“9 Establishment and conduct of reviews (1) In this section “domestic homicide review” means a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by— (a) a person to whom he was related or with whom he was or had been in an intimate personal relationship, or (b) a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death. (2) The Secretary of State may in a particular case direct a specified person or body within subsection (4) to establish, or to participate in, a domestic homicide review. (3) It is the duty of any person or body within subsection (4) establishing or participating in a domestic homicide review (whether or not held pursuant to a direction under subsection (2)) to have regard to any guidance issued by the Secretary of State as to the establishment and conduct of such reviews.
“As a result of a disclosure from a witness in the coronial investigation Leicestershire police investigated an historic report of domestic abuse from February 2021. This involved an alleged assault on CB causing a black eye. This was not reported at the time, and there was no evidence uncovered to prove any involvement by M or evidence stating M was responsible. The case has been filed no further action. In May 2021, a month before her death, CB provided information to a support agency she was engaging with for anxiety. She stated she felt at no risk from others in her life and provided M’s details as a person who helped her manage her mental health and to keep her safe.”
“Pathology Findings Completed by Dr Biggs July 2021 • Cause of death – Internal Haemorrhage, Abdominal Injuries • Presence of multiple bruises, abrasions to face, torso and limbs, significant injuries to the abdomen. Distribution of injuries appear to correlate to the stated scenario • Deceased had an alcohol blood level 6.2 times above the legal driving limit. It is probable this would have been higher at the time of sustaining her injuries • Alcohol level may have led to drowsiness and masked symptoms of pain • Alcohol level would account for the CCTV appearance of the deceased moving as if under the influence of alcohol and would have placed her at risk of falls, including down stairs • Multiple bruises and abrasions to the face, torso and limbs, majority over bony prominences could be accounted for by a number of falls. However, the possibility of inflicted injury cannot be excluded • The report concludes that a fall down the stairs followed by death at some point over the next few hours is entirely consistent with the observed injuries Supplementary Report April 2022 • The number and pattern of injuries observed were not sufficiently specific to conclude that the deceased was assaulted or forcibly restrained prior to her death • No typical defensive injuries identified • No old or healing fractures were identified, and so all of the observed fractures are likely to be represent recent trauma (i.e. fall or falls down stairs) • The report does not exclude the possibility of additional factors (e.g. an assault) having taken place but the pathological evidence does not contradict the witness account given • The additional report upholds the findings of the June 2021 report • Pathology voluntarily peer reviewed by Dr Hollingbury who supports the conclusions reached in the reports • The overall pattern of injuries was consistent with a fall or falls down the stairs” • Cause of death – Internal Haemorrhage, Abdominal Injuries • Presence of multiple bruises, abrasions to face, torso and limbs, significant injuries to the abdomen. Distribution of injuries appear to correlate to the stated scenario • Deceased had an alcohol blood level 6.2 times above the legal driving limit. It is probable this would have been higher at the time of sustaining her injuries • Alcohol level may have led to drowsiness and masked symptoms of pain • Alcohol level would account for the CCTV appearance of the deceased moving as if under the influence of alcohol and would have placed her at risk of falls, including down stairs • Multiple bruises and abrasions to the face, torso and limbs, majority over bony prominences could be accounted for by a number of falls. However, the possibility of inflicted injury cannot be excluded • The report concludes that a fall down the stairs followed by death at some point over the next few hours is entirely consistent with the observed injuries • The number and pattern of injuries observed were not sufficiently specific to conclude that the deceased was assaulted or forcibly restrained prior to her death • No typical defensive injuries identified • No old or healing fractures were identified, and so all of the observed fractures are likely to be represent recent trauma (i.e. fall or falls down stairs) • The report does not exclude the possibility of additional factors (e.g. an assault) having taken place but the pathological evidence does not contradict the witness account given • The additional report upholds the findings of the June 2021 report • Pathology voluntarily peer reviewed by Dr Hollingbury who supports the conclusions reached in the reports • The overall pattern of injuries was consistent with a fall or falls down the stairs”
“The police rationale for the decision not to make an agency DHR referral was that the death was not suspected to be as a result of violence, abuse or neglect Whilst there is some limited domestic abuse history and the family have raised concerns about domestic abuse, as this is not deemed to be a suspected suicide, DA related controlling and coercive behaviour would not be relevant to any DHR identification Therefore, based upon the evidence uncovered during the police investigation, the police position remains that the case does not meet the criteria for a DHR referral.”
“• On two occasions police had been called to domestic abuse incidents with CB the victim. • CB’s father has accounts of the abusive behaviour: • Holding CB and her friend A hostage with a knife • Beating CB • Coercive control including limiting her spending, limiting her friends, being a nuisance at her place of work, even accompanying her to the hairdressers. • In the 999 call following CB’s death, her partner claimed that “she fell down the stairs multiple times”
“There are past domestic incidents in the relationship between [CB] and [M], (the most recent alleged incident occurring in February 2021. There is no evidence to suggest any causal link between the past domestic incidents and the death of [CB] which at this stage is believed to be accidental, subject to the Coroner’s findings. In light of this currently there is no information or evidence to support the proposition that the death “has or appears to have” resulted from violence, abuse or neglect. Therefore based on the current information available applied to the statutory criteria for a DHR no Homicide has occurred and therefore no grounds to undertake a domestic homicide review despite the tragic circumstances resulting in [CB]’s death”
“5. The SSHD retains a broad discretion to order a DHR. The statutory guidance on conducting DHRs states: 11. DHRs are not inquiries into how the victim died or into who is culpable; that is a matter for coroners and criminal courts, respectively, to determine as appropriate. DHRs are not specifically part of any disciplinary inquiry or process. Where information emerges in the course of a DHR indicating that disciplinary action should be initiated, the established agency disciplinary procedures should be undertaken separately to the DHR process. Alternatively, some DHRs may be conducted concurrently with (but separate to) disciplinary action. 6. The letter [a reference to the pre-action protocol letter sent by the claimant] seems to suggest that the conclusions of the coroner and police are the end of the matter. That is a misreading of the breadth of the discretion and the purpose of a DHR. The police look at potential criminal liability and the coroner looks at the reasons that that individual died. The DHR is an additional process to examine what has gone before including dealing with multi-agency evidence to see if there are any lessons that can be learnt as per section 9(1) of the Act. Therefore, whilst the coroner’s inquest and police investigation will be of considerable assistance to the DHR, they are not determinative of the examination of the facts or any findings as to lessons learnt. 7. The letter seems to challenge that the SSHD has given a broad interpretation to “or appears to have, resulted from violence abuse or neglect”
“(5) Be clear or evident to the understanding, be manifest… (6) … Seem to the mind, be perceived as, be considered…”
“seem to the mind, be perceived as, be considered”