Domestic Homicide Review DHR03 - Executive Summary

Executive summary of a Domestic Homicide Review into the circumstances of the death of a 77 year old man on 3 October 2015.

Pseudonyms and condolences

It is the family’s wish the deceased in this case should be referred to as Wayne, the perpetrator as Joe, the sister of Joe as Tracey and the wife of Wayne as Shaney. The older brother is referred to as B.

The DHR Panel members express their sincere condolences to the family regarding the deaths of Wayne and Tracey.


Wayne was born on the 17 January 1938. At 1:44pm on Wednesday 16 September 2015 Northamptonshire Police were notified of an altercation outside his home address. Officers arrived and established that Joe, one of Wayne’s sons, had pushed his father to the floor following an argument; Joe had asked Wayne to take him to the hospital to see his sister, Tracey who was unwell. Wayne refused whereupon Joe picked up the family dog and threw it to the floor which led to the argument and the push. Wayne declined to pursue a complaint against his son; having recorded the incident and completed a pocket book entry to that effect which he signed. The throwing of the dog was considered to be a ‘one off’ incident acted out in temper and frustration. There is no suggestion of any animal abuse throughout this report.

Later that day Wayne was taken to Kettering General Hospital (KGH) due to pain in his hip. Once there it was established that he had fractured his hip during the fall as a result of the push by Joe and he was admitted to a ward. In hospital Wayne developed pneumonia and his condition deteriorated; he subsequently died on Saturday 3 October 2015. Joe was arrested and interviewed. He replied ‘no comment’ to all questions put to him. He was charged with the offence of Manslaughter. He was bailed to appear at Northampton Magistrates Court on the 18 January 2016. The Court hearing was delayed for some time due to various toxicological tests that were performed. A trial was set for March 2017 at the Crown Court where Joe pleaded guilty to the offence of manslaughter. On 16 March 2017, Joe was sentenced to 18 month suspended sentence and 100 hours community service.

A summary of the sequence of events

Wayne was 77 years of age at the time of his death. He was divorced from Shaney and had three children with her, two sons, B the oldest and Joe, and one daughter Tracey. It will be explained during this report that the daughter Tracey sadly died from a long standing illness a very short time before Wayne died.

Wayne had suffered a serious injury to his foot some years ago which limited his mobility and he was registered disabled in the 1960s and was in receipt of benefits. Although quite immobile, he could drive and owned a car.

Shaney described how she had suffered 48 years of serious physical and sexual abuse from Wayne. Joe had also been subject to long periods of abuse from Wayne. Tracey had learning disabilities and although Wayne did not abuse her, she witnessed years of abuse against her mother and brother Joe. The older brother B was at school during the abusive periods therefore he did not witness or was not subjected to any abuse. Wayne was arrested for two offences of grievous bodily harm and two offences of actual bodily harm on Shaney. These offences included stabbing her with a knife, inflicting blows to her head and wrist with a fire poker and a chair leg. He was convicted in August 1993 of assaults, no evidence being offered on the GBH offences and he was sentenced to a Probation Order for 2 years.

There are records of numerous domestic arguments and incidents within the family and trouble with neighbours. Tracey was subjected to abuse from neighbours regarding her disabilities which involved the police and the issue of Anti-Social Behaviour Orders. It was recorded that Shaney was having difficulty in coping with the rest of the family due to her fear of violence or the threat of violence. There was also some suggestion that Wayne had access to a firearm. A subsequent investigation found no evidence of a firearm or that Wayne had access to one.

Shaney was twice offered refuge accommodation by the Council in an attempt to remove her from her violent circumstances but she refused to move into a refuge.

Following the divorce from Shaney, Wayne went to live with his own brother for a time but that arrangement did not work out. Once he had left his brother’s accommodation, Wayne took to living and sleeping in his car. Joe was living in a one bedroomed flat rented from Spire Housing. Wayne moved in with Joe. Joe asked Spire Housing for permission which was refused on the basis that the flat was a one bedroomed accommodation and was not suitable for two people. That decision was later reversed and Wayne was allowed to stay with Joe.

On 23 October 2014, Tracey contacted the police following a domestic dispute with Wayne and Joe. Officers had concerns about her mental health and submitted an Adult Safeguarding form. The risk was assessed as standard risk.

On 10 December 2014, a Non-Molestation Order was issued preventing Wayne from seeing Tracey or Shaney.

During January 2015, Joe contacted Mind and he was advised to contact Citizens Advice Bureau but he failed to attend 3 weeks of a self-esteem course at Mind and was re-coursed. He had self-referred. He attended 3 peer support sessions and participated in the walking group on 8 and 15 May 2015. However, after that, he did not continue to attend or participate and did not respond to Mind’s attempts to contact him on 30 November 2015. He was discharged from Mind on 11 December 2015.

Adult Social Services IMR states that on 10 February 2015, a worker from the Young Adults Team of Adult Social Care, raised concerns about abuse of Shaney by Wayne as well as neglect of Tracey. A home visit was made and found that Tracey was sleeping on a sofa in the lounge and Wayne was also sleeping on another sofa in the same room. Wayne threatened the worker if she took Tracey away from the family by saying he would slit her throat and made threats that the two brothers, Joe and B, who Wayne described as ’nutters’, would get involved if necessary.

On 2 March 2015, Shaney and Tracey were evicted from their home due to unpaid rent. Wayne was by now living in Joe’s flat,

In June 2015, Tracey was admitted into hospital following a fall. Male members of the family were prevented from visiting her for fear of violence and intimidation towards Tracey.

In July 2015, the living conditions deteriorated in Joe’s flat. The bedroom became cluttered with furniture and clutter that it was inhabitable, so Joe slept on a sofa in the lounge and Wayne slept on a broken recliner chair also in the lounge. There were rent arrears mounting for the flat.

Wayne’s mobility became worse, so much so that when he was eventually seen by a nurse during a home visit, she found Wayne in a filthy condition with serious pressure sores. He was emaciated and had not changed his clothes for months. He had a problem with his personal hygiene. He told the nurse that Shaney was cooking his meals for him which clearly was not true. Joe told the nurse and a Spire Housing representative that he could not cope with looking after his father. Respite care was discussed with Wayne who stated that he preferred to be at home. He was found to have a grade 2 pressure ulcer to his sacrum.

On 31 July 2015, an Occupational Therapist visited Wayne at the flat. The door was unlocked and open allowing access. He was asleep on the chair. Due to the footrest being broken it was not possible to fit a pressure relieving mattress to the chair. He explained that his son was in the process of getting him a bed. There is nothing to suggest that the Occupational Therapist followed this up.

On 5 August 2015, a letter supporting a move for the two men to a two bedroom flat was sent from the GP and received by Spire Homes. It was at this point that Spire Housing conceded that the flat was not overcrowded and was suitable for two people and these arrangements were better for Wayne than living in his car.

In August 2015, Wayne was admitted to hospital because of the condition of his ulcers and pressure damage to his sacrum. He was dehydrated and had pitting oedema to his legs. The following day Wayne was discharged from hospital back to the flat. There was no suggestion that the GP was to continue treatment to the oedema to his legs or what circumstances had changed at home to make life easier for both Wayne and Joe.

Following his discharge Wayne was visited by a nurse who found that he was not eating properly and had clearly remained in the same chair for days. The nurse raised concerns about possible neglect and financial abuse of Wayne by Joe. She made a referral to Adult Social Care.

On 19 August 2015, a strategy discussion took place following the referral made. It was decided that the Safeguarding Adults Team should investigate the concerns.
On 20 August 2015, a social worker from the Safeguarding Adults Team visited Wayne at the flat. Joe was present. Wayne was found to be unshaven and wearing stained clothes. Wayne stated that his sister had his bank cards but had not returned the cards since he was discharged from hospital. He was unsure if his sister was spending his money but he didn’t want to inform the police as this would upset her. He also thought that she may be looking after the cards to prevent his sons getting them. He stated that he would get his own food and manage his own personal care but he was clearly unable to do so. He declined a referral to the Older Persons Team. The outcome of the investigation was the allegation was unsubstantiated and there was no need for a protection plan.

A further home visit by a nurse revealed that Wayne was not taking his diuretics as prescribed. Joe stated to the nurse that there was a chance that they could be made homeless and social services were helping them. An appointment was made for Wayne to see his GP on 25 August 2015, but he did not go. The following day the GP received notification that the hospital had discharged Wayne from the Intermediate Care Team as his condition was now stable.

The condition of Tracey was also deteriorating in hospital. Joe discovered how ill Tracey was and asked Wayne to take him to see her. Wayne initially said he would but changed his mind and refused to take Joe. An argument took place during which it is alleged that Joe threw the pet dog to the ground and then he pushed Wayne over. There is some suggestion that Wayne was on the floor, unable to get up for some time, but these facts are unclear. This incident happened in the street outside the flat.

An ambulance was called and ambulance personnel found that Wayne was a very frail man, who was in a dirty, unkempt condition, with filthy clothes and feet. On arrival at hospital he was found to have a sub capital fracture of his left hip. His bilateral lower limbs were swollen and he had sores under his feet probably caused by wearing the same socks and shoes for a long time. The living conditions were described by the paramedics as squalid. A safeguarding referral was made to Adult Social Care regarding possible physical abuse by Joe.

Two days later, medical staff determined that Wayne probably had pneumonia and indications were that he was of high risk of falls. On the same day, after consulting with Wayne’s own sister and his son B, ‘Do Not Attempt CPR’ documentation was completed as the medical opinion is that in the event CPR would not be successful.

Two days later medical staff was considering palliative care for Wayne, his condition had deteriorated so significantly.

On 23 September 2015, Wayne’s care was changed to ‘end of life care’ and the following day Tracey died in the same hospital.

Wayne’s condition continued to deteriorate. He died in hospital on 3 October 2015. A police investigation followed with a Forensic Post Mortem being carried out on Wayne the result of which showed he died as a result of septicaemia.

Joe was arrested and made no comment in interviews. He was charged with the manslaughter of his father and bailed to appear before criminal courts. A trial was set for March 2017 at the Crown Court where Joe pleaded guilty to the offence of manslaughter. On 16 March 2017, Joe was sentenced to 18 month suspended sentence and 100 hours community service.


All principle members of this family had health problems and their medical and mental needs were dealt with in isolation. There was no evidence of a holistic view of all of their needs.

The same can be said for Spire Housing who lacked an overview of the needs of Wayne and Joe, especially when the physical health and wellbeing of Wayne was realised. It was clear that Joe was not able to cope with his father’s needs and the housing conditions in which they both lived was wholly unsuitable for these two men.

Adult Social Care made home visits and could see the conditions in the flat but considered that there was no need for concern. It was later when paramedics attended to Wayne following the dispute with Joe, that they described the conditions in the flat as being ‘squalid’.

Wayne was admitted to hospital with serious pressure sores and leg problems. He remained in hospital overnight but discharged the following day back to the flat he had been taken from. There does not appear to have been any assessment about his ability to care for himself or to what extent he could be cared for by his son Joe.

A MARAC meeting was convened in November 2014. Wayne’s situation deteriorated after that day and the need for a further multi-agency forum was not recognised despite all of the facts that were known at that time.

Tracey’s admission to hospital resulted in a restriction on the male members of the family visiting her or knowing her whereabouts. This was due to her fear of threats and intimidation from them. That fact was known and there was no evidence of any assessment or review of those circumstances that may have uncovered the extent of the abuse from Wayne that is known now, purely from the disclosure made by Shaney and Joe after the criminal proceedings had been completed.

Although Wayne was accused of abusing and ill-treating Shaney and to an extent Tracey, he became a victim once he moved into the flat with Joe. The incident that led to his injury resulting in his death was one of him being pushed by Joe in frustration because Wayne had refused to give Joe a lift to hospital to see his daughter who at that time was terminally ill.


Despite intervention Wayne’s vulnerable situation was not recognised by Adult Social Care or any other agency. His living conditions were totally unsuitable and the risk to his health not acknowledged. The housing association ignored the fact that he was living with his son despite being initially told that he could not live there.

Wayne was admitted to hospital from the flat due to his ailments caused by living the way he was, only to be discharged back to the flat days later.

The details of Wayne’s violent history involving Shaney was not known to many agencies. Only health had an insight into Shaney’s problems from historical reports. Many of her disclosures were made at a time when professionals responded to domestic abuse in an entirely different way. It may be said that if these incidents were reported today agencies would take a more proactive and positive stance.


The panel are content that all of the issues identified within this report that require mentioning in form of recommendations are dealt with accordingly and effectively within IMR recommendations. IMR author were encouraged to identify areas that required improvement or where learning was necessary and to include them in the respective IMR recommendations. Therefore the Panel and the East Northampton Community Safety Board were satisfied that all aspects of learning, change and improvement were included in the action plans for agencies and it would have been repetitive for Overview recommendations to addressing the same issues to be made.

Recommendation 1

Safeguarding concerns and referrals should be documented in the patient’s notes to increase communication and information sharing across teams and also communicated to the trusts safeguarding team.

Recommendation 2

When referring a patient to another provider, concerns around safeguarding issues should be clearly documented and shared with other professionals.

Recommendation 1

Safeguarding concerns and referrals should be documented in the patient’s notes to increase communication and information sharing across teams and also communicated to the trusts safeguarding team.

Recommendation 2

Update Interagency staff procedures on self-neglect to reflect the latest research and professional guidance, along with the updated Care Act guidance.

Recommendation 3

Take steps, through training and staff workshops, to fully embed the changes in assessment, carer’s assessment, safeguarding and other areas, ensuring that ASC practice fully reflects current legislation and best practice.

Recommendation 4

Ensure robust quality assurance and oversight once the safeguarding transformation plan has been fully implemented.

Recommendation 1

GPs to be reminded that if someone presents with an injury, that the reason or context of the injury is clearly documented, even if the person declines to inform the GP of how it was sustained.

Recommendation 2

GPs to be reminded to access advice and support from other multi-agency partners when complex families present with domestic violence issues.

Recommendation 3

GPs to be reminded of the management of high risk domestic violence cases through the MARAC process.

Recommendation 1

Risk Management Policy: Review and update if appropriate.

Recommendation 2

Domestic Abuse Risk Policy: Not currently available. This could be beneficial both in the formulation of the policy and subsequent training for staff.

Recommendation 3

Staff training: Staff development plans required.

Recommendation 1

Spire Homes would recommend that agencies involved in safeguarding issues consider the need where appropriate to involve social landlord partners. If there had been concerns around the living conditions, then as landlord we may have had possibilities for intervention.

Recommendation 1

All officers and staff should be reminded of the importance of submitting Form SA1 where appropriate.

Recommendation 2

The Safeguarding Adults Unit should undertake an audit of referrals to verify compliance with the current policy.

Recommendation 3

An audit should be undertaken to check compliance with the Safeguarding Adults referral policy paying particular attention to DA related incidents.

Recommendation 4

Review DA / MARAC processes to identify cases where intervention opportunities linked to vulnerability are correctly identified and actioned.

Recommendation 1

Clinical staff to be encouraged to explore the possibility of Domestic Abuse (DA) during assessment and care delivery, mindful of the indicators of DA at all times and recognise their role in escalation of same.

Recommendation 2

Clinical staff to ensure consideration of the role and involvement of carers and reflect this clearly in their documentation to include any concerns regarding the risk from the family and the capacity in which they are empowered to act.

Recommendation 3

Staff should be aware of how to recognise and raise a Safeguarding concern, and retain this information within a dedicated area of the patient medical records.

Recommendation 4

Staff to contact Named Nurse Safeguarding Adults where concerns may have been raised by Partner agencies in order to confirm receipt of the concern with Northamptonshire County Council (NCC).

Recommendation 5

Increase awareness of the need for professional curiosity where there is conflicting information or concern regarding injury or circumstances of the individual.

Last updated 26 October 2022