I said I would be collating and sharing a list of Domestic Homicide Reviews (DHRs) as they are published. So, these are the DHRs that I am aware of that have been published since the start of September 2018:
Bexley Community Safety Partnership – case of Nargiza (in the interests of full disclosure, this is a DHR which I chaired and wrote)
Birmingham Community Safety Partnership – a joint domestic homicide, serious case and Multi Agency Public Protection Arrangements (MAPPA) review into the murder of a women and her child. Rather uncomfortably, the review refers throughout to ‘the women’ and ‘the child’. The report reference is BDHR/2013-14/02
Haringey Community Safety Partnership – case of Louise.
But my focus in this blog is on a specific report: a review published by Hertfordshire Council into the death of Ms M. Interestingly, the review is not actually a DHR, although it was conducted along lines similar to a DHR. When I read it, a few things struck me which I wanted to share here.
Firstly, let’s talk about why this review wasn’t a DHR. Was that the right decision?
Ms M died in Hertfordshire. Her death was initially considered by the Epping Forest District Community Safety Partnership (EFCSP), as this was the local authority area in which she was normally resident, which decided that Ms M’s murder should not be the subject of a DHR.
So, let’s track that decision as best as we can. DHRs are conducted when someone’s death has, or appears to have, been caused by someone with whom they were or had been in an intimate relationship (they can also be conducted for homicides involving family members, but I am not thinking about that in this blog). That’s consistent with the definition of domestic violence and abuse, which talks about “those aged 16 or over who are or have been intimate partners”. In this case, the relationship between Ms M and Mr O (who was convicted for her murder) is described as follows in the review:
“In December 2015, Ms M met Mr O, whom she had met through an Internet dating site, face to face for the first time. They met at a bar in East London, following which they took a taxi to a hotel in Hertfordshire, where he subsequently murdered her” (p. 3).
The review also makes it clear that the nature of their relationship (specifically it’s short duration) led directly to the decision that Ms M’s death did not meet the criteria for a DHR:
“Given the apparent nature of the relationship between Ms M and Mr O, in that they did not co-habit and there was nothing to suggest that they had been in an intimate relationship, the EFSCP formed the view that a Domestic Homicide Review was not required, and they notified the Home Office to that effect” (p.3).
So, that’s all ok then? Well, perhaps by the letter of the Multi-Agency Statutory Guidance For The Conduct Of Domestic Homicide Reviews. And presumably the Home Office’s Quality Assurance Panel agreed with the decision not to conduct a DHR (although as an aside: one of the problems with the current DHR process is that Community Safety Partnerships are not required to report on homicides where they decide not to conduct a DHR, so we lose track of cases in circumstances like this).
But on reading the review, an issue crystallised for me. Specifically, what ‘counts’ as a DHR and what doesn’t? I think there is a problem with the current statutory guidance where DHRs are commissioned into homicides in an ‘intimate relationship’ because this is both undefined and potentially exclusive. The lack of definition may not be an issue in many cases, where it’s clear that someone was a boyfriend/girlfriend, partner or spouse. But there are going to be times when cases don’t meet any one of those categories. Like in this case. And then we have to ask ourselves, at what point does a relationship become sufficiently ‘intimate’ to count? Here, Ms O was murdered by someone she met on an internet dating site, and with whom she went to a bar and then travelled to a hotel. But apparently that wasn’t sufficiently intimate. That feels like a badly drawn definitional line to me. And badly drawn lines have two problems. I have no idea how many other cases there are like this, but I am sure there are others, which means that some deaths are likely being excluded from the scrutiny that the DHR process brings. What’s more, in the absence of a clear definition, decisions about what cases count may be subjective. And where decisions are subjective, they may be influenced by bias and stereotypes. In cases like these, which are effectively short-term encounters, that means (inappropriate) judgements may be made. Both these problems are troubling. Taken together they mean some deaths won't be considered on the absence of sufficient intimacy rather than because of a perpetrator’s behaviour. That’s not ok and should change.
Secondly, this was not initially considered as a DHR. Surely then, it’s good that the review happened at all?
The short answer is yes. In this case, as well potentially being a DHR, it also sounds like a Safeguarding Adult Review was discussed but found not to ‘fit’ either. Having exhausted both options, the Chief Constable of the Hertfordshire Constabulary (the area where the homicide happened, but not where Ms M lived) pushed for a multi-agency review. That is reported to be on the basis of the “complexity of the case and that a number of agencies had been in contact with the perpetrator over an extensive period of time before Mr O committed the murder” p.3). So, this looks to be an example of a local partnership, with a bit of encouragement from Senior Leaders, going that extra mile. That's great. But what is interesting in the context of the DHR process is that the review justifies the decision to conduct a review with reference to the old (2013) version of the statutory guidance. The review points to one paragraph in particular:
“5.13 In some homicides that do not meet the criteria for a DHR but give rise to concern, it may be valuable to conduct a single agency individual management review or a smaller-scale audit. For example where there are lessons to be learnt about the way staff worked within one agency rather than about how agencies worked together".
I’m not here to quibble the referencing. The homicide happened while the old guidance was in place and it was being conducted along similar lines to a DHR in order to provide a structure to the process. We wouldn’t necessarily expect it to reference the newer (2016) guidance. But what this did make me realise is that the old (2013) version of the statutory guidance had a flexibility that has been lost. While the new (2016) guidance addresses the conduct of DHRs when a victim dies by suicide (paragraph 18), as well as the overlap with other ongoing reviews (paragraphs 22 and 23), it no longer covers homicides that do not meet the criteria for a DHR. Perhaps in updating the statutory guidance we have lost some of the flexibility of the old, which might make it harder for cases like this to be reviewed in future? That’s something for the Home Office (or perhaps the Domestic Abuse Commissioner if the Government’s plans come to fruition) to consider.
Thirdly, what does this review tell us about how perpetrators are held to account?
Well, sadly, it illustrates why perpetrators continue to escape scrutiny. Mr O is reported to have stated that he “encountered difficulties entering into and maintaining relationships with females” (p.10). Indeed, some of the earliest contact with Mr O relates to two suicide attempts in his late teens and early twenties, where it seems “difficulties in relationships with girlfriends were instrumental in his self-harming” (p.10). The Judge in Mr O’s trial is also cited in the review as having said that Mr O posed a "very great danger to women and young girls" (p.8) …But, despite this, violence against women is unexplored.
That’s not to say that Mr O’s attitudes, beliefs and behaviours towards women are not present. Reading the timeline of key agency interventions / interactions in the review (p.11 – 26), it’s possible to identify at least 11 incidents between 2009 and 2015:
Report to a Police Force - battery against ex-girlfriend
Report to a Police Force - criminal damage to home of ex-partner
Report to a Police Force - a girlfriend reported threatening calls, messages and Facebook postings
Report by a Mental Health Trust to a Police Force – reported concerns regarding Mr O expressing desires to hurt and rape women (which the trust took seriously enough that Mr O would be visited by staff in pairs)
Report to a Police Force - malicious electronic communications sent to female acquaintance
Report by a Mental Health Trust to a Police Force – reported a call from Mr O threatening to kill, strip and rape his girlfriend’s sister. Mr O also threatened to kill a Community Psychiatric Nurse (CPN) (sex unknown). Mr O telephone the same Police Force to repeating the same threat(s)
Report to a Police Force - informed that Mr O was attempting contact via Facebook with female prison officers
Report to a Mental Health Trust - Mr O in inappropriate contact with female patient (three reported incidents of Mr O making inappropriate sexual approaches to female service users)
Report to a Mental Health Trust – Mr O’s Care Coordinator reported to an internal review panel that she found him intimidating and did not want to visit him at his home address or alone (which the trust took seriously enough that Mr O was seen at his Community Mental Health Team’s offices rather than in the community)
Report by a Mental Health Trust to a Police Force - report that Mr O’s girlfriend stating that Mr O had threatened her brother
Report by a Mental Health Trust to a Police Force - allegation from husband of service user of inappropriate sexual behaviour by Mr O.
But the review’s analysis focuses on the management of Mr O’s mental health problems, assessment of risk and issues around information sharing between the various agencies involved (several Police Forces, Mental Health Trusts and the National Probation Service). These are of course important issues. Rightly, the review concludes that there are lessons to be learned from the tragic death of Ms M and the treatment / management of Mr O leading up to her murder.
But why is the pattern of his behaviour towards women not named? Why is it easier to make this case about one man and agency policy and procedure rather than place his behaviour towards Ms M in a wider context?
I don’t think this is about this review alone: The silence around perpetrators in DHRs is part of a wider silence about men’s violence towards women in our society. Only last month, Karen Ingala Smith published a blog naming the women killed during this year to the end of September. It’s a sobering read and a reminder of the all too real context and scale of men’s violence, which somehow continues to just be 'one of those things'. At the same time, in accounts of domestic homicide, the media's use of reductive, perpetrator excusing or victim blaming headlines appears unabated (something that Level Up (among others) is challenging with its ‘Dignity for Dead Women’ campaign).
DHRs (and other reviews) cannot solve this silence. But we can recognise that they make a contribution to it. Until they identify, name and account for the behaviour of perpetrators, DHRs (and other reviews) will continue to be part of the problem and our attempts to learn the lessons will be limited.
Let’s change that.
As a final note: please let me know if you know of any other DHRs that have recently been published and I will include them in my next update.