Sophie Naftalin and Vanessa Munro examine why there are persistent failures to investigate suicides in the context of domestic abuse, despite the mechanisms available to do so.
In England and Wales, the majority of suicides are by men and, consequently, the national suicide prevention strategy has until very recently focused on men at risk.
1The most recent government suicide prevention strategy, published in September 2023, for the first time recognises victims of domestic abuse to be at high risk of suicide: Suicide prevention in England: 5-year cross-sector strategy, Department of Health and Social Care, 11 September 2023. However, a growing body of research has established a link between domestic abuse and suicide, which disproportionately affects women.
2Hannana Siddiqui and Meena Patel, Safe and sane: a model of intervention on domestic violence and mental health, suicide and self-harm amongst Black and minority ethnic women, Southall Black Sisters, March 2011; Lis Bates et al, Domestic homicides and suspected victim suicides during the Covid-19 pandemic 2020–2021, Home Office/Vulnerability Knowledge and Practice Programme (VKPP)/National Police Chiefs’ Council (NPCC)/College of Policing, August 2021; and Lis Bates et al, Domestic homicides and suspected victim suicides 2021-2022 – year 2 report, Home Office/VKPP/NPCC/College of Policing, December 2022.In their review of over 3,500 client case files in Refuge’s database, Ruth Aitken and Vanessa Munro confirmed a substantial prevalence of suicidality among this cohort, with factors likely to increase risk including a lack of community support networks, the co-existence of depression, drug or alcohol dependency, and interactions with healthcare, social service, immigration or justice agencies that undermined the victim’s confidence in the prospects of being understood, believed and helped to escape their situation.
3Ruth Aitken and Vanessa Munro, Domestic abuse and suicide: exploring the links with Refuge’s client base and work force, Warwick Law School/Refuge, 13 July 2018. Recent analysis has also shown that women who suffer intimate partner violence are three times more likely to attempt suicide than those who do not, with the scale of domestic abuse-related suicide likely to be significantly larger than that of domestic homicide.
4Sally McManus et al, ‘Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England’, The Lancet Psychiatry, vol 9, no 7, July 2022, page 574. See also Underexamined and underreported – suicidality and intimate partner violence: connecting two major public health domains, Agenda Alliance/VISION, February 2023. See further Domestic homicide reviews: key findings from analysis of domestic homicide reviews, Home Office, September 2021, and ‘Men still killing one woman every three days in UK – It is time for “Deeds not Words”’, Femicide Census press release, 28 February 2022.Inquests and domestic homicide reviews (DHRs) provide a mechanism for the investigation of (apparent) suicides in the context of domestic abuse. Both provide the possibility of lessons being learned about risk and intervention to improve future prevention. However, as we discuss below, systemic failings in identification and the police investigation in the aftermath of these deaths have often curtailed such opportunities, just as they have limited the possibility of the prosecution of perpetrators.
Police investigation
The primary concern of families on the death of their loved one following domestic abuse is often for the perpetrator to be held accountable in the criminal courts. The acts of the police in the immediate aftermath of the death not only impact the extent to which there will be any prosecution, but also the prospects of having a DHR commissioned and the effectiveness of the subsequent inquest. Despite training initiatives, frontline officers continue in too many cases to struggle to identify and effectively investigate domestic abuse-related offences where the victim is alive.
5Evidence led domestic abuse prosecutions, Criminal Justice Joint Inspection (HM Crown Prosecution Service Inspectorate/HM Inspectorate of Constabulary and Fire & Rescue Services), January 2020. It is perhaps unsurprising, therefore, that they may not be primed to recognise or investigate them when the victim is dead and the death appears to have been the result of a ‘straightforward’ suicide.
6Vanessa Munro, Vanessa Bettinson and Mandy Burton, ‘Coercion, control and criminal responsibility: exploring professional responses to offending and suicidality in the context of domestically abusive relationships’, Social & Legal Studies, forthcoming.When police attend a death, an assessment as to whether it is suspicious tends to be made quickly. While this will be key in governing how the case will proceed, appearances are often deceptive in this context.
7The deaths of Caroline Devlin and Susan Nicholson, both victims of Robert Trigg in 2006 and 2011 respectively, illustrate the potential for such cases to be too easily discharged as non-suspicious with an attendant investigative failure (‘British man jailed for life for killing two former girlfriends’, Guardian, 6 July 2017). So too does the case of Lesley Potter, whose death was presented to the police by her husband as a suicide but he later admitted that he strangled her to death (‘Lesley Potter death: suicide lie husband jailed for murder’, BBC News, 8 November 2018). Families frequently report that crucial evidence was lost at this initial stage. Alleged perpetrators are not questioned, the scene is not secured, forensic tests are omitted, neighbours are not asked to provide statements, phones are not reviewed. Thus, a disturbing Catch-22 arises: the family are unable to justify their suspicions that the perpetrator was involved in the death because, having concluded from the start that the case
was not suspicious, the police have not investigated and important evidence may have been irreparably lost.
Unlawful act manslaughter
While in France there is a specific offence of causing suicide as a result of domestic abuse,
8‘France: parliament adopts law against domestic violence’, US Library of Congress, 7 August 2020. in England and Wales there is only the possibility of a criminal charge of unlawful act manslaughter. This is possible even if the final act causing death is self-inflicted, provided it can be shown that the accused’s unlawful acts made a more than trivial contribution to the death (
R v Wallace [2018] EWCA Crim 690 at para 68). To date, the prospect of securing such convictions remains limited. In
R v Dhaliwal [2006] EWCA Crim 1139, the accused was charged with unlawful act manslaughter and Offences against the Person Act 1861 s20 grievous bodily harm following the suicide of his wife, upon whom he had inflicted many years of domestic abuse. Despite substantial evidence, including diary entries, witness statements and medical records, the court ruled that there was no basis upon which a reasonable jury could convict of either offence, since the prosecution was grounded on psychological (rather than psychiatric or physical) injuries.
Since
Dhaliwal, there have been important developments, crucially the creation of a criminal offence of coercive and controlling behaviour, which now captures psychological harm. In
R v Allen Stafford Crown Court, 28 July 2017,
9David Connett, ‘Stalker jailed for manslaughter of former partner who killed herself’, Guardian, 28 July 2017. this paved the way for a manslaughter conviction when the perpetrator pleaded guilty after his partner, Justene Reece, took her life following years of coercive control, stalking and harassment. Allen’s conviction does not authoritatively settle the complex questions of causation that might be raised in other cases, however, since he admitted guilt pre-trial.
Domestic homicide reviews
The purpose of DHRs is to identify lessons from domestic homicides. A failure in the police investigation to chart any abuse history in the aftermath of a death means, among other things, that it will be difficult to make a case for commissioning a DHR, despite their formal extension, since 2016, to suicide cases. Moreover, even where DHRs are commissioned, recent research has indicated the existence of particular challenges in conducting rigorous reviews in suicide cases.
10Sarah Dangar, Vanessa Munro and Lotte Young Andrade, Learning legacies: an analysis of domestic homicide reviews in cases of domestic abuse suicide, Advocacy After Fatal Domestic Abuse/University of Warwick, March 2023. These include a one-sided focus on the deceased because of concerns regarding breach of privacy or reputational damage to partners who have not been formally established through any justice process as perpetrators of abuse. This, in turn, can encourage victim-blaming and a perception among bereaved families that the DHR process is not sufficiently robust or probing.
Inquests
Following any sudden or unexplained death, it is the duty of the coroner to investigate (R v HM Coroner for North Humberside and Scunthorpe ex p Jamieson [1995] QB 1 at para 14). An inquest is not limited, however, to determining the ‘last link in the chain of causation’ (R v Inner West London Coroner ex p Dallaglio [1994] 4 All ER 139 at 164); there is also a broader duty to seek out as many facts concerning the death as the public interest requires (R v South London Coroner ex p Thompson (1982) 126 SJ 625). While a coroner is prohibited from making findings of criminal or civil liability, the extent to which domestic abuse may have contributed to a death may be a key part of the factual matrix. A poor police investigation risks undermining this process, leading to reluctance on the part of coroners to explore the role that domestic abuse, and its perpetrator, played in the death. The scope of the inquest is likely to be narrowed, with no live witnesses or legal representation.
There are, however, some recent examples of coroners who have been willing to broaden the scope of their inquiry. In June 2022, the Area Coroner for East Riding conducted a
European Convention on Human Rights article 2 inquest into the death of Jessica Laverack, a vulnerable woman with alcohol dependence who had been subjected to serious physical, psychological and sexual abuse by her partner, and identified at a multi-agency risk assessment conference as at a high risk. Jessica sought the assistance of local police but her allegations were not investigated. Her mental health deteriorated and after repeatedly expressing suicidal ideation, she took her own life. After hearing five days of evidence, the coroner concluded that Jessica died in the context of domestic abuse and made the first known prevention of future deaths report in this terrain, identifying a failure on the part of agencies to link domestic abuse and suicide.
11Jessica Laverack: prevention of future deaths report, ref no 2022-0344, 27 June 2022.Recent research into DHRs commissioned to date in suicide cases reflects a profile of victims struggling in plain sight of statutory services as they navigate complex needs.
12Learning legacies: an analysis of domestic homicide reviews in cases of domestic abuse suicide, ibid. However, it is likely that, given notorious under-reporting of domestic abuse and the use of isolation as a strategy of control by perpetrators, many victims will not have been involved with agencies at all. Families in this situation will encounter arguments that article 2 is not engaged, which is likely to be a barrier to accessing funding for the inquest. However, in
Dove v HM Assistant Coroner for Teesside and Hartlepool and Rahman [2023] EWCA Civ 289; June 2023
Legal Action 28, the Court of Appeal found that it was in the interests of justice for an inquest to consider, in a non-article 2 case, the extent to which the actions of agencies contributed to the deceased’s deteriorating mental health.
The UK Supreme Court’s decision in
R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46; February 2021
Legal Action 21
13See also June 2021 Legal Action 28. has also increased the possibility of inquest conclusions of unlawful killing for suicides that follow domestic abuse, if it can be shown on the balance of probabilities that the elements of the offence of unlawful act manslaughter are made out.
14See Chief coroner’s law sheet no 1: unlawful killing, Courts and Tribunals Judiciary, 21 September 2021. Previously, suicide and unlawful killing conclusions could only be reached if the evidence met the criminal standard of proof, beyond reasonable doubt.
The implications of this were demonstrated by the jury’s return, in July 2023, of an unlawful killing conclusion in the inquest into the death of Kellie Sutton.
15‘Jury conclude that Kellie Sutton was unlawfully killed in self-inflicted death following domestic abuse’, Bhatt Murphy, 10 July 2023. Significantly, there had been a substantial investigation here by specialist officers into the actions of Kellie’s partner, Steven Gane. Gane was treated as a suspect almost immediately: arrested and interviewed regarding his possible role in her death. Witness evidence was obtained from friends, neighbours and family members. Both Kellie’s and Gane’s phones were seized, evidencing their communications and that he had encouraged her to take her own life. Gane was convicted of two counts of assault and one count of coercive control in relation to his treatment of Kellie in the months before she died. On this basis, the inquest jury was directed to find that he had committed an unlawful act, and was thereafter asked to deliberate on whether that unlawful act had caused Kellie’s death. The unlawful killing conclusion is a significant development and will hopefully pave the way for other coroners to conduct similar inquiries and reach similar conclusions.
Conclusion
Deceased victims and their families have, for many years, been let down in the aftermath of suicides in the context of domestic abuse, with limited police investigations preventing avenues to justice and learning. Although there is no room for complacency, there is some cause for optimism grounded in recent developments.
The need to improve prevention initiatives, as well as mechanisms for responding in the aftermath of suicides, has been acknowledged across government domestic abuse policy, with reform to DHR mechanisms underway and judicial innovation impacting on the outcomes of inquests. In its recently updated version, the national suicide prevention strategy has now recognised victims of domestic abuse to be a category of case at high risk of suicide. Policy commissioned by the National Police Chiefs’ Council, the College of Policing and the Home Office
16Lis Bates et al, Domestic Homicide Project spotlight briefing #5: suspected victim suicide following domestic abuse, NPCC/VKPP, December 2022. has also made recommendations regarding how police should respond to a sudden death following domestic abuse, and steps that should be taken to improve knowledge on safeguarding and suicide prevention in this context. The conclusions of the inquests of Jessica Laverack and Kellie Sutton, hard fought for by family members, can also help to improve public recognition of the impact of domestic abuse on suicidality.
An effective examination of the circumstances of death gives dignity and bears witness to the experiences of victims, who may have gone through unimaginable horrors. Legal advocacy and specialist support to bereaved family members should, moreover, be routinely available in these cases: without it, they are left to navigate complex criminal and coronial law processes in the midst of acute grief, and this does a disservice to them, their loved ones and all victims in need of protection.