APPENDIX 6
Memorandum submitted by the Independent
Police Complaints Commission
1. The Independent Police Complaints Commission
(IPCC) is a non-departmental public body which became operational
on 1st April 2004. The IPCC is funded by the Home Office, but
by law is entirely independent of the police, interest groups
and political parties and its decisions on cases are free from
government involvement.
2. The IPCC has a legal duty to oversee
the whole of the police complaints system created by the Police
Reform Act 2002. Our aim is to transform the way in which complaints
against the police are handled.
3. A vital part of the complaints system
is to ensure that recommendations and lessons learned from complaints
and subsequent investigations are highlighted, implemented and
disseminated across forces nationally. A Learning the Lessons
Committee consisting of the IPCC, Association of Chief Police
Officers (ACPO), Her Majesty's Inspectorate of Constabulary (HMIC),
Association of Police Authorities (APA), National Policing Improvement
Agency (NPIA) and the Home Office have been studying how to share
lessons effectively.
4. The IPCC, under the aegis of the Learning
the Lessons Committee, is establishing a system under which organisational
learning gleaned from conduct investigations carried out by the
IPCC, police forces, Serious Organised Crime Agency (SOCA) or
Her Majesty's Revenue & Customs (HMRC) is collated. The Learning
the Lessons Committee will draw on these reports to produce Learning
the Lessons bulletins, which will provide an insight into cases
where things have gone wrong and act as a conduit for improving
policing practice by demonstrating where action may need to be
taken.
5. The first of these bulletins was published
in June 2007 and focussed on the police response to the victim
in cases of domestic violence. In addition to containing case
studies, it provides an overview of common themes and points for
learning. Future bulletins may also be on a specific theme or
more general in nature, depending on what issues arise in the
course of investigations.
6. The 10 cases featured within this first
Learning the Lessons bulletin focussed on the response of the
police to the victim. Historically, this was an area that gave
rise to serious failings in policing. It is acknowledged that
great progress has been made in recent years following detailed
guidance introduced by ACPO in 2004 and its statutory reinforcement
by the Domestic Violence, Crime and Victims Act 2004.
7. The cases selected for inclusion within
the bulletin do however suggest that there may still be some way
to go before good practice is embedded and consistent throughout
the police service.
LEARNING THE LESSONS BULLETIN 1 JUNE 2007
DOMESTIC VIOLENCE
1. HEADLINES
A brief outline of recurring concerns in the
cases in this bulletin, and related learning, follows—more
detail can be found on these concerns at pages 5 and 6 and on
recommendations in the reports.
1.1 Holistic approach
Concern
Lack of a co-ordinated overview of all relevant
incidents and intelligence by staff with specialist training in
domestic violence.
Learning
Role of the domestic violence unit crucial to
an inclusive and co-ordinated response to domestic violence, but
active supervision needed generally to ensure follow through of
incidents.
1.2 Record keeping Concern
Failure to capture and accurately record the
nature of an incident/series of incidents.
Learning
Full and accurate recording essential, otherwise
intelligence cannot be assessed and cross-referenced.
1.3 Awareness of triggers and risk indicators
Concern
Lack of awareness of the circumstances likely
to trigger domestic violence and failure to recognise factors
in perpetrator's history that showed a need for intelligence in
order to assess risk.
Learning
Greater awareness of domestic violence triggers
and risk indicators critical if such tragedies are to be avoided
in the future.
1.4 Arrest
Concern
Opportunities to arrest missed, sometimes repeatedly.
Learning
Adopt positive action policy—consider
arrest for breach of bail conditions regardless of the victim's
wishes—and pursue search/arrest strategies on a consistent
basis.
1.5 Risk Assessment
Concern
No risk assessment/risk assessment informal
or based on partial evidence/no review on escalation of violence.
Learning
Immediate response operational police cover
not enough, staff need specialist training in domestic violence
to ensure effective risk assessment.
1.6 Proactive investigation/resources
Concern
Failure to pursue investigation effectively
or provide adequate support to victims, often because of insufficient
resources.
Learning
Make early contact with the victim, assess and
proactively investigate in a proportionate and professional manner—vital
to allocate sufficient resources for these purposes.
1.7 Interaction with other agencies
Concern
Poor communication between the police and other
agencies.
Learning
Need for force to share intelligence with other
forces, also for agency to be aware that someone has been professionally
assessed as a serious risk to bring this to the attention of police
at a senior level.
2. CASE SUMMARIES
2.1 Keeping a search/arrest strategy going
A man released from prison on licence condition
that he lived at a named address in England travelled immediately
to Northern Ireland. There he committed and was arrested for an
assault on his landlady. A notice to recall him to prison and
a warrant for his arrest were promptly issued and the UK authorities
alerted via the PNC. Despite this he was given a suspended sentence
on conviction for the assault and released without the recall/arrest
being implemented or the authorities notified.
He returned to England, still listed as wanted.
The police were alerted when he applied for social housing. The
police were told that he was not in the hostel where he was in
fact living and did not visit the hostel to check. Later, he murdered
his partner and it then came to light he was wanted on recall
to prison for the breach of his licence condition.
Key lesson is the need for robust processes
to keep a search/arrest strategy going, including closer co-ordination
between the police and other MAPPA partners (information sharing,
thorough physical checks etc) and inclusion of people circulated
as wanted by the probation service on forces' local wanted persons
systems.
2.2 Co-ordinating the police response
A woman had complained to the police over a
number of years about incidents involving her ex-husband, including
threats and an assault. A silent 999 call was received from her
address. After attempts to get a response failed, the call was
logged but not referred for action.
Later that morning a neighbour called about
a woman screaming at the address. This was logged as a domestic
incident. The call was marked for immediate action and recorded
as assigned. It is not clear whether it was in fact assigned and
no vehicle responded. This was only discovered at about 3 pm.
A unit was then assigned to attend.
Meanwhile, the sister of the woman living at
the house had rung that afternoon to report her as missing. She
told the police about the previous domestic violence. The call
was graded "S" (as soon as possible and in any case
within one hour) and arrangements made to meet the caller at the
house. Meanwhile the unit responding to the neighbour's report
arrived and met the caller there. The officers at the house were
not aware of the missing person report and the caller was not
aware of the neighbour's report. Despite signs that something
was amiss, the officers let the caller walk ahead into the flat.
She found her sister stabbed and strangled, murdered by her ex-husband.
Key lessons are the need not to deal with incidents
in isolation without reference to previous intelligence; to ensure
effective corporate management of the Computer Aided Despatch
system and silent calls; to assess a possible crime scene fully
before allowing a member of the public to go ahead of police.
2.3 Recognising where urgent action needed
A woman was stabbed to death by her ex-partner
after a series of complaints she had made to the police about
domestic violence and harassment by him.
Two weeks before, she had reported the brake
pipes on her car had been cut. The police did not take a statement
until three days later. A handover statement was then left in
the in-tray of a probationary constable who had seen her on a
previous occasion when she had complained and the inspector in
charge of the team that took the statement did not use the duty
inspector's handover sheet to alert the inspector coming on duty
of the case.
The probationary constable was away for five
days. On his return he referred it to the domestic violence unit.
No positive action had been taken, no proper risk assessment carried
out and no referral made to the domestic violence unit before
then. The domestic violence officer, who had little experience
in the post, was going on leave for three days and decided to
leave it until his return. Two days later the woman was murdered
and similarities to her ex-partner's behaviour in previous relationships
came to light.
Key lessons are the need to capture intelligence
on previous history; for experienced supervision of incident reports
to ensure action where urgent; to treat crimes such as cutting
brake pipes seriously.
2.4 Need for proactive approach
A couple whose relationship was deteriorating
each complained to the police about the other on several occasions
over a period of three months. These complaints were handled by
a number of officers over the force area.
The woman's complaints included threats by the
man to kill her and an alleged assault on a cruise holiday. Her
first complaint was graded as not time critical and this grading
was not changed when subsequent complaints were added. Her partner
had 18 previous convictions, including for violence. Despite this,
the force made no risk assessment. Nor was he arrested in connection
with the allegation of assault or harassment. Support for her
was on a reactive basis only.
The incidents reported culminated in the man
stabbing his partner to death.
Key lessons are that incidents should not be
dealt with in isolation, an overview of the suspect's behaviour
is needed; the need for a proactive investigations capability
and a positive action policy; grading should be robust and supervised.
2.5 Getting there in time
A woman whose 20-year relationship had broken
down went to live with her sister. On two occasions when she called
the police about her ex-partner, they failed to respond adequately.
On the first occasion she made a 999 call in
the evening to report that he was refusing her access to their
children and told the police he had been violent towards her in
the past. She was told the police would come but not when. Units
were assigned but redeployed before they arrived and by next morning,
when the force rang to apologise, the police had still not reached
her (by then the immediate issue had been resolved).
Three weeks later she called at the police station
at midday to complain about threats by her ex-partner. No units
were available and a contact number was taken. This was her work
number but was inadvertently recorded as her home number. Fruitless
attempts were made to contact her until the police discovered
in the evening that it was a work number. She was located next
day and arrangements made to see her at her sister's home.
Before the police reached her, she was murdered
outside the police station by her ex-partner.
Key lessons are the need for proper training
in domestic violence for front office staff; improved recording
of phone numbers; clarity in ownership on outstanding commitments;
better capture of intelligence.
2.6 When violence escalates
A woman was involved in an on/off relationship
with a man who had a long history of drug abuse and violence.
He had been in prison several times. There were some isolated
domestic incidents between the two until he moved into her home,
when the incidents escalated.
She reported an assault and death threats to
the police. Arrangements were made for an alarm to be fitted and
her partner was arrested and charged. One of the bail conditions
was no contact with her. A detective inspector countermanded the
alarm as it would have meant withdrawing one from elsewhere and
referred the case to a domestic violence officer for assessment.
He did not follow up the assessment as the man was placed on remand.
An occupational therapist who assessed him as a serious risk told
his probation officer, but not the police. The probation officer
left a message at the police station but did not speak to a senior
officer.
A few days later the man was arrested at his
partner's home and charged with assault and breach of bail conditions.
He threatened to kill her if she did not drop the charges. He
was then arrested for witness intimidation and detained. Further
reports of threats were received but the police took no action
as he was now in prison. He was released after the court made
a restraining order but the police did not monitor court action,
so made no risk assessment on his release.
His partner then reported receiving threatening
text messages from him. She only wanted these recorded and the
police took no other action. Shortly afterwards, he murdered her
at her home.
Key lessons are to allocate alarms on the basis
of comparative risk assessments; actively supervise domestic violence
report forms and follow up assessments; need for cohesive intelligence
and effective liaison between police and other agencies; need
to consider action on breach of bail conditions regardless of
victim's wishes.
2.7 Investigating properly
A woman suffered over a year of terror and harassment
after ending a relationship. She alerted the police to her fears
on several occasions, reporting (among other things) assault,
damage to her car, threatening calls, an attack during a robbery
(which she believed her ex-partner was behind) and finally threats
to kill her. At no stage did the police identify her as vulnerable
or categorise her case as high risk.
There was no meaningful investigation of the
robbery. Statements were not taken from key witnesses who had
seen two men near the scene at the time, forensic tests were not
carried out on a Mars bar wrapping found in the telephone box
from which the robbers had called her first, the descriptions
of the robbers were not circulated and her ex-partner was not
interviewed though there were strong grounds for suspecting he
was behind the robbery. No risk assessment was made in relation
to the victim's safety.
Her ex-partner shot her dead. He was subsequently
tried and convicted of the robbery as well as her murder. Although
he used an unlicensed firearm to kill her he had a valid firearms
licence at the time. The last renewal was after he had been bound
over in relation to the allegation of assault and while he was
still under suspicion for the robbery. The firearms licensing
officer renewing the certificate looked only at bind over and
did not consider the whole of the man's record.
Key lessons are the need for better training
in domestic violence and proactive management, based on greater
awareness of risk factors; to ensure ownership of policies and
investigatory procedures by those responsible for implementing
them; for processes to identify potential critical incidents and
ensure referral to the command team; for rigorous examination
of the background of an applicant for a firearms licence.
2.8 Giving it the right priority
A woman who was pregnant by her former partner
made a 999 call reporting that he had assaulted her and was threatening
to kill her. The police instituted a search with a view to arresting
him for assault. The force assessed the case as low risk.
The investigation into the allegation was flawed:
support for the victim was slow and inadequate; photographs of
her injuries were taken by a constable not a police photographer;
she was not kept informed and the force's response was not co-ordinated.
The police missed two good opportunities to
arrest her former partner. On one occasion she named the pub where
he was drinking; the duty sergeant said all officers were elsewhere
deployed (two officers were dealing with a distressed dog in a
car and a female sergeant refused to go to the pub to arrest him
on her own because of personal health and safety concerns). He
had left by the time the police arrived. On the second occasion,
police stopped his car because the rear light was broken; he was
issued with a ticket to produce his documents but not detained.
Shortly afterwards he murdered his ex-partner.
He was convicted for the original assault on her as well as the
murder.
Key lessons are the need for effective implementation
of ACPO Guidance on Investigating Domestic Violence; for the domestic
violence unit to give priority to early contact with the victim
rather than inputting of statistical data; follow through on arrest
decisions; training for staff in the domestic violence unit.
2.9 Breach of bail
A woman came from Pakistan as the wife of a
man who had lived in the UK for many years. There was a series
of domestic violence-related incidents between the couple and
the man was arrested, charged and bailed for assault on his wife.
A condition of bail was not to go to the family home but his wife
was not told of this. The police then attended at the house several
times as a result of further incidents but no action was taken
against the husband for breach of the bail condition.
The wife was then arrested for assault on a
woman who appeared to be married to the same man. The wife made
a counter-allegation against the other woman. The officers involved
failed to investigate those counter-allegations, because they
were investigating the allegation against the wife, but did not
refer them to any other officer.
The wife says that she attended the police station
to report that threats were being made against her and her family
in Pakistan to force her to drop the assault allegation. The General
Occurrence Book did not appear to have been properly completed
and there was no record of such a visit. She subsequently made
a statement, indicating that she felt in danger. She mentioned
pressure being put on her family in Pakistan, but did not identify
a threat to them. She complained that the police were not taking
her allegations of being threatened seriously. She could not speak
English, so the statement was taken by an interpreter without
direct involvement from the police. Her complaint was not recorded
and no risk assessment was made of her safety.
Shortly afterwards, her brother-in-law was shot
dead in Lahore, according to her family by her husband's brother.
When informed, the police authorised regular checks on the wife's
home and a "police watch" incident was created. This
was cancelled when her home had little attention from patrols
due to other incidents. There was a delay before the force decided
to investigate the threats against the wife and record her complaint.
Key lessons are to ensure the victim is told
of bail conditions and knows what to do on a breach; cross refer
new incidents with previous incidents; resource and monitor regularly
"police watch" incidents; clarify use of interpreters
when interviewing witnesses and procedures on investigating counter-allegations;
follow through on investigations; use General Occurrence Book
properly.
2.10 Christmas Day Cover
In the early hours of Christmas Day a married
couple made a 999 call. It concerned an argument between them
which involved a knife and threats being made. Two constables
were sent to the scene.
The officers spoke to husband and wife separately.
Neither wanted to take formal action against the other and this
was the main reason no arrest was made. Each officer completed
most of a crime DIAL (Domestic Investigation Arrest Log) form
and left, in the belief that the incident was formally closed.
Among other reasons noted in one of the forms for not arresting
was that it would have resulted in detention on Christmas Day.
Back at the police station, the officers submitted
the paperwork. Normal procedure would have been to finish off
the DIAL forms and submit them to the public protection unit,
where a Domestic Violence Perpetrator Officer and Domestic Violence
Victim Officer would have been appointed. They did not do this,
as it was Christmas Day and the public prosecution office was
not staffed over the holiday. Nor was there any supervisor on
duty at the station to review the DIAL forms. They left a note
to the following shift to complete the necessary crime complaint
documentation with the public service desk.
On Christmas Day evening the husband's mother
called the police with worries about her daughter in law's safety.
Police officers were dispatched to the house and found the wife
dead. She had been stabbed by her husband.
Key lesson is the need for adequate resources
over periods like Christmas notorious for serious/increased levels
of domestic violence.
3. RECURRING
ISSUES
The 10 cases in this bulletin focus on the response
of the police to the victim. Historically, this was an area that
gave rise to serious failures in policing. Great progress has
been made in recent years, following the introduction by ACPO
in 2004 of detailed guidance on investigating domestic violence
and its statutory reinforcement by the Domestic Violence, Crime
and Victims Act 2004. These cases suggest, however, that there
may be some way to go before good practice is embedded throughout
the police service. Concerns that recur are identified below.
3.1 Holistic approach
The major issue to come out of the cases in
this bulletin is the need for a co-ordinated overview of all relevant
incidents and intelligence by staff with specialist training in
domestic violence. Domestic violence requires an inclusive and
co-ordinated response—coherent control of the investigation
on the one hand and effective communication with the victim on
the other coupled with risk assessment made on the basis of the
full picture and information shared with other forces and agencies
as relevant. The role of the domestic violence unit is crucial
here.
This holistic approach was lacking in several
cases:
— No overall control of investigation
of one incident or a number of related incidents.
— No overview by specialist domestic
violence officer.
— Lack of specialist training for domestic
violence and call centre staff.
— Lack of ownership of outstanding
assignments.
— Failure of the specialist domestic
violence officer to make early contact with the victim and priority
given instead to inputting statistical data.
ACPO and Home Office guidance aims to improve
how the police investigate domestic violence, but serving officers
are not compelled to undergo training in domestic violence.
3.2 Record keeping
This is a fundamental discipline. Without it
intelligence cannot be assessed or cross referenced. In several
cases the police failed to keep adequate records of calls and
incidents or at all:
— Failure to capture the overall nature
of the incident.
— Details entered incorrectly.
3.3.1 Awareness of triggers and the victim's
circumstances
Awareness of circumstances likely to trigger
domestic violence is important to risk assessment. A 2002 Metropolitan
Police study of domestic violence showed that:
— The level of domestic violence escalates
quickly with 1 in 3 households having a second incident with five
weeks.
— Repeat victims are much more likely
to be killed.
— Women who try to end relationships
are frequent victims.
— Violence can often be triggered by
pregnancy.
These and other recognised triggers are reflected
in the cases in this bulletin:
— Arguments over custody and child
contact.
— Social isolation of the victim.
Empathy with the victim, taking the victim's
situation seriously and treating domestic violence as violent
crime is vital. In the past, domestic violence was viewed by some
as less serious than a similar offence in a non-domestic context.
The domestic context was viewed, in the words of the CPS, almost
as a mitigating factor whereas in reality it is an aggravating
factor, involving as it does a severe breach of trust in what
should be a safe home environment.
3.3.2 Risk indicators
Common factors in the background of the perpetrators
in these cases show a need for intelligence on the perpetrator's
history in order to assess risk:
— Drug abuse and Mental Health issues.
— Threats to commit murder and escalation
of violence.
Since the increased use of mobile phones, stalking
is often evidenced by persistent threatening and nuisance phone
calls. A 2002 Metropolitan Police study found that stalking by
men is a strong indication that they can show extreme violence.
These risk indicators and triggers are also
set out in the ACPO guidance on Identifying, Assessing and Managing
Risk in the Context of Policing Domestic Violence (February 2005).
3.4 Arrest
ACPO Guidance on Investigating Domestic Violence
emphasises the importance of positive action and approach to the
arrest of the perpetrator. Where evidence exists the perpetrator
should be arrested, officers must always make use of intervention
and safety options available and will have to justify any decision
not to arrest. Opportunities were missed in seven of these cases,
sometimes repeatedly, due to:
— Inadequate deployment of resources.
— A failure to appreciate the full
circumstances.
— Poor use of intelligence.
— Indecision arising from counter-allegations.
— Victims unwilling to press charges.
— Failure to take offences/breach of
bail conditions seriously.
3.5 Risk Assessment
Risk assessment and review is at the heart of
ACPO Guidance on Investigating Domestic Violence, its purpose
being:
— To reduce the likelihood of future
harm including the effects of further violence, serious injury
and homicide on adult and child victims, future victims and the
public.
— To facilitate the effective use of
police powers in protecting the public, investigating crime, targeting
offenders, intelligence-led policing, reducing and preventing
crime, narrowing the justice gap and in contributing to the Criminal
Justice System function of holding offenders accountable.
Several of the cases demonstrate serious failings
in risk assessment:
— Lack of formal risk assessment or
assessment based on partial evidence.
— No risk assessment or review/regrading
of priority on escalation of violence.
However, research shows that risk assessment
alone is not the answer. In 2002 the Metropolitan police subjected
a month's worth of reported domestic violence assaults ranked
as GBH or more serious to their risk assessment procedure. Two
of the domestic violence homicides were ranked as "low risk".
3.6 Proactive investigation/resources
A key lesson from the cases is the need not
just to record domestic violence, but to assess and then proactively
investigate in a proportionate and professional manner. In some
cases the failure to do so was rooted in a lack of adequate resources.
— Investigation poorly co-ordinated.
— Basic evidence gathering and pursuing
lines of enquiry.
— Lack of Christmas cover (Ellis).
— Lack of resources for domestic violence
unit.
— Inadequate supervision.
— Limited supply of alarms.
3.7 Interaction with other agencies
Information management and sharing between police,
social services and health professionals is key to reducing domestic
violence. The ACPO lead on Domestic Violence has said at Refuge's
2006 Annual Conference that despite recommendations in the past
and lessons learned from public inquiries, agencies are still
not sharing information that would help protect the public and
that legislation is needed to oblige agencies to share information
and save lives.
In several cases poor communication between
the police and other agencies contributed to the outcomes:
— The perpetrator was a wanted foreign
national.
— The police, local MAPPA agencies,
the council and probation and offender management failed to share
information.
— Health and probation services failed
to communicate effectively to the police.
Bulletin 1 June 2007
DOMESTIC VIOLENCE
The purpose of Learning the Lessons bulletins
is to summarise reports on recommendations for improving policing
practice which have arisen out of conduct investigations carried
out by the Independent Police Complaints Commission (IPCC) or
by police forces, Serious Organised Crime Agency (SOCA) or Her
Majesty's Revenue and Customs (HMRC).
This bulletin focuses on the police response
to the victim in cases of domestic violence. In addition to containing
summaries of cases it provides a brief analysis of common factors.
These cases have been chosen because they provide
learning opportunities for other police forces facing similar
situations and may help them improve their policies and practices.
They were selected from independent, managed and supervised investigations
relating to domestic violence (as defined by ACPO) carried out
since 1 April 2004. Cases which did not concern the response to
the victim or did not contain significant learning were eliminated.
Cases whose inclusion in the bulletin might prejudice possible
legal proceedings or pending inquests were also excluded. The
analysis has benefited from input from ACPO and NPIA/Centrex.
Full reports of the cases referred to are available
on the IPCC website (www.ipcc.gov.uk). Names have been changed
in the learning reports to make it possible to circulate them
more widely.
This bulletin is issued by an inter-agency forum
called the Learning the Lessons Committee. Its members are:
— Association of Chief Police Officers
(ACPO).
— Association of Police Authorities
(APA).
— HM Inspectorate of Constabulary (HMIC).
— Independent Police Complaints Commission
(IPCC).
— National Policing Improvement Agency
(NPIA).
27 September 2007
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