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CARMARTHENSHIRE COMMUNITY SAFETY PARTNERSHIP
DOMESTIC HOMICIDE REVIEW PANEL
EXECUTIVE SUMMARY
OF THE REPORT INTO THE DEATH OF ‘ANN DAVIES’
Report produced by D.R. MacGregor (Independent Chair)
Published September 2015
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Homicide Case Review: Enhancing Interagency Collaboration in Carmarthenshire, Exams of History
The findings of a review into a homicide case in Carmarthenshire, Wales. The aim was to identify the most important issues and develop recommendations for local agencies to strengthen their arrangements. The review focused on the involvement of various statutory and third sector organizations with Ann and Thomson, communication and information sharing between agencies, and potential gaps in service provision. Key issues included the need for greater harmonization of risk assessment tools, offering multi-agency support to individuals susceptible to domestic violence, and improving training for staff to assess sensitive issues.
What you will learn
- What were the key findings of the review regarding interagency collaboration in Carmarthenshire?
- What role did substance misuse agencies play in the review and what were their findings?
- How did the review address the issue of incomplete and inaccurate information sharing between local agencies?
- What recommendations were made to improve information sharing and risk management arrangements?
- How can agencies better support individuals susceptible to domestic violence?
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RESTRICTED
CARMARTHENSHIRE COMMUNITY SAFETY PARTNERSHIP
DOMESTIC HOMICIDE REVIEW PANEL
EXECUTIVE SUMMARY
OF THE REPORT INTO THE DEATH OF ‘ANN DAVIES’
Report produced by D.R. MacGregor (Independent Chair)
Published September 2015
CONTENTS
Page Number
Preface 3
Panel Membership 4
1 – Introduction 5
2 - The Review Process 5
3 – The Facts 7
4 – Analysis 8
5 - Key Issues arising from the Review 10
6 - Conclusions and Recommendations 11
Appendices:-
- The Scope and Terms of Reference of the Review
- Action Plan
PANEL MEMBERSHIP
Name Position Agency/Organisation
David MacGregor Independent Chairperson N/A Chris Burns Assistant Chief Executive Carmarthenshire County Council Kate Thomas Community Safety Manager Carmarthenshire County Council Simon Plant Manager – Local Safeguarding Children Board
Carmarthenshire County Council
Frances Lewis Service Manager – Children’s Services
Carmarthenshire County Council
Chris Beer Housing Options Manager Carmarthenshire County Council Christine Harley Assistant Chief Executive Wales Probation Debbie Osowicz Deputy LDU Head Wales Probation Stuart Moncur Assistant Director – Assurance, Quality & Improvement
Hywel Dda University Health Board
Gill Phillips Service Manager, West Wales Substance Misuse Service
Hywel Dda University Health Board
Steve Cockwell Chief Inspector Dyfed Powys Police Neil Jenkins Detective Inspector Dyfed Powys Police Louise Harries Detective Sergeant Dyfed Powys Police Jason Smith Operations Manager Catalyst, Turning Point Cymru Kevin Fisher Chief Executive Helping Groups to Grow Lisa Kieh Carmarthenshire Manager Kaleidoscope Project Tim Charlton Manager, Drug Intervention Programme (DIP)
Prism Cymru
Mark Richards Head of Housing Services Bro Myrddin Housing Association Paul Sheridan Carmarthenshire Manager The Wallich
1.0 INTRODUCTION
1.1 The key purpose in 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 and abuse. In order for these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future.
1.2 To help protect the family of the victim, the process requires that details of all individuals are anonymised; throughout this report, the victim is referred to as Ann and the perpetrator is referred to as Thomson (ie not their real names).
2.0 THE REVIEW PROCESS
2.1 All the statutory agencies and third sector organisations that were known to have had any involvement with either Ann or Thomson were approached and asked to identify a senior representative to join the Panel.
2.2 An individual with considerable experience in senior management roles within local government (including interagency partnership working) was identified as a potential Independent Chairperson. He retired from local government service in 2012 but for thirteen years prior to this, had no significant involvement with any of the agencies involved in the Review as he had been employed in the Bridgend area.
2.3 The Scope and Terms of Reference for the Review were discussed and agreed and these are included as Appendix 1.
2.4 The local agencies and organisations that were known to have had an involvement with either Ann or Thomson have willingly participated in this review; these are:-
West Wales Substance Misuse Services (WWSMS) - This agency forms part of the range of NHS services provided in Carmarthenshire by the Hywel Dda University Health Board. The Health Board is both a commissioner and provider of services for people who misuse substances. Turning Point – Is a third sector organisation that provides health and social care services. It has delivered the Catalyst service in Carmarthenshire for the last 5 years; this provides a range of semi structured interventions to people concerned about their own drug use or somebody else’s drug or alcohol use. Helping Groups to Grow (HG2G) – Is a third sector organisation that provides counselling services; the participants are referred from other local agencies
The Wallich – Is a third sector organisation that is commissioned to deliver a tenancy support service which assists people with a substance misuse issue to gain or sustain their tenancy. The service is complementary to treatment with the aim of supporting
her murder; at his trial he pleaded guilty to this crime and was sentenced to life imprisonment. The family had no knowledge of previous incidents of domestic violence occurring in their short relationship.
3.2 Ann was born in Carmarthen and lived locally throughout her life. She was part of a large family many of whom lived in close proximity and they all had strong and positive relationships with each other. She was the fourth of six siblings and had three children of her own. She was known to a number of local agencies/organisations in both the statutory and voluntary sectors.
3.3 She did not have stable long term relationships with any of her partners and it is known that domestic abuse featured in some of these. She had a history of drug and alcohol abuse and had been accessing substance misuse services for a number of years. Ann’s family supported her in a range of ways and made significant efforts to encourage her to stop using drugs as they could see the adverse effect that these were having on her.
3.4 Ann was a local authority tenant and she maintained her own home which was also in Carmarthen. Her three children lived with her and she had been expected to return to her home to be with her family later on the evening that she died.
3.5 At the time of her death, she was aged 37 years; her daughters were aged 19 and 14 and her son was 11 years of age. Since that time, the younger children have been cared for within the family and they spoke very positively about the way in which the schools have worked with them to support the children.
3.6 Richard Thomson is 29 years of age and the father of three children. He has a long history of drug and alcohol misuse and criminality; his convictions include domestic violence, robbery, assault and drug dealing. He was born in Watford but the family moved to Aylesbury when he was very young, and they later moved to Carmarthenshire when he was a teenager. Thomson returned to Aylesbury around 2006 and lived there for a period with a girlfriend with whom he had two children.
3.7 That relationship ended and he subsequently returned to Carmarthenshire. In 2008 he is known to have had a partner from the Swansea area with whom he had a further child. She lived with him in Carmarthen for a short period in the summer of 2008; it is now known that domestic violence was a significant feature of their relationship. Regrettably, very little of this domestic violence was reported but she left him and was then supported for a period via Women’s Aid. Aspects of this information have relevance in the context of ‘Information Sharing’ between agencies in neighbouring areas.
4.0 ANALYSIS
4.1 None of the local agencies knew of the relationship that Ann had formed with Thomson. She was not co-habiting with Thomson and there had not been involvement with them as a couple. In view of this, the Review examined the involvement of local agencies with each of them as individuals in order to establish if any lessons could be learnt. The following summary analyses reflect the findings from this approach.
Re: Ann
The agencies and organisations within Carmarthenshire which had any level of involvement with Ann between 2008 and 2012 are listed below:-
West Wales Substance Misuse Service (WWSMS)
Turning Point (Catalyst)
Helping Groups to Grow (HG2G)
The Wallich
Carmarthenshire CC – Children’s Services
Carmarthenshire CC – Housing Services
Dyfed Powys Police
4.2 Ann accessed support from WWSMS and other commissioned service providers between July 2010 and July 2012. Referrals were also made to partner agencies to secure Housing support services and assistance with daily living for her; these services were provided between August 2011 and November 2012.
4.3 There is evidence of joint working and good communication between WWSMS and other service providers; referrals were made for housing support services, assistance with securing benefits and the other presenting needs. It is important to address these types of issues to enable a stable platform on which to engage a client in more structured treatment that can be safe, effective and focused.
4.4 In the period covered by the Review, Ann was never before the Courts and had no ongoing involvement with any of the criminal justice agencies. There were no active concerns in regard to domestic violence during Ann’s involvement with substance misuse and/or housing support services and there was therefore no need to progress a referral under the MARAC arrangements. Isolation was more of a concern; during this time risks were low and she achieved an increased level of stability.
4.5 The key finding from the work undertaken is that there was strong evidence of good interagency working with Ann and appropriate referrals between local services to provide support to her; the main ones being linked to substance misuse, benefits advice and housing
4.9 There is evidence of good ongoing inter-agency activity and communication between professionals around meeting the needs of this individual. His treatment was quite specific to the substance misuse and related general health care needs. This was in itself a difficult task as his motivation and presentation fluctuated on a regular basis. The focus from a service point of view developed into keeping him engaged in treatment to reduce further risks to himself, whilst remaining aware of his potential for violence and the wider community safety risks.
4.10 Throughout the management of his Community Orders, Thomson was an entrenched substance misuser. There are multiple instances of close working between Wales Probation and local substance misuse agencies to endeavour to manage his chaotic behaviour; this demonstrates good practice. Additionally there is evidence of the sharing of intelligence about his behaviour connected with the drug culture and incidents of violence that had not led to a prosecution.
4.11 A number of the agencies acknowledged that working with people with chronic dependencies who are not fully or consistently motivated or resourceful enough to combat their addictions requires great skill and a coordinated approach. Any active treatment relies on the engagement and motivation of the individual concerned.
5.0 KEY ISSUES ARISING FROM THE REVIEW
a. The most significant cross cutting issue identified from the Review and which impacts on all the contributing agencies is the need to ensure that all relevant information is routinely and consistently shared with partner agencies. Whilst the Review has found much evidence of good information sharing between local agencies, it has also identified that in relation to Thomson, there have been some failings in this area and it is important that this issue is addressed. The information provided to substance misuse agencies in 2012 when Thomson was discharged from prison was both incomplete and inaccurate. A similar situation arose with Housing Services the previous year. Good quality service intervention plans and effective risk assessments are entirely reliant on having access to complete and accurate information. The Prison Service was not involved with the Review but some follow up work with this service will be necessary.
b. The difference between the WIISMAT and the outcome of the risk assessments undertaken by other agencies via different methodologies is a source of concern. Local agencies need to explore the potential for greater harmonisation of the Risk Assessment tools currently in use.
c. The Panel consider that there is an opportunity for agencies to identify some individuals with potential vulnerabilities to be offered greater levels of multi agency support where they may be susceptible to (or have experience of) domestic violence. It is recognised that there are challenges in determining which interventions, if any, may be appropriate but the panel believe this should be fully explored on a multi agency basis.
d. The concerns held by agencies in the neighbouring area of Swansea in connection with Thomson’s actions towards his previous partner Jane were not known by Dyfed Powys Police or Children’s Services in Carmarthenshire as the focus within the MARAC process was on the victim (Jane) and where she resided. This highlights a challenge for agencies on what information to share when victims and perpetrators reside in different administrative areas.
e. Contributions from agencies involved with this Review identify that there is a need for further training for staff on the techniques and approaches to use when individuals do not ‘open up’ or are evasive about discussing sensitive issues; it is important to get behind this ‘front’ in order to be able to assess whether any additional service interventions may be needed.
f. Throughout the management of his Community Orders, Thomson was an entrenched substance misuser. There are multiple instances of close working between Wales Probation and local substance misuse agencies to endeavour to manage his chaotic behaviour; this demonstrates good practice.
g. The local authority and Registered Social Landlords should investigate ways in which relevant records of violent offences, including domestic violence, could when appropriate be ascertained and recorded in a manner which would enable them, as landlord, to identify any ‘warning signs’ which might come to their attention during the tenancy so that they could initiate appropriate action if/when necessary.
6.0 CONCLUSIONS AND RECOMMENDATIONS
6.1 This Review has been approached in an open and honest way by all the agencies. A great deal of analysis has been undertaken of the evidence of the various services’ involvement with both Ann and Thomson. Nothing has come to light to suggest that any of the agencies could have foreseen the events that led to Ann losing her life.
6.2 The key finding from the review of the agencies’ involvement with Ann is that there was strong evidence of good interagency working and appropriate referrals between local services to provide support to her; the main ones being linked to substance misuse and housing support. It was encouraging to learn that the views expressed by her family are consistent with this finding.
6.3 The Review has also found evidence of good interagency working with Thomson, good information sharing and good practice. However, this was not consistently the case and some gaps were identified. Consideration of all known relevant information is important when developing treatment plans as this leads to more effective clinical interventions, but it is also a pre requisite for good Risk Assessments. Some weaknesses were identified in local information sharing arrangements in relation to Thomson; this inevitably impacted on the quality and effectiveness of some of the Risk Assessments undertaken in relation to him.
APPENDIX 1
AIM
The aim of this Domestic Homicide Review is to identify the most important issues to address in learning from this Homicide and develop recommendations that will strengthen existing arrangements.
SCOPE
The Review will examine the actions/responses of relevant agencies between 1st April 2008 and December 2012 Consideration will be given to the reports of the trial in the Crown Court Each agency/organisation that had involvement with either Ann or Thomson will be requested to undertake a comprehensive Individual Management Review (IMR) of their involvement; each of these IMRs to be completed and produced in accordance with the Home Office Guidance Family members will be briefed on the process and offered the opportunity to contribute
TERMS OF REFERENCE
Within the context of the above, the Panel will:-
Identify which agencies/organisations had involvement with Ann and Thomson Review their responses to referrals and consider the appropriateness of any services provided Seek to identify which agencies/organisations (if any) were providers of relevant services but had no involvement with either Ann or Thomson Review the extent to which agencies/organisations worked together when responding to the needs and circumstances of both Ann and Thomson Consider potential gaps in service provision, alongside potential barriers to accessing services Consider the extent and adequacy of information sharing between local agencies in Carmarthenshire and other areas Consider whether any safeguarding issues arose in relation to the children of either Ann or Thomson Identify areas of good practice