Cherylee Shennan

for Lancashire & Blackburn with Darwen

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Lancashire Constabulary
Force Headquarters
Saunders Lane

Lancashire
PR4 5SB

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
tegulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On the 215 March 2014 an investigation into the death of Cherylee Yvette Shennan aged 40 was
opened. The investigation concluded at the end of the inquest on 15" July 2019. The conclusion
of the inquest was:

Unlawful killing

The death of Cherylee on 17'* March 2014 was more than minimally contributed to by the
following:

e The failure to recall the perpetrator to prison once reports were made of violence to
Cherylee and the perpetrator drinking

The following possible contributed to the death of Cherylee on 17" March 2014:

© The lack of inter-agency management or appropriate sharing of information prior to the
18! March 2014.

e The lack of inter-agency management or appropriate sharing of information following the
1st March 2014.

CIRCUMSTANCES OF THE DEATH

In brief the deceased was a 40 year old woman who was murdered by the perpetrator on the 17"
March 2014. The perpetrator was an individual who was on "life licence" having murdered his
Previous partner in 1998. He was released on "life licence" in April 2012. His licence was
managed by the Greater Manchester Probation Trust and had been assessed as a high risk to
known individuals with trigger points for offending including relationship breakups, jealousy and
alcohol and substance misuse.

He began a relationship wi etime i e 013. Evidence was heard
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752

that Cherylee was the victim of domestic abuse, manifesting across the range of forms of abuse,
inctuding violence, at the hands of the perpetrator from as early as late October 2013. The
violence included a broken nose, multiple accounts of facial bruising, a fractured jaw, and being
held hostage at knife point on at least two occasions.

Although a previous relationship had led to communication between agencies not only locally but
also across into neighbouring counties, there was no such communication when the relationship
with Cherylee started. In particular there was no contact with the Lancashire Constabulary, in

whose jurisdiction, Cherylee lived.

On the 15! March 2014 Cherylee disclosed the abuse to a family member, which resulted in a
isit-initially-by-uniform-officars-and-subsequently_by-specialist Domestic Abuse-officers,-however.
the deceased did not directly report the abuse, and subsequently denied that the abuse had
occurred. The perpetrator was however identified but no information was held on him by
Lancashire Constabulary.

On the 12‘ March 2014 the perpetrator reported to his offender manager that an allegation had
been made against him, but withdrawn. On the 14'* March 2014 details of the police's visits was
provided to the offender manager by the domestic abuse officers.

On the 17 March 2014 Cherylee informed the offender manager that the allegations had in fact
been true. This was communicated to Lancashire Constabulary and two officers attended
Cherylee's address. The officers who attended carried either none of their personal protective
equipment or an incomplete set. Whilst there the perpetrator assaulted not only Cherylee but
also the two officers and subsequently proceeded to stab Cherylee repeatedly in the street. The
perpetrator was subsequently charged and convicted of Cherylee's murder.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

Foliowing the death of Cherylee, her death, and actions taken in the months leading up to it were
the subject of two detailed reviews. Following the Domestic Homicide Review a number of
recommendations were made by the author of the Individual Management Report, Mr Gary
Fishwick including concerns regarding initial grading of calls to identify initial responses, the
obtaining of information as part of initial attendances on reported domestic abuse incidents and
the carrying and use of personal protective equipment. Whilst the recommendations were made,
Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether
those recommendations had in fact been actioned or not, and accordingly whether anything had
changed following the death of Cherylee and the learning exercise that were subsequently
undertaken.

!n particular reference was made to, but unsupported by documentation, or any other form of
evidence:

Policies reflecting recommended changes;
Information sharing agreements between agencies;
MARAC emergency policy or notes;

DASH Training or policy regarding obtaining GP details; and
Audits of Grade 2 'Ethical fails‘ and reasons for such fails.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

YOUR RESPONSE

Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 NB
Tel 01772 536536 | Fax 01772 530752

You are under a duty to respond to this report within 56 days of the date of this report, namely by
13" September 2019. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons

C/o OPG Solicitors
National Probation Service - North West Division

lam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

Dated 19/07/2019

sionatue LZ

for Lancashire & Blackburn with Darwen

Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB-
Tel 01772 536536 | Fax 01772 530752

for Lancashire & Blackburn with Darwen

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Her Majesty's Prison and Probation Service
102 Petty France

London

SW1H 9AJ

1 CORONER
| am James Newman, HM Area Coroner for Lancashire & Blackburn with Darwen

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.qov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://Awww.legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On the 215 March 2014 an investigation into the death of Cherylee Yvette Shennan aged 40 was
opened. The investigation concluded at the end of the inquest on 15!" July 2019. The conclusion
of the inquest was:

Unlawtul killing

The death of Cherylee on 17" March 2014 was more than minimally contributed to by the
following:

e The failure to recall the perpetrator to prison once reports were made of violence to
Cherylee and the perpetrator drinking

The following possible contributed to the death of Cherylee on 17" March 2014:

« The lack of inter-agency management or appropriate sharing of information prior to the
15! March 2014.

e The lack of inter-agency management or appropriate sharing of information following the
15! March 2014,

CIRCUMSTANCES OF THE DEATH

In brief the deceased was a 40 year old woman who was murdered by the perpetrator on the 17%"
March 2014, The perpetrator was an individual who was on ‘life licence" having murdered his
previous partner in 1998. He was released on "life licence” in April 2012. His licence was
managed by the Greater Manchester Probation Trust and had been assessed as a high risk to
known individuals with trigger points for offending including relationship breakups, jealousy and
alcohol and substance misuse.

He began a relationship with Cherylee at sometime in the summer of 2013. Evidence was heard
that Cherylee was the victim of domestic abuse, manifesting across the range of forms of abuse,
including violence, at the hands of the perpetrator from as early as late October 2013. The

Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752

violence included a broken nose, multiple accounts of facial bruising, a fractured jaw, and being
held hostage at knife point on at least two occasions.

Although a previous relationship had led to communication between agencies not only locally but
also across into neighbouring counties, there was no such communication when the relationship
with Cherylee started. In particular there was no contact with the Lancashire Constabulary, in
whose jurisdiction, Cherylee lived.

On the 1 March 2014 Cherylee disclosed the abuse to a family member, which resulted in a
visit initially by uniform officers and subsequently by specialist Domestic Abuse officers, however
the deceased did not directly report the abuse, and subsequently denied that the abuse had
Lancashire Constabulary.

On the 12'* March 2014 the perpetrator reported to his offender manager that an allegation had
been made against him, but withdrawn. On the 14" March 2014 details of the police's visits was
provided to the offender manager by the domestic abuse officers.

On the 17 March 2014 Cherylee informed the offender manager that the allegations had in fact
been true. This was communicated to Lancashire Constabulary and two officers attended
Cherylee's address. The officers who attended carried either none of their personal protective
equipment or an incomplete set. Whilst there the perpetrator assaulted not only Cherylee but
also the two officers and subsequently proceeded to stab Cherylee repeatedly in the street. The
perpetrator was subsequently charged and convicted of Cherylee’s murder.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

The perpetrator was managed on release at MAPPA Level 1. Following his release there were
no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency
communications regarding the perpetrator, no detailing of his licence conditions, and no
information regarding either his nature or the trigger factors for his offending. Evidence was
heard regarding the findings of two separate reviews that took place following the death of
Cherylee, and the recommendations that were made as a result of those reviews, in particular
centred on the lack of inter-agency communications. My concern is that despite this, and the
findings of the report, when evidence was heard regarding how systems had changed, there is
still no mandatory process for the sharing of information between agencies where the offender
despite a known, and extensive, history of domestic abuse and identified trigger factors, is then
managed at MAPPA Level 1.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely
by13th September 2019. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons:

Coroner's Court, 2 Furaday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752

0 DPG Solicitors

National Probation Service — North West Division
Lancashire Constabulary

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

Dated 19/07/20

for Lancashire & Blackburn with Darwen

=
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB-
Tel 01772 536536 | Fax 01772 530752

PROFESSIONAL STANDARDS DEPARTMENT
Legal Services

Legal Services
Lancashire Constabulary Headquarters Hutton Preston Lancashire PR4 5SB
Telephone: 01772 412357 Fax: 01772 412853 Email;

Ourref 1N/3/18
13 September 2019 Your ref:

Mr James Newman,

HM Coroner for Lancashire and Blackburn with Darwen,
Coroner’s Court,

2 Faraday Court,

Faraday Drive,

Fulwood,

Preston,

PR2 ONB

Dear Mr Newman,

Re: Cherrylee Shennan Inquest — Regualtion 28 Response

Please see below for the Chief Constable’s response to your regulation 28 report of 19" july 2019.
The response deals with each recommendation from the Domestic Homicide Review (DHR) that is
directed at the Lancashire Constabulary. A number of the DHR’s recommendations relate to other
parties and not the Constabulary. Where this is the case each has been left out of this response.
The number of the recommendation as it appears in the DHR is in brackets after the response
number.

Recommended changes following Domestic Homicide Review

1. (DHR Recommendation 1)
National recommendation

When offenders who are released on life license or temporary license following a conviction for a
domestic violence associated murder, or manslaughter, disclose that they are forming a
relationship with a new partner, this should trigger an immediate referral to MARAC.

Lancashire Constabulary are leading a multi-agency systems thinking review of the MARAC process
and this is encompassing the journey from initial referral through to the MARAC meeting itself.

This follows recognition of potential inefficiencies, time delays and ineffectiveness in the process.

Currently in ‘re-design’ the multi-agency team is testing new models which are specifically aimed
at responding to cases in ‘live-time’ through information sharing practices, tasking and adoption of
a lead professional to co-ordinate work to safeguard the victim. The team are also recognising
that the MARAC process needs to be cognisant of the wider family and are addressing the needs
of children/other parties in the household, and also the perpetrator’s needs — to provide
opportunity to address root causes of abuse.

In case of emergency ca'! 999, non-emergency cal! 101

www. lancashire.police.uk © @LancsPolice facebook.comiancspolice

Lancashire
Constabulary

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The approach is therefore holistic, public health orientated and focused on problem solving whilst
keeping the victim at the heart of the response.

Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a
Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced
specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in
question.

The guidance is clear that responsibility for the referral lies with the Offender Manager and the
cases MUST be prioritised as High Risk.

The document produced, outlining the flow and criteria is attached
2. (DHR recommendation 2)

Local Recommendation: The local MARAC protocol should be revised to ensure that anyone who is
forming an intimate relationship with domestic abuse offenders who have been convicted of
murder or manslaughter and are on life licence and are referred by an offender manager are
prioritised as high risk cases and immediately heard at MARAC. This should include the immediate
sharing of information with the NHS and General Practice as an integral part of the MARAC process

The attached document “MARAC operating protocol” (LC1) accounts for these criteria following
the recommendation of the DHR.

3. (DHR recommendation 8)

The learning from this case should be used to review multi agency data sharing for those offenders
previously convicted of domestic abuse murder or manslaughter who are on life licence

The Lancashire Constabulary are a key stakeholder in the MASH (Multi-Agency Sharing Hub),
which has dedicated and co-located National Probation Service staff able to access national
databases to ensure quality research can be conducted on nominals subject of safeguarding
referrals — in particular those with previous convictions and actionable orders — such as licence
conditions.

A perpetrator under a life licence is considered as high risk and would be referred to the MASH
Probation staff who identify the perpetrator’s offender manager to share information from the
referral to prompt any necessary action — for example a recall on licence. MASH shares
appropriately in parallel with partner agencies from these referrals in addition to Probation — for
example with Social Care should children be a factor.

This message is be refreshed periodically by the MASH police lead to MASH staff.

4. (DHR recommendation 9}

(a) Local Recommendation:

MASH information systems and processes should be audited and tested against the learning from
this case to ensure that there are no gaps in the system.

A Corporate systems thinking review of MASH was conducted from 2016-18 and amongst a
number of changes implemented was a move from a process-driven response to safeguarding
referrals to a model where MASH staff understood their role in supporting people and keeping
them safe, achieving this by considering each case on its merits, including the specific needs of the
victim, adult and/or children involved and responding accordingly in partnership. Staff
Supervisors/Team Leaders were trained and are now focussed on this approach to recognising the
risk, sharing information to achieve early interventions.

With specific regard to this DHR and the processes to ensure information intended for sharing
lands with it’s recipient, a statement has been provided to the Coroner by MASH team leader
Antonio Angelone. Extracted from that statement:

“The MASH are responsible for sharing information with partners, to safeguard vulnerable people
both within Lancashire and outside.

“In 2014 the force recorded vulnerability reports via an IT system called “Sleuth”. This was achieved
through the submission of a PVP (Protecting vulnerable persons) report, which the MASH would
share. At that time, information was predominantly shared by a system generated email within
sleuth. It was identified that sending emails directly through the Sleuth system did not inform the
sender if they failed to be delivered. in light of this when the constabulary changed its IT system
from “Sleuth” to “Connect” on 27" November 2018, the operating practice for sharing information
changed with it. It was agreed that when information is shared via email it must be done via a
personal email address rather than a system generated address. This means that if an email fails to
deliver to the intended recipient, the sender is immediately informed and can therefore take
immediate action to ensure delivery.

“This is particularly important when sending information to addresses outside of Lancashire as it
highlights if an address has been incorrectly inputted or is inaccurate. Whilst this is less likely to
occur Locally within Lancashire, {due to the addresses being used regularly) it provides the added
benefit of highlighting any technical difficulties within email addresses. Since adopting this
approach there has been a number of occasions when technical difficulties have arisen associated
to delivering emails, which have, been quickly overcome.

“When sharing information with agencies outside of the Lancashire area the process is that the
MASH complete research to identify appropriate sharing pathways. Each pathway can vary
dependent upon agency structures and unique working practices. it is therefore necessary to adopt
a bespoke approach to meet the needs of each agency. In the majority of occasions, this will
involve contacting the local police area’s MASH (where this exists) or alternatively the police
vulnerability departments. Once the locally agreed pathways are determined, information is shared
via agreed emails. In 2014 Lancashire was one of the few force areas which had a MASH, making
this process, challenging. The MASH model is now much more widely used nationally and therefore
identification of agreed sharing pathways is much easier to determine.”

(b) Local Recommendation:

The mechanism for communication across all agencies involved in the MASH needs quality
assurance, in this case email communication alone was not sufficient to ensure the transfer of
important information, therefore e-mail communication alone should not be relied upon.

See response above at 4 (a).

5. (DHR recommendation 10)
National Recommendation:

Specific guidance should be issued to LSCB’s in relation to the risks posed by violent offenders on
life licence and should be explicitly referenced in the continuum of needs thresholds for Child
Protection.

The LSCB published report “Lancashire Continuum of Needs and Thresholds Guidance” (Oct 2018)
makes specific reference to children living in domestic abuse settings:

e Domestic abuse and/or violence within the family which is having significant adverse impact on the
child/unborn

e Aperson convicted for domestic abuse related murder, manslaughter, or serious assault is known to be
developing a relationship with a parent or guardian of a child or young person.

e Achild or young person is living in a home where domestic abuse related assaults and incidents are a
regular occurrence for agencies, or a referral to MARAC has taken place

The full report is attached (LC2).
6. (DHR recommendation 11)
{a) Local Recommendation:

The Domestic Abuse Strategy Group should ensure that local independent sector agencies have a
robust disclosure and referral policy in place and that suitable training is available to promote
compliance.

Lancashire commissioning agencies (including Lancashire County Council, OPCC) for victim services
groups including IDVA provision include within their contracts policy on compliance with
disclosure and referrals — including engagement with Domestic Homicide Reviews.

All locally commissioned IDVA services undergo Domestic Abuse training incorporating referrals
and disclosure processes.

(b) Local recommendation:

All relevant statutory and voluntary/independent agencies that work to support families, should
undertake domestic abuse training.

In terms of police training around Domestic Abuse:
e All new recruits receive a full ‘programme’ of DA, Stalking & Harassment Training. (All DA
Training includes Coercive & Controlling behaviour)
e Additional DA and Stalking and Harassment Training is provided on the Probationers
Development Course (Officers with 14-18months service)
e Additional DA, Stalking and Harassment Training is provided to the new recruits on the
‘New Style’ new recruits course (2019).

e DA, Stalking and Harassment, HBV/FM/FGM Training provided to all new Contact
Management recruits (Force Control Room).

e DAand Stalking and Harassment Training is provided to the Dedicated Decision Makers —
Crime Data Integrity Teams.

e DAand Stalking and Harassment Training was provided to Investigation Management Unit
— when they were newly formed (2018).

e DVDS (Clare’s Law) and DVPN/O’s Training is provided at regular intervals to BCU/Frontline
staff.

e DA, HBV/FM/FGM Training provided to Initial CID (ICIDP) course

Multi- Agency Training which includes police staff/officers:

e DA and HBV/FM/FGM Training provided on behalf of Blackpool Safeguarding Children’s
Board.

e HBV/FM/FGM Training provided on behalf of Lancashire Safeguarding Children’s
Board. (Support has also been provided in re-writing LSCB DA ‘programme’ — yet to be
delivered.)

e = DAand HBV/FM/FGM Training has been provided to Preston based Probation Officers.

The attached document (LC3) provides details (as supplied by the OPCC) of training delivered to
partner agencies and organisations for domestic abuse in the past 12-18 months:

In support of this the OPCC has also provided the following documents (attached):
1. Pan-Lancashire Domestic Abuse Strategy (Feb 2017) (LC4)

2. Lancashire Safeguarding Adults Board — DA Guidance (Aug 2018) {LC5)

The implementation of ‘Operation Encompass’ (early disclosure to Lancashire-based schools
hosting children involved in/party to domestic abuse incidents in the preceding 24 hours — to offer
silent or active support) during 2018/19 included DA training provision to Dedicated Safeguarding
Leads (DSL/ADSLs) from over 800 Lancashire County Council Schools, over 60 Blackburn with
Darwen Schools and over 40 Blackpool schools. This training was delivered jointly by police and
education.

This training was supplemented by awareness raising inputs of Op Encompass to Police Officers
and staff.

Op Encompass has been ‘live’ in Lancashire since May 2019.

The constabulary through its Public Protection Unit has adopted a force-wide model of “SIP” ~
Safeguarding, Investigation & Prevention which is for officers/staff to apply to all incidents they
deal with and will help appreciate wider vulnerabilities of the individuals, families, groups and
environments they come into contact with and instil ‘professional curiosity’ in dealing with
vulnerability, not least domestic abuse. SIP is incorporated into vulnerability training in all related
courses/inputs and has recently been delivered at ‘Vulnerability Coach launch sessions to over 250
frontline police officers/staff which has seen the recruitment of over 100 Vulnerability coaches in
these roles to support, guide and coach their colleagues.