BARNET COMMUNITY SAFETY PARTNERSHIP
Report Completed: 6 March 2015DOMESTIC HOMICIDE REVIEW
into the death of
Songul in October 2013
OVERVIEW REPORT
Report Author
Gaynor Mears OBE, MA, BA (Hons), AASW, Dip SW
CONTENTS
Section / PagePreface …………………………………………………………………………. / 1
1 / Introduction …..……………………………………………………………… / 2
Timescale ……………………………………………………………………… / 2
Confidentiality ……………………………………………………………….. / 2
Dissemination ……………………………………………………………….. / 2
Terms of Reference ………………………………………………………. / 3
Methodology …………………………………………………………………. / 4
Contributors to the Review …………………………………………….. / 6
Review Panel Members ………………………………………………….. / 7
Author of the Overview Report ……………………………………….. / 8
Parallel Reviews …………………………………………………………….. / 8
2 / The Facts ……………………………………………………………………… / 8
3 / Chronology – Background information …….……………………… / 10
Chronology from October 2011 to October 2013……………….. / 14
4 / Overview – Summary of Information Known to Agencies …. / 40
Ethnicity, Cultural, and Equality Issues ………………………..…… / 44
Other relevant facts and information......
About Songul and Damon…...... …. / 47
47
5 / Analysis ……………………………………………………………………….. / 48
Early Learning ……………………………………………………………….. / 67
6 / Conclusions …………………………………………………………………… / 67
Lessons Learnt ………………………………………………………………. / 70
Identification of Good Practice ………………………………………… / 75
Recommendations …………………………………………………………. / 75
Appendix A - Home Office Letter ...... 81
1
Barnet Domestic Homicide Review – Final Version
DOMESTIC HOMICIDE REVIEW
Preface
The Barnet Domestic Homicide Review Panel would like to express their sincere condolences to the family members affected by the sad events which have resulted in this Review. The death of a family member is never easy to come to terms with, and when it is the result of the actions of another family member the loss is undoubtedly particularly keenly felt.
The independent chair and author of the Review would also like to express her appreciation for the time, commitment, and valuable contributions of the Review Panel members and contributory report authors. This Review has been complex and the Panel has carefully considered many issues concerning the victim and the perpetrator in coming to its findings. We believe there is important learning on a national as well as local level from this Review, particularly with reference to vulnerable adults and their carers.
This report of a domestic homicide review examines agency responses and support given to the victim, a resident of London Borough of Barnet prior to the point of her death in October 2013. The Review will consider agencies contact and involvement with the victim, and with the perpetrator, from October 2011 up to the date of the fatal incident.
The key purpose for undertaking a Domestic Homicide Review (DHR) is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence. In order 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 in order to reduce the risk of such tragedies happening in the future. The victim’s death met the criteria for conducting a domestic homicide review under Section 9 (3)(a) of the Domestic Violence, Crime, and Victims Act 2004, namely the homicide appeared to be by a person to whom the victim was related, or with whom they had, or had been in an intimate relationship. The Home Office defines domestic violence as:
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, and 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
The term domestic abuse will be used throughout this Review as it reflects the range of behaviours encapsulated within the above definition, and avoids the inclination to view domestic abuse in terms of physical assault only.
- Introduction
1.1The circumstances leading to this Review are the result of a phone call to the London Ambulance Service in the early hours of 5 October 2013 by a concerned relative requesting their attendance at the home of the victim and her son. Due to the concerns raised by the relative the Ambulance Service requested Police attendance. There was no response to knocks on the door and a forced entry had to be made to the property. The victim’s body was found in the living room with her son lying downclose to her. Her son was arrested at the scene and later charged with his mother’s murder.
Timescales
1.2The Barnet Community Safety Partnership held a meeting on 29 October 2013 following notification by the Police of the death on 10 October. The Home Office was informed of the Partnership’s decision to undertake a Domestic Homicide Review (DHR) on 11 November 2013. It was not possible to complete the Review within six months of commencement as required by statutory guidance due to the timescale of the criminal proceedings which concluded on 23 July 2014 after which the Review recommenced.
Confidentiality
1.3The findings of this review are confidential. Information is available only to participating officers/professionals and their line managers until the Review is approved by the Home Office Quality Assurance Panel for publication.
1.4Statutory Guidance requires that this report is anonymised to protect the identity of the victim, the perpetrator, and their families. To fulfil this duty the following pseudonyms have been used throughout this report:
The victim: Songul. At the time of her death Songul was 69 years old.
The perpetrator: Damon was the victim’s son. At the time of the homicide Damon was 42 years old.
1.5Songul was of Iranian ethnicity. She was of insecure immigration status having been refused leave to remain in the United Kingdom. She had appealed this decision a number of times and was in the process of a further appeal.
1.6Damon is of also of Iranian ethnicity. He is a naturalised British citizen (see 3.3).
Dissemination
1.7The following will receive copies of this report.
Chair and Board members Barnet Safer Community Partnership Board
Chief Executive, Royal Free Hospital NHS Trust (formerly Barnet & Chase Farm Hospital NHS Trust)
Commissioner (Chief Constable), Metropolitan Police
Borough Commander for Barnet, Metropolitan Police
Deputy Mayor for London Policing & Crime
Chief Executive of the London Borough of Barnet
Director of Adults & Communities, London Borough of Barnet
Chief Executive, Barnet, Enfield & Haringey Mental Health Trust
The Chair of Barnet Clinical Commissioning Group
The Chief Officer of Barnet Clinical Commissioning Group
Board Chair of Central London Community Healthcare Trust
Chief Nurse, Central London Community Healthcare Trust
Chief Executive of Central London Community Healthcare NHS Trust
Chief Executive, London Ambulance Service NHS Trust
The Chair, Safeguarding Board for Adults & Children, London Borough ofBarnet
Medical Director, NHS England,
Chief Executive,Victim Support
Senior Partner Longrove Practice
Senior Partner Vale Drive Medical Practice
Terms of reference of the review
1.8Statutory Guidance states the purpose of the Review is to:
- Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
- Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
- Apply these lessons to service responses including changes to policies and procedures as appropriate; and
- Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.
- To seek to establish whether the events leading to the homicide could have been predicted or prevented.
This Domestic Homicide Review is not an inquiry into how the victim died or who is culpable. That is a matter for coroners and criminal courts.
1.9Terms of Reference for this Review:
1. To review the events and associated actions that occurred which relate to the victim and the alleged perpetrator between October 2011 and 5 October 2013 the date of the victim Songul’s death. Agencies with knowledge of the victim or alleged perpetrator in the years preceding the timescale for detailed review are to provide a brief summary of that involvement.
2. The agencies which had involvement with the victim and the alleged perpetrator to assess whether the services provided offered appropriate support, resources, and interventions, and that procedures were followed. This to include any interaction with family members or friends which have relevance to the scope of this review as identified within agencies’ records, Individual Management Reviews (IMR) or other information sources as deemed appropriate.
3. To assess whether agencies have sufficient and robust relevant policies and procedures in place, and whether these are up to date and fit for purpose in assisting staff to practice effectively where domestic abuse is suspected or present.
4.To examine the knowledge and training of staff involved in relation to safeguarding of vulnerable adults, the identification of indicators of domestic abuse, the application and use of appropriate risk assessment tools and safety planning including:
- The CAADA DASH[1] risk indicator checklist and referral mechanism to MARAC[2].
- Agencies own specialist risk assessment tools to assess risk posed by a
perpetrator and/or risk posed to victim and follow up processes;
- Knowledge and use of appropriate specialist domestic abuse services.
5. Examine the effectiveness of single and inter-agency communication and information sharing, both verbal and written.
6. Explore what issues if any prevented the perpetrator accepting the services offered to support him.
7.To consider what impact the victim’s immigration status had on how agencies responded to her needs.
Methodology
1.9Following enquiries ofagencies to ascertain which had contact with the family agencies were ask to secure their files and chronological information was gathered and submitted. The information formed the source of the chronology of this Review. This provided the initial picture of what had taken place and a basis for further enquiry via the submission of Individual Management Review (IMR) by agencies. The IMRs were discussed and quality assured by the DHR Panel. A number of IMRs had gaps or required additional information to meet the terms of reference and this was requested from their authors.
1.10Agencies undertook a review of their electronic systems and records and in some cases paper records where these pre-dated the introduction of electronic records. Mental Health and Adults & Communities also reviewed meeting minutes and relevant email communication. Interviews were held with appropriate staff within the hospital including physiotherapy. The Ambulance Service was unable to interview staff due to the number of call-outs over the time period and the shift patterns worked by those involved. Practitioners in the Old Age Psychiatry Team were interviewed as part of the Mental Health Board Level Enquiry. The victim’s GP IMR stated that there were discussions with the practice GPs in two separate groups, but no individual interviews took place. This IMR does not summarise the outcome of these discussions. Staff involved within Adults & Communities from whom social work and social care services were delivered were interviewed, however one key member of staff had left the organisation and one was on maternity leave therefore contributions from these staff members could not be obtained. The Farsophone Association which provides a range of support services to the Iranian community as well as working towards mutual cultural appreciation between Iranian and UK residents has provided information, although their information was limited as their attempts to contact the family were not successful. Barnet College reviewed their electronic records and staff that had contact with the perpetrator were interviewed for their IMR. The victim’s solicitor who was acting on her behalf to appeal the Immigration Service rejection of her application for leave to remain declined to take part in the Review due to the Solicitor's Code of Ethics on client confidentiality.
1.11All bar one of the IMR authors were independent of case involvement and/or the line management of practitioners who had contact with the family. Statutory agencies IMRs were undertaken by authors holding a strategic role i.e. safeguarding leads, director of nursing or by an officer in a dedicated Review unit as was the case with the Police and Ambulance Service. The victim’s GP practice IMR was undertaken by one of the GPs who is a partner in the practice who had not seen the victim or perpetrator. The Victim Support IMR was undertaken by a senior service delivery manager, who declared that they had line management responsibilities for those who had telephone contact, but they had not personally had contact with the perpetrator. This IMR was signed off by a divisional manager. The DHR chair and author is satisfied that the Victim Support IMR has looked openly and critically at their practice in this case.
1.12The Review was hampered during its process by the inability to achieve an IMR or adequate report from the perpetrator’s GP. The practice helpfully provided brief dateline information for the chronology and answered a number of specific questions via email and an attendance at a Panel, but aReview conducted from within the practice’s own resources was not appropriate as it is a very small practice and the GPs are related. The Panel was informed that resourcing an independent IMR was not possible for the practice and other means of achieving resources from a variety of sources proved unsuccessful. Communication with NHS England and the Clinical Commissioning Group has been unable to resolve this matter. The Panel believes this is an issue for the Department of Health to investigate and resolve as soon as possible and a recommendation has been made to this effect.
1.13Unfortunately, it was not possible to combine the Mental Health enquiry process with the DHR. The short timescale for the commencement of the Root Cause Analysis Enquiry meant this was completed before the DHR terms of reference were agreed, and although the DHR chair attempted to combine the terms of reference into the Board Level Enquiry which followed this did not happen for administrative reasons. Additional information was therefore requested to supplement the Board Level Inquiry to meet the DHR terms of reference.
1.14Agencies were asked to examine their policies and assess whether these were appropriate and were followed in practice. Policies reviewed were:
- Mental Health Safeguarding Adults at Risk Policy (2010 reviewed July 2013
- Carers Strategy (2006 reviewed November 2011)
- Sharing Information Policy
- Health and Adults & Communities Section 75 Agreement
- Mental Capacity Act 2005
- Protecting adults at risk: London multi-agency policy and procedures to safeguard adults from abuse (January 2011)
1.15Information was also requested from NHS England regarding safeguarding and information sharing policies for the NHS 111 Service, however this was not received by the time the DHRwas concluded.
1.16NHS Direct archives department provided information regarding calls to their service before it was disbanded.
1.17The author was given access to psychiatric reports used at Damon’s trial, and on application to one of the authors was granted permission to cite passages from their report. The author is grateful to Dr Phillip Joseph, consultant forensic psychiatrist for his assistance. The author is mindful of patient confidentiality and the passages have been used sparingly. They have been selected because they provide helpful insight and learning for practitioners.
1.18The DHR Panel has had advice to assist in their understanding of Iranian cultural life and customs from the Iranian, Kurdish Women’s Rights Organsiation (IKWRO). The chief executive of Barnet Mind was also invited onto the Panel to provide a non-statutory perspective and constructive challenge with regard to the mental health aspects of this Review, and they were able to attend one Panel.
1.19The author sought the medical opinion of the consultant responsible for Damon’s care in hospital concerning the possibility of interviewing him for this Review, but was advised that he was not well enough to take part. It was also not possible to gain his consent to access hisinformation on health grounds; therefore it was obtained in the public interest and under Section 115 of the Crime and Disorder Act 1998 which allows relevant authorities to share information where necessary and relevant for the purpose of the Act, namely the prevention of crime. In addition, Section 29 of the Data Protection Act 1998 enables data to be transferred if it is necessary for the purpose of the prevention or detection of crime, or the apprehension and prosecution of offenders. The purpose of this Domestic Homicide Review is to prevent other similar crimes.