The Independent Police Complaints Commission investigation into the interactions Gwent Police had with Male Y and Woman L before he shot and wounded her on 19 August 2011 in Newport found there were issues with the way the force dealt with her reports of domestic abuse.
At 2.21pm on 19 August a member of the public called 999 to report that Woman L had been shot at a hairdressing salon on Malpas Road, Newport. The offender was immediately identified as Male Y, the woman's estranged husband. Male Y had fled the scene and following a police search found his body in a wooded area off Brickyard Lane, Newport, at around 9pm that evening.
At the time of the shooting Male Y was bailed by the court on 12 August 2011 after he had been charged with assaulting Woman L on 9 July. Gwent Police had opposed the bailing of Male Y.
The IPCC has upheld four complaints out of 13 made and has made a number of recommendations to the force about call handling and dealing with domestic abuse cases.
Following evidence found during the IPCC investigation Gwent Police decided that two police constables and one sergeant should be subject to management action, and a police constable to be subject to management advice. The force has also accepted all of the IPCC recommendations and suggestions for improvements.
A police sergeant retired during the IPCC investigation, although there was sufficient evidence gathered for a case to answer for him.
IPCC Commissioner for Wales Tom Davies said: "This has been a very difficult case for all concerned and I hope that the family and friends of all those involved find some measure of peace.
"Gwent Police's handling of domestic abuse had been in the public spotlight since the Joanna Michael case and the All-Wales domestic abuse conference held in June 2011.
"Despite the high awareness and public profile of the positive measures the force had put in place, our investigation into how this woman's concerns were dealt with highlighted issues with call handling, record-keeping and awareness of force policy and procedures.
"I hope that appropriate lessons have been learned and we have shared the learning from our investigation with Her Majesty's Inspectorate of Constabulary and the Serious Case Review and Attempted Domestic Homicide Review into how all agencies acted within this case."
The IPCC has agreed not to publish the names of those involved in this case as this is the approach being taken to the publication today of an executive summary of a Serious Case Review and attempted Domestic Homicide Review.
The IPCC investigation identified a number of incidents involving Male Y and Woman L prior to the shooting on 19 August 2011. Police dealt with a total of seven calls made to Gwent Police Control Room between 9 July 2011 and 18 August 2011.
In addition, the police were involved with both individuals on a number of other occasions. Woman L made two visits to her local police station where she was seen by local officers.
Male Y was arrested on 6 August in respect of assaulting Woman L, before being released on police bail.
On 10 August, Male Y was arrested for making threats to kill against a male and Woman L. Following that arrest, he was charged with the assault from the 9 July. After appearing before magistrates he was released by them with a number of bail conditions. Bail was opposed by the police and Crown Prosecution Service.
Woman L was assessed as being at high risk of significant harm after reporting the assault that had occurred on 9 July 2011 to Gwent Police on 19 July. She was dealt with by the Domestic Abuse Unit (DAU) and assigned a dedicated Domestic Abuse Officer (DAO).
Due to her being classed as a high risk victim her case was subsequently discussed at the Multi-Agency Referral Assessment Conference (MARAC). As a result, she was referred to an Independent Domestic Violence Advisor (IDVA). The IDVA worked closely with the DAO. The role of the IDVA was to support Woman L through the criminal justice system and provide support in other areas such as housing, and provision of legal services. The IDVA was expected to liaise with the DAO and advise them of any changes to victim's circumstances which may affect the safety planning and risk assessment in place.
Summary of complaint outcomes
· The police took too long to arrest Male Y after a statement on 25 July 2011 - Upheld.
· On 14 August 2011, the police were informed that Male Y may be breaching his bail conditions. The response from the officer was inappropriate - Not upheld. The complainant also felt no action was taken in relation to her concerns - Not upheld.
· A detective constable was informed of the potential breaches of bail; it was believed no action was taken - Upheld.
· The police failed to advise that the bail variation hearing had taken place on 18 August 2011 - Not Upheld.
· Not all relevant information was put before the court in order for it to make the initial bail decision - Not Upheld.
· Not all information was put to the court for it to later vary the bail conditions - Not upheld.
· A detective sergeant was advised that Male Y needed to be remanded in custody. The DS was told that if Male Y was not remanded those responsible for releasing him on bail would be signing Woman L death certificate. Not upheld.
· Male Y should have been sectioned - Not upheld.
· When a detective constable was telephoned their voicemail had been left on although the DC had in fact returned to work - Upheld.
· The detective constable said it was inappropriate for other family members to call her - Upheld.
· A detective constable was assigned to family liaison duties for both families. This was inappropriate - Not upheld.
· The detective constable took issue with the family plan to hold a small funeral for Male Y - Not upheld.
Findings and Recommendations
Finding 1 - Lack of co-ordination between departments - Serious and Violent Crime team (SVCT), DAU and the local Division
Communication problems regarding breaches of bail: This investigation established that key risk information was not available to those responsible for managing the offender, or to those responsible for managing the victim. It is apparent that neither the SVCT nor the DAU were fully aware of the potential breaches of bail allegedly committed by Male Y on 14 and 16 August 2011 respectively.
The NPIA's 2008 Guidance on Investigating Domestic Abuse clearly states that any breaches of bail 'will be treated as such', even in circumstances where the suspect and/or victim state they have reconciled. In addition, the Domestic Abuse Stalking and Harassment (DASH) assessment form identifies breach of bail as a risk factor. It is suggested that Male Y's breaches of bail were not treated with sufficient rigour: Should the evidence have supported the allegations, more could have been done to flag the fact that he had allegedly repeatedly breached his bail conditions (by imposing ORIS/PNC/local Intel warning markers) and these breaches should have been evidenced at court. It is possible that Male Y would have been remanded in custody if these breaches were pursued and evidenced.
Local recommendation 1
It is recommended that a working group is established to generate working practices which will ensure that information regarding potential breaches of bail is readily available to the DAU and SVCT. It is suggested that one way in which this could be achieved is through using command and control tags or qualifiers in orders that ORIS logs can be searched for relevant information, e.g. A 'domestic abuse breach of bail' tag could be created, appended to the relevant logs and used as search criteria. Daily searches could then be conducted ahead of the DACC.
Partnership between SVCT, the DAU and Division
From the statements taken from officers in the SVCT, DAU and on Division it was apparent no procedure existed relating to which domestic abuse cases would be dealt with by the SVCT. It was not clear whether all cases where the victim was identified as being at high risk of harm were referred, or only those where there were other factors involved.
Local Recommendation 2
The force should identify and set out a clear set of factors which will clarify which cases will be referred. This will alleviate any subjectivity and ensure all victims receive the same level of service.
On two occasions, response officers on division, who came into contact with the offender and/or victim when additional incidents were reported, failed to notify either the SVCT or DAU. The evidence indicated officers were not aware of the necessity to do this. They were unaware Male Y was classed as a high risk offender and Woman L a high risk domestic abuse victim. Furthermore, response officers did not appear to have carried out sufficient research to identify these issues. Supervisors stated there was an expectation divisional officers should be notifying the SVCT of any additional incidents, such as breaches of bail. Supervisors in the SVCT also stated they would expect divisional officers to deal vigorously with allegations such as breach of bail. It was not made clear how these expectations were cascaded to divisional officers.
While response officers should exercise common sense when dealing with incidents and carry out a certain degree of research to establish the risks posed by the offender, it was accepted they have limited resources to do this. Expectations such as the requirement to pass on certain information, needs to be clearly communicated to officers. The investigation found there were a number of individuals operating within different departments, who were in possession of various pieces of information relating to Male Y and Woman L. This information was not always co-ordinated and considered as a whole.
It is appreciated it was not possible for the SVCT to utilise their own officers to deal with all reported incidents involving an offender they are managing. It is recommended that if in the first instance all incidents are reported to the SVCT they will have first hand knowledge of relevant incidents. As a result the SVCT would then be able to have an input into the investigation of incidents, ensuring they are being dealt with robustly.
Local recommendation 3
Gwent Police should consider developing a policy outlining who is ultimately responsible for overseeing a domestic abuse investigation and the correct procedure to highlight the correct channels through which additional information should be fed to the relevant departments. There needs to be clear guidance on the most appropriate, and efficient way to pass information onto the SVCT, and DAU, to ensure they are in receipt of any relevant information regards offenders and victims at the earliest opportunity.
The investigation identified there was no standardised procedure to pass over the handover file when the SVCT had decided to take on a case. The criteria for hand delivering a file to the SVCT, collect it personally, or request it be put it in the internal mail, was based on several factors and open to interpretation. Action would not be taken in respect of making an arrest until the handover had been received. The very fact the SCVT only deal with high risk domestic abuse cases would indicate any action to affect an arrest should be taken as soon as possible. Allowing a handover file to be place in the internal post contradicted this and afforded the possibility of files going astray.
Local Recommendation 4
The force need to establish a standardised procedure for dealing with handover files.
Finding 2 - Control room issues
The wording of the operational information marker appended to two addresses indicated that 'urgent' attendance was required. The Gwent Police call gradings are aligned with those advocated by the National Call Handling Standards (NCHS): Emergency, Priority, Scheduled and Resolution Without Deployment.
Consequently, any call handler/dispatcher researching the OE markers on the various addresses would be required to interpret 'urgent' and attempt to correlate it with one of the force call grades. This was unacceptable, as it allowed too much room for discretion.
Local recommendation 5
It is recommended that in future where the wording of an OE marker refers to a call grade; it must be one of the accepted force call grades. This will ensure consistency of approach and will also ensure the intentions of the person who created the OE marker are fulfilled.
Several of the incidents reported to the control room were not dealt with as effectively as they could have been. On one log a search on the force computer system would have revealed Male Y was on police bail. Despite the log containing information regarding potential threats made by Male Y, there was no record of the information being passed onto the SVCT or the DAU which indicates no additional research was carried out.
Two further logs revealed the failure of control room operators to identify domestic abuse elements of a call. While logs were correctly classified there was no additional domestic qualifier attached. This indicated the operators had not researched the command and control systems and identified the on-going domestic abuse investigations.
One log was incorrectly classified, being classed as administration and information when it should have been a concern for safety. Further logs were graded incorrectly given that reports were made from an address on which a marker had been placed stating all calls were to be treated as 'urgent'. In addition, these logs were classed as domestic related incidents, indicating there was a domestic abuse element which in the least should have warranted a priority response.
Four logs were found to have been closed without the correct qualifiers. The failure to close a log with a domestic qualifier would prevent it from appearing on the list reviewed by the Domestic Abuse Conference Call (DACC). The DACC was a daily telephone conference which included reviewing logs opened or closed with domestic qualifiers. The DACC was attended by professionals from multiple agencies including social services, probation and housing. Logs were passed to a dedicated closure team who had the responsibility for checking these prior to closure. While the work carried out by the closure team was not reviewed as part of the investigation, a failure to identify domestic qualifiers was identified. Failure to correctly classify calls not only prevents the matter from being flagged up to the DAU, it also provides misleading statistics for Gwent Police in respect of the number of domestic abuse
Gwent police should ensure that all of the issues identified within the control room relating to classification, grading and closure of logs relating to domestic abuse are given due consideration. Call handlers must be adequately trained to ensure they recognise incidents related to domestic abuse, and that this needs to be added as a classification on the incident log. In addition the closure team must ensure they are correctly identifying calls that have domestic abuse related elements.
Finding 3 - DASH Submissions
IPCC investigators were not able to initially locate the DASH form submitted on 21 July. It was clear a DASH had been completed as this was reflected on both the call log and the DAU Guardian log. However, when a copy of the DASH was requested it proved difficult to locate it. The Inspector in the Domestic Abuse Unit stated it was only possible to search the DASH database on date or log reference, not by name of offender or victim or address. The DASH form was later located, however these restrictions with search parameters could cause potential problems for officers in Gwent.
Local recommendation 6
The system requires a review as officers require the ability to easily locate a DASH submission in order to review the information submitted
The investigation established that a DASH form was not submitted for at least one incident that could potentially have been classed as a domestic incident. The criminal damage to Woman L's clothing was clearly linked to domestic abuse, yet there was no consideration given to submission of a DASH form. The NPIA 2008 Guidance informs officers they must be alert to incidents that do not present as overtly domestic abuse. The guidance mentions criminal damage, assault and neighbourhood disputes as some of these incidents. The guidance goes on to say domestic abuse element and risk must be properly identified so the appropriate processes can be put in place.
Local recommendation 7
Domestic abuse training must be provided for all divisional officers. An audit of training records should be carried out to establish where there are any gaps, these can then be acted on, and officers provided with DASH training.
Notification of bail variation applications
The Crown Prosecution Service does not routinely notify police of applications to vary bail conditions in cases heard at the Magistrates' Court. Normal practice dictated that cases such as common assault would not be considered grave enough for police to be notified.
The area manager in the CPS administration team explained that the police would only be notified of an application to vary conditions depending on the nature of the application. For example, if there was a request to change a bail address, police would be asked to perform checks on the address. Woman L was not informed of the bail application by either CPS or the witness care unit. The Area Manager explained victims would only be consulted if there was any issue, or a doubt as to whether the variation should be opposed. CPS confirmed the court service should usually notify the witness care team of any bail variations but in this case there was no record this had taken place.
Neither Gwent Police nor Woman L were made aware of the hearing to vary the bail. They were not afforded the opportunity to inform the court of the allegations that Male Y had breached his bail on at least one occasion. Where a case is considered to be of such significant concern to warrant investigation by the SVCT it would be reasonable to expect the CPS to liaise with the police and inform them when any application is made to vary bail conditions. This communication would also ensure the police had the opportunity to notify the victim who may be in possession of additional information they wish to put forward at any hearing.
It is recommended that a working group is established to discuss whether a way of working could be achieved which would ensure the two-way sharing of information between CPS and police. With the introduction of the partnership between the SVCT and the DAU it is clear Gwent Police recognise the importance of robustly managing domestic abuse cases. In order for the management of domestic abuse cases to be effective and to provide a gold standard of service, it would seem sensible to introduce a procedure where CPS routinely inform the SVCT and or DAU of any applications to vary bail. Likewise police could routinely inform CPS of any additional incidents involving an offender on bail as and when they occur, rather than only at a court appearance, this would alleviate any possibility of pertinent information failing to be disclosed.
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