Domestic Homicide Review DHR01 - Executive Summary

Executive summary of a Domestic Homicide Review into the circumstances of the death of Jane aged 62 years in August 2019.

Pseudonyms and condolences

The Domestic Homicide Review Panel expresses their sincere condolences to the family of Jane, who died in August 2019.

The family have chosen the pseudonym Jane for the victim.


This Domestic Homicide Review concerns the death of Jane, aged 62 year who died in hospital in August 2019 of natural causes. She had lived for many years with her partner in his house in Northamptonshire. She was a Health Care Assistant at a local hospital. Jane was a white British citizen.

Enquiries made into the circumstances of Jane’s death uncovered significant evidence of coercive controlling behaviour by her partner over a long period of time, something the partner emphatically denies.

It is known that Jane had an alcohol misuse problem and an eating disorder and her partner’s view is that his controlling behaviour was to ensure that she would eat regular meals and by doing so, he was preventing her from becoming ill.

Summary of events

As stated in the Overview Report, information obtained from agencies and from Jane’s family suggest that the Partner’s behaviour towards her met the criteria of coercive and controlling behaviour as defined by the Serious Crimes Act 2015, thus justifying this review to be undertaken. The partner, however, refutes that any of his actions were coercive and controlling and what he did was in the best interests of Jane who lived with an alcohol problem as well as other illnesses. It is not the position or role of the Domestic Homicide Review or its panel to make a judgement as to who’s version of events is to be believed and the facts are set out from both sides in an accurate and unbiased manner.

The sequence of events start in 2010, with frequent neighbourly disputes where the partner claimed that damage was being caused to Jane‘s car. As a result of that the partner installed CCTV around his house and even inside Jane’s car. The partner called the police on numerous occasions to report the damage but there were no visible signs of damage to Jane’s vehicle. 

The partner, on one occasion, being convinced that damage was being caused to Jane’s car whilst she was at work at the local hospital, aggressively complained to the security at the hospital and he demanded the security pay attention to her car to prevent it from being damaged. The partner’s obsession with CCTV eventually extended to him installing cameras around the house and in Jane’s bedroom.

The Police were called to the house of the partner on several occasions following domestic arguments and incidents between him and Jane. These usually resulted in Jane not assisting the Police with the completion of DASH risk assessment forms.

On one occasion the partner threatened to complain to the Independent Police Complaints Commission for the lack of action being taken by officers who attended the domestic disputes due to Jane not wishing to pursue a complaint.

It wasn’t until August 2011, when officers were called to another domestic incident and Jane was spoken to alone, that she disclosed about the partner’s overpowering, controlling and influencing behaviour. She was convinced that the disputes with the neighbour was somehow a way of him controlling her.

In October 2011, Police received information that Jane was sleeping in her car overnight and 5 days later she reported being assaulted by her partner, causing injury to her fingers. She was taken to hospital, but no treatment was required to a cut to her finger. Apparently, her partner had asked her to leave the house and had grabbed her finger causing a slight injury. Jane stated the injury was accidental and no further action was taken.  

In June 2012, as a result of the execution of a firearms warrant at the partner’s house where officers were looking for gas canisters, Jane told officers of her partner’s controlling behaviour towards her. He didn’t allow her to drive her car, she had no keys to the address, she had no access to her own money, she was not aware of passwords for her own financial accounts and her partner did not allow her to use the telephone to call her family. She disclosed that she was drinking alcohol secretly in order to cope and that the partner had stopped her from attending dancing classes. A referral was made to the domestic violence unit.

Suitably trained officers were in contact with Jane and she mentioned that her own children did not visit her as this would cause problems with her partner. She stated that he called her names and constantly belittled her. It was clear that she was constantly petrified of her partner and his possessive behaviour.

On another occasion in December 2012, officers attended the address for another domestic incident. They found the partner had removed the door to the Jane’s bedroom. When questioned about that by the Police, he said it was his house and he hadn’t caused any damage

Police continued to attend calls to the address for domestic incidents throughout 2013 and into 2014.

In April 2014, the partner called the Police saying Jane was drunk. She was seen and repeated details of the controlling behaviour of her partner, which now had extended to following her to work and waiting outside her work for her to finish, removing batteries from her mobile phone and isolating her from her friends and family. 

During May 2014, Police were called to the house on numerous occasions for domestic arguments between Jane and her partner. The officers noted a CCTV system in the house as well as a Dictaphone that was apparently recording the incident and the Police response. On one occasion Jane was very drunk, and she was removed to the Police station to prevent a breach of the peace. She was released when she was sober but immediately returned to the house and was rearrested and appeared before the Magistrates Court. 

In August 2014, an alert was put on record at the local hospital where Jane worked to the effect that if she shows any sign of injury, the management were to contact the Police. Later that month Jane attended Change Grow Live, S2S (Substance 2 Solutions) with her partner. There is nothing to suggest she was seen alone. At subsequent visits to CGL, she reported a reduction in her alcohol consumption, and she continued to keep appointments with her GP.

The domestic incidents continued into 2015, but on the majority of occasions when the Police attended, Jane was reluctant to pursue any complaint against the partner.

In March 2019, the partner wrote to Jane’s GP saying that she was an alcoholic and requesting the GP to do something about it. The GP telephone Jane and she described her situation at home. It was clear that Jane’s manager at work was supporting her as much as she could.

The partner again wrote to the GP about Jane’s health but the GP advised the partner that there was no consent to share medical information.

Later that month Jane saw the GP and described the extent of the coercive and controlling behaviour from the partner. She was given contact details for a Northampton Domestic Abuse Service (NDAS). On returning home from the surgery she found she had been locked out by her partner. The partner had become angry, threatening, and intimidating.

On the 20th March 2019, the GP tried to telephone Jane without success. As this was happening a member of the public called the Police reporting a lady slumped in the foot well of her car on a shopping centre car park. There was an empty bottle of wine next to her. Police attended and found Jane in her car. Officers persuaded her to see her GP who made a referral to Adult Safeguarding and The Sunflower Centre.

On the 26th March 2019, a request was made to EMAS for an ambulance to attend to outside Jane’s house where she had again been found slumped over the steering wheel of her car. By the time they had arrived she had moved into the house but due to her condition and appearing very slim and obviously not eating well, EMAS staff made a referral to Adult Social Care and the GP. 

Three weeks later, on the 12t April 2019, EMAS were again called, this time to the house where Jane was on the floor of her bedroom. She was taken to KGH with suspected sepsis, for her-self neglect and for alcohol detoxification. A Safeguarding for Vulnerable Adults (SOVA) was completed as Jane disclosed abuse by her partner.

Three days later on the 15th April 2019, Jane was transferred to the digestive disease unit where referrals were made to a dietician, to S2S and to Adult Social Care.

Whilst in hospital it was noted that Jane had marks and bruises on her back, spine, arms and her side. It was considered that these marks could have been caused by the use of Enoxatarin injections.

Jane was discharged from hospital on the 18th April 2019.

In June 2019, Jane’s GP contacted her by phone regarding the extension of her medical certificate for her work place. The partner had made a complaint to the NHS England regarding issues he had with Jane’s GP and she told the GP that she had been forced to sign a medical consent form for medical consent to be disclosed to her partner.

On the 10th July 2019, the partner again called EMAS concerned about the Jane’s physical and mental health and on arrival the EMAS crew noted four areas of concern.

  • Jane was still using alcohol daily and had been for a number of years which resulted in liver damage.
  • Jane was not eating and the partner alleges he was finding food in her pockets
  • Jane’s behaviour is odd. She drives to a supermarket and sits in her car on her own for several hours. Her mood swings from passive to verbally aggressive.
  • She was non concordant with her medication

The EMAS crew determined Jane was extremely thin with a distended abdomen and a raised temperature. All of this information was referred to Adult Social Care and the GP.

In August 2019, the partner called EMAS again concerned about Jane being unwell. The EMAS crew liaised with the GP who persuaded her to go to hospital. As the EMAS crew were concerned about Jane’s heath and self-neglect and personal hygiene, they completed a care concern. On arrival at hospital she was referred to urgent care and a ‘Do Not Attempt Pulmonary Resuscitation’ form was completed. She had Decompensated Chronic Liver Disease and Peritonitis.

Over the following days, Jane’s condition deteriorated, and she died in August 2019. Her death was recorded as primary-peritonitis and secondary comorbidities of alcoholic liver disease, malnutrition, alcohol mental disorder and chronic pancreatitis.

A Police investigation into the allegations of coercive and controlling behaviour by the partner was launched in September 2020 and resulted in there being insufficient evidence to meet the threshold for prosecuting the partner. The Serious Crime Act 2015 does not allow evidence of coercive and controlling behaviour committed before the implementation of the Act to be considered. No further police action was taken.

Views of Jane’s family and the partner

Jane’s family have been involved with this review from its commencement and they attended a virtual panel meeting in December 2021. The Overview Report contains a lengthy account from Jane’s son and daughter in which they explain how the partner separated them away from their mother and controlled her daily life. They also explain how at the end of a telephone conversation their mother would say out loud ‘Good bye to (partner)’ making the partner believe that the son or daughter had said that. More detail of the views of the son and daughter are contained in the Overview Report.

The partner has engaged with the author of the review by telephone and email on several occasions. In March 2021 he  submitted a 19 page document setting out his version of events saying that whatever he did and how ever he treated Jane it was in her best interests and he did so to help her stop drinking alcohol and to make sure that she was eating proper meals. Again a more detailed account of his contact with the review is contained in the Overview report.

The partner has been provided with a copy of the Overview Repot for his comments. He has replied by letter saying that he does not agree with any conclusions. His letter is attached as an appendix to the Overview Report.


As the Sequence of Events in this report illustrates there was considerable concern that the partner was using coercive and controlling behaviour for almost all of the time that he and Jane were together in this relationship. As a result of the Community Safety Partnerships decision to commission a Domestic Homicide Review and as the natural cause of the review took place information was obtained from various agencies that Jane had been in contact with. That information contain evidence to suggest that the partner’s behaviour constituted behaviour as outlined in the Serious Crimes Act 2015.

Section 76 of The Serious Crimes Act 2015 received Royal Assent on 3rd March 2015 and created an offence of controlling and coercive behaviour in intimate or familial relationships. The new offence closed the gap in the law around patterns of controlling and coercive behaviour and carries the maximum sentence of 5 years imprisonment, a fine, or both.

The offence is committed by a perpetrator who repeatedly and continuously acts in a coercive or controlling way. The victim and perpetrator must be personally connected at the time of the behaviour taking place and the behaviour must have had a serious effect on the victim. This means that it caused the victim to fear violence on at least two occasions or that it had a substantial adverse effect on the victim’s day to day activities. The perpetrator must have known that their behaviour would have a serious effect on the victim or that the behaviour must have been such that he ought to have known it would have had that effect.

Typical behaviour associated with coercion and control are described in the act to include

  • Isolating a person from their friends or family
  • Depriving them of their basic needs
  • Monitoring their time
  • Monitoring a person with on line communication tools or using spy wear
  • Taking control over aspects of their daily life such as where they can go, who they can see, what to wear.
  • Depriving them of access to support services
  • Repeatedly putting them down, belittling them
  • Using behaviour humiliate or dehumanise the victim.
  • Financial abuse including controlling their finances
  • Threats to hurt or kill
  • Assault, rape, criminal damage etc

The Overview report makes reference to the possibility of the partner’s action and behaviour constituting abuse known as ‘gaslighting’. Gaslighting’ is a form of persistent manipulation or brainwashing that causes the victim to doubt themselves and to ultimately lose one’s own sense of perception, identity and self-worth. ‘Gaslighting’ statements and accusations are usually based on blatant lies or exaggeration of the truth. It can be seen that a number of the above illustrations of behaviour were present in this relationship. However, there are some examples of this behaviour that evidently took place before March 2015 and as far as a Police investigation is concerned such incidents cannot be considered in the overall case assessment.

Northamptonshire Police conducted a thorough investigation with the information that came to light as a result of the DHR process, but with the caveat of being unable to consider examples of the behaviour before March 2015, a decision was made that the evidence that was pertinent did not meet the threshold for a criminal prosecution.

The partner was interviewed under caution about those incidents that were relevant but he maintained that there was no criminal intent involved and that his actions were in ‘Jane’s best interest’ in order to keep her safe and well, help her stop drinking alcohol and to ensure that she ate a balanced diet. With regard to the CCTV surveillance the partner’s view was that this was to monitor her drinking habits.

However, it is only right that this report presents a balanced view of the information available from agencies, Jane’s family and associates, research, but also that from partner. The partner’s views are contained in a section of this report specifically dedicated to his account.

It is intended to look at the various aspects of this relationship that pertained to the list of behaviours as outlined above.

Financial control

In June 2012 when Police executed a Firearms warrant at the partner’s house, Jane approached the officers and disclosed that he would no longer allow her to drive her car because of the alleged damage caused to it. He prevented her from using the landline to telephone her family, she had no access to her own money, and she was not allowed to know her own passwords to her own financial accounts.

Fontes states

an abusive man might isolate a woman by controlling her finances, denying payment for basic needs or taking away her money.Fontes stated

Jane’s daughter told the Overview Report Author that two days before she died, the partner had removed £36,000 from her account to his account. In a Police interview the partner explained that a banker’s card for that account had been lost and he moved the money for safe keeping but had replaced it into her account a short time later.


In April 2014, when officers attended a domestic dispute Jane disclosed that the partner had removed the light bulbs from her bedroom and installed CCTV inside the house. He would follow her to and from work, removed the battery from her mobile phone to prevent her from using it and isolated her from her family. 

Not only did Jane tell officers that the partner was isolating her from her family, she also reported the same to her GP. Jane’s children describe how they stopped going to see their mother because they knew that the partner objected to her contacting her family and it would make things worse for her if they did visit. In April 2019, Jane explained to a registered nurse that she knew that her family were concerned about her home environment.

might try to persuade the mother that her attachment to her children is unhealthy or unnatural and interferes with their life as a couple. He might force the woman to constantly choose between siding with her child and siding with him or between spending time with her child and spending time with himFontes is of the opinion about a controlling coercive partner

Jane’s family describe initially how the relationship between Jane and partner appeared to be good and it was sometime before she mentioned anything to her children about the details of her relationship.

It is uncomfortable for a woman to tell her family the details of her partner’s abuse of her. She feels ashamed and wants to avoid them having them ask ‘why are you with him?’ But the abuser can take advantage of how much her family do not know.Bancroft states

Belittling and Degrading  

In December 2012 when Police responded to a domestic incident, they found Jane in her bedroom and noticed the door had been removed. The partner stated that he had removed it and when questioned why he said it was his house and no damage had been caused. When asked about the removal of the door, the partner said that some of his doors had swollen and would not shut so he had removed them. The bedroom door was the only one that had been removed at that time. The removal of a bedroom door could be considered an act of degrading control. Whilst at her GP’s surgery in October 2014, Jane reported that she was a victim of emotional abuse from partner, and in April 2019 whilst at the KGH, Jane reported to a ward sister that the partner called her names. The sister made a referral to NCC customer services unit. 

According to Fontes belittling and degrading behaviour involves treating someone as an inferior and men who use coercive control deliberately belittle or degrade their partners to establish ‘ownership’ and ‘moral superiority’ damaging the woman’s self-respect.

Name calling, belittling, attacking their self-confidence, humiliating them in front of others are all common behaviours among abusive men.Bancroft opinion

Monitoring and surveillance

Throughout the Sequence of Events references are made to the partner installing CCTV on the outside of the house potentially with regard to the alleged damage being caused to Jane’s car. It became apparent however, that the installation of CCTV was extended by the partner to areas inside the house and in the Jane’s own car. This was noticed by officers when they attended in April 2014 and on the same occasion officers noticed a Dictaphone being used by the partner to record conversations within the house. Jane’s family told the Overview Author that on the occasions, she was allowed to contact them by telephone or when the family rang her, the partner would insist that the conversation was conducted with the loud speaker turned on so that he could hear everything that was being said.   

The partner’s monitoring Jane extended to him following her to and from her place of work and the reason behind his visit to the security office at the hospital where she worked could have been to monitor her movements.

According to Stark these types of surveillance techniques inject fear into abused partners. Stark maintains that surveillance of one sort or another is almost universal in abusive relationships.                                                                               

It is interesting to note that on several occasions when Police were called to the house officers commented that on their arrival the partner was in the street or at the front door waiting for them and was quick to give an explanation of Jane’s behaviour or alcoholic state before the Police had opportunity to speak to her. On occasions the partner acted in a similar way when EMAS attended his home address.

Unfortunately an abuser can sometimes succeed in convincing people that the partner is so irrational and out of control that her judgement is so poor that she has to be saved from herself. Never believe a man’s claim that he has to harm his partner in order to protect her; only abusers think this way.Bancroft interestingly observes

Given that arrests for domestic abuse specifically focusing in coercive and controlling behaviour are nationally low, around 3% of all arrested for domestic abuse and the report makes a recommendation that all agencies should review their domestic abuse training to ensure that coercive and controlling behaviour is enshrined into training.


All agencies review their domestic abuse training to ensure that coercive and controlling behaviour is seen as a major focus of that training.

In conjunction with training there is a need for a campaign to be lunched by all agencies to raise awareness specifically about coercive and controlling behaviour.

All agencies in Northampton to combine under the lead of NDAS to create a county wide publicity campaign regarding domestic abuse but in particular the signs, symptoms and outcomes of coercive controlling behaviour. The campaign should consist of leaflets, posters and seminars to inform the public of this kind of domestic abuse and how to seek support from agencies.

In accordance with the Prevention priorities, early identification of victims of domestic abuse and intervention is critical. In support of this Northamptonshire Police, the Adult Safeguarding Board and other agencies have introduced a MADRA process, (Multi-Agency Daily Risk Assessment. All high and medium risk Domestic Abuse Notifications where children are present or involved are progressed through the MADRA meeting since end of March 2020. The MADRA meeting will also progress standard risk Domestic Abuse notifications where there have been 3 incidents of Domestic Abuse within a 12-month period and those where professional judgement applied identifies risks to the child/ren. There needs to be an extension of this process to include identified vulnerable adults to ensure that such people are identified at the earliest opportunity and therefore receive the appropriate care and support needed.

Consideration to be given to extend the MADRA (Multi-Agency Daily Risk Assessment) process to include identified vulnerable adults where early intervention by services and support can be offered and given.

There were occasions when opportunities to consider the possibility of domestic abuse, particularly coercive and controlling behaviour by the partner towards Jane were missed and where a more curious, enquiring approach may have identified risks that she faced in her relationship with him. The installation of CCTV in her car and around the house and the removal of Jane‘s bedroom door as witnessed by police officers, may have raised suspicion of the existence of controlling behaviour. The constant complaining about neighbours and the allegations of damage being caused to Jane’s car and thereby the excuse to install CCTV may have given clues about the relationship between Jane and the partner. There were also occasions when as referral could have been made to MARAC: June 2015 and April 2019. 

All agencies should be encouraged to ensure that their individual training on domestic abuse re-enforces the importance of professional curiosity and lateral thinking.

All agencies are to ensure that training regarding domestic abuse stresses the importance of professional curiosity and lateral thinking so as to ensure that indicators of abuse are not missed.

In 2015 there was a missed opportunity by S2S to make a MARAC referral. So too in 2019 when KGH could have made a similar referral. It may have been the case that more frequent referral by agencies to MARAC may have resulted in the fuller picture of what life was like for Jane and thereby a more positive and supportive response given to her.

All agencies to ensure that Domestic Abuse training is to include an update on the use of MARAC referrals, the process, the outcomes of a referrals and the benefits that may result from the referral process.

The Sunflower Centre had significant dealings with Jane all of which were in line with the Sunflower Centre Case Management Policy. The Sunflower Centre, after examining their dealings with Jane make the following recommendations:                      

  • Regular coercive control training to be delivered to all Sunflower Centre staff including the MARAC Team.
  • Data recording instructions within Case Management Policy to be updated and staff to be reminded of recording responsibilities.
  • Source additional Mental Awareness Training
  • Identification of primary victims in cases to ensure appropriate support is provided.

Northamptonshire Adult Social Services also had dealings with Jane and a review of those dealing result in the following recommendations being made:

  • Northamptonshire County Council Customer Service Centre (CSC) to have a better awareness of risk, exercising professional curiosity, safeguarding processes, and assessing cumulative information organised by a lead social worker.
  • A monthly auditing of decision making by the Pro-Support Team in CSC.
  • Northamptonshire Safeguarding Adult Board Quality and Performance Sub-group to provide additional training for staff around the new Adult Risk Management (ARM) toolkit (Safeguarding Adult Review reference 016 2020 has made similar recommendations)
  • NCC ASC Team to be reorganised in line with the move to a Unitary Authority in April 2021.
  • To embed into policy Adult Social Care’s revised Serious Incident Policy to ensure that IMRs are systematically and routinely actioned in all cases.

Northamptonshire Police make one recommendation:

  • It is recommended consideration be given by Northamptonshire Police to the use of a Single Point of Contact (SPOC) in cases where there is a high frequency of incident occurrences where controlling or coercive behaviours is suspected. This could prove beneficial in terms of gaining a victims trust thus empowering them with confidence to provide comprehensive and coherent evidence to be gathered effectively.  

The following agencies have examined their dealings with Jane and have concluded that there are no recommendations to be made:

  • East Midlands Ambulance Service
  • Kettering General Hospital                          
  • S2S                                                    
  • Northampton Domestic Abuse Service
  • GP Practice
  • Kettering General Hospital
  • Northamptonshire Health Foundation Trust


As mentioned on previous pages of this report, the facts as set out are an illustration of information the DHR Panel has obtained from agencies, from accounts from Jane’s family, friends and colleagues and also from the version of events given by the partner.

The account from the partner differs considerably to that given by Jane’s family. It is not the position of the DHR Panel to make judgement on which version is factual and correct. The role of the panel in this case is to report accurately what has been recorded and said, to make recommendations based on that information and to present equally all accounts for consideration.

Overview Report recommendations have been made on the basis that the information gathered identifies areas where services could be improved. That is also the case for those agencies that have made internal recommendations.

The report recognises that the police investigation was unable to gather evidence that reached the threshold for any criminal offence being identified and no charges have been brought against the partner.

The report also recognises that the circumstances, allegations and disclosures made by Jane do satisfy the requirement for a review as set out in the Home Office Guidance of 2016.

28 December 2023

Antonia Malpas
Safer Corby Manager
North Northamptonshire Council
Deene House, Corby,
NN17 1GD

Dear Antonia,

Thank you for resubmitting the report (Jane) for North Northamptonshire Community Safety Partnership to the Home Office Quality Assurance (QA) Panel. The report was reassessed in December 2023.

The QA Panel felt that it was a good report with a clear, easy to read chronology and appreciated the footnote explaining why Panel members are not named. The report also benefitted from the participation and contribution of Jane’s family and the sensitive and impactful tribute that they provided to their mother. This helped to provide a powerful picture of Jane as a mother, friend, and work colleague.

The report also provided good analysis and recommendations around controlling and coercive behaviour. The updated action plan provides a full outcome of the recommendations and is helpful regarding areas for development.

The Home Office noted that most of the issues raised in the previous feedback letter following the first submission have now been addressed.

The view of the Home Office is that the DHR may now be published.

Once completed the Home Office would be grateful if you could provide us with a digital copy of the revised final version of the report with all finalised attachments and appendices and the weblink to the site where the report will be published. Please ensure this letter is published alongside the report.

Please send the digital copy and weblink to [email protected]. This is for our own records for future analysis to go towards highlighting best practice and to inform public policy.

The DHR report including the executive summary and action plan should be converted to a PDF document and be smaller than 20 MB in size; this final Home Office QA Panel feedback letter should be attached to the end of the report as an annex; and the DHR Action Plan should be added to the report as an annex. This should include all implementation updates and note that the action plan is a live document and subject to change as outcomes are delivered.

Please also send a digital copy to the Domestic Abuse Commissioner at [email protected]
On behalf of the QA Panel, I would like to thank you, the report chair and author, and other colleagues for the considerable work that you have put into this review.

Yours sincerely,

Home Office DHR Quality Assurance Panel

Last updated 27 March 2024