Review highlights the need to recognise coercive control and financial and carer abuse

A Domestic Homicide Review*(DHR) into the death of Helen (pseudonym) has today been published by the Norfolk Community Safety Partnership (NCSP) to share the multi-agency recommendations that have been identified from the tragedy.

Helen was killed by her long-term partner at their home in 2018. Her body was discovered in 2021. Helen was being coercively controlled by her partner, which included financial abuse that continued after her death.

Mark Stokes, Chair of the Norfolk Community Safety Partnership said: “We wish to express our deepest sympathies to Helen’s family and friends and to thank them for their involvement in this review – their input throughout the process gave the partnership an invaluable insight into the woman they loved.

This review is a reminder that coercive control and financial abuse are forms of domestic abuse and we hope that the changes implemented will help others who may find themselves in similar circumstances or have concerns about loved ones.”

Agencies involved in the review identified key themes of learning, which informed the recommendations. Many of these have already been implemented since Helen’s death and the NCSP is working with the agencies involved to ensure that the learning is taken forward. Some of the key recommendations are as follows:

1. Creation of a missed appointments process for adult patients, which includes guidance for specialist clinics for when a patient does not attend successive appointments.
2. GP practices should adopt a policy for both Safeguarding Adults and Domestic Abuse, including new patient registration forms to include a question about domestic abuse. They should also be encouraged to have a domestic abuse champion within their practice teams.
3. The Home Office and Domestic Abuse Commissioner to be made aware of the need for a national routine enquiry review and/or guidance for ICBs nationally.
4. Wider learning for all agencies in the partnership to be developed and shared regarding financial abuse. This will be shared with the Domestic Abuse Commissioner to assist national learning regarding the financial abuse and welfare of vulnerable people.

The learning from the review around family engagement with DHRs and the invisibility of intimate partner carers will be shared with:

• Independent Chair
• Norfolk Community Safety Partnership
• Police and Crime Commissioner for Norfolk
• Chief Constable Norfolk Constabulary
• Chief Officer, Norfolk and Waveney Integrated Care Board
• Chief Officer, Norfolk and Suffolk Foundation Trust
• Chief Executive, Cambridge University Hospitals NHS Foundation Trust
• Chief Executive, Norfolk and Norwich Hospital University Foundation Trust
• Executive Director – Adult Social Services, Norfolk County Council
• Domestic Abuse Commissioner - who uses statutory powers set out in the Domestic Abuse Act 2021 to raise public awareness and hold both agencies and government to account in tackling Domestic Abuse.

Tricia D’Orsi, Executive Director of Nursing at NHS Norfolk and Waveney Integrated Care Board (ICB), said: “The ICB welcomes this report and is committed to learning from this tragic case. We are committed to implementing the report’s recommendations in full and will continue to ensure these lessons are embedded going forwards. Our deepest sympathies are with the family and friends of the victim and those affected.”

Debbie Bartlett, Interim Executive Director Adult Social Services at Norfolk County council said: “Our thoughts are with the family and friends of the victim and anyone who has been affected by this case. It is important that we reflect on these incidents and learn from them, so we welcome this report. The County Council has already taken action on this issue, introducing a dedicated Financial Abuse and Safeguarding Officer. This sits alongside a wider strengthening of our staff training and processes in this area. We are committed to continuing this work and implementing the recommendations in the report.”

Helen’s family said: “In 2021 our family were devastated to learn that Helen had been killed by her partner. She was a wonderful sister and aunt and had taught us all about the importance of living in the moment. She was a funny and kind person. She had bravely dealt with living with a long-term debilitating health condition which had made her vulnerable in many ways.

The DHR process helped us, alongside health and social care professionals, to identify how her vulnerabilities, in the context of the COVID pandemic, seemed to make her invisible in various systems. We hope that the learning from this DHR will enable professionals to be ever curious about the people behind their "patients" or "cases".

We would want professionals to be more vigilant to people who have not attended appointments and to "join the dots" where concerns have been raised to other agencies.

Helen was precious to many people and her loss will always be felt.

We will all continue to reflect as to whether we could have done more to protect her and would encourage professionals to join us in their own reflections to lessen the risks for other people.”

 Domestic Homicide Review report into the death of Helen can be found here

* A Domestic Homicide Review (DHR) is a locally conducted, multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a relative, partner or member of the same household. DHRs were established on a statutory basis by the Domestic Violence, Crime and Victims Act 2004.

A DHR panel consists of key members of staff from statutory, non-statutory, third sector and charitable agencies who provide support for victims of domestic abuse. Working together in this way will ensure the voice of the victim is addressed through the lessons learnt and recommendations of this DHR.

How to find help:

In an emergency always call 999. For further help and support please visit the following websites:

• NIDAS – Norfolk Integrated Domestic Abuse Service
• Norfolk Constabulary

For more information or press enquiries, please contact:

Suzannah Armstrong Cobb, Communications Officer, Norfolk Community Safety Partnership: suzannah.armstrong-cobb@norfolk.police.uk