Prevention of Future Deaths reports · 2019

Kay Martin

Regulation 28 report to prevent future deaths, reference 2019-0262, written 27 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Aug 2019
Reference2019-0262
DeceasedKay Martin
CoronerDerek Winter
Coroner areaSunderland
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

Derek Winter DL
Senior Coroner for the City of Sunderland

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

The Rt Hon Priti Patel MP

Secretary of State for the Home Department
2 Marsham Street

London SW1P 4DF

CORONER

I am Derek Winter DL, Senior Coroner for the City of Sunderland

CORONER’S LEGAL POWERS

I 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.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

Kay Michelle Martin (referred to herein as Kay Richardson) was born on 26" December
1968 and died on 21% September 2018, aged 49 years. The cause of her death was
Strangulation and Blunt Force Head Injury.

I opened and adjourned an Inquest into her death as part of my Investigation on 27"
September 2018.

The Inquest was heard on 22"¢ August 2019 when I gave a conclusion that Kay
Richardson was unlawfully killed and further recorded that: -

‘Kay Michelle Martin (nee Richardson) died on 21st September 2018 at 00:30 hours at
as Sunderland following a brutal and sustained attack.’

CIRCUMSTANCES OF THE DEATH

Kay Richardson had a volatile relationship with her husband They were
joint owners of the matrimonial home at [i 7M in Sunderland.

Between 1* January 2011 and 12" September 2018 there were 12 reported incidents of
domestic abuse.

On 8" September 201 8 MER was arrested for assault and rape and later released
that day by the Police under investigation. The keys to the former matrimonial home
were returned to

Civic Centre, Burdon Road,Sunderland, SR2 7DN
Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland
www.sunderlandcoroner.co.uk

Kay Richardson was assessed by the Police as being high risk.

On 17" September 2018 Kay Richardson attended the Family Court and was granted a

non-molestation order. MEE was served with that order (and other papers

including a detailed statement about his behaviour) on 18" September 2018 with a return

date of 26" September 2018 to the Family Court to consider the continuation of the non-

molestation order and for the Judge to consider making an Occupation Order to exclude
from the family home.

On the evening of 19" September 201 y gained entry to the family home
with his keys, hidupstairs. subjected Kay Richardson to catastrophic injuries to cause
her death before icc his own life by hanging.

CORONER’S CONCERNS

I was concerned to hear that from 8"" August 2018 to 18" September 2018 Kay
Richardson had no protection in place. HE Was only under investigation by the
Police and was not subject to any conditions of police bail or other restrictions such as
confiscation (or encouragement) to surrender his family home keys, all of which may
have acted as a deterrent.

I was wondering whether you would review these procedures and resources available to
protect victims of domestic abuse to prevent future deaths arising.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I 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 by 24'" October 2019. I, 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

Lhave sent a copy of my report to the Chief Coroner and to the following Interested
Persons: -
e Family and their Advocate from AAFDA (Advocacy After Fatal Domestic
Abuse)
e Northumbria Police
e Domestic Homicide Review Team
e IOPC (Independent Office for Police Conduct)

I 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 this 27" day of August 2019

f

Signature
Senior Coroner for the City of Sunderland

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Home Office (PDF)
Home Secretary 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

17 October 2019 

Mr Derek Winter  
Civic Centre   
Burdon Road  
Sunderland  
SR2 7DN 

Dear Mr Winter 

I am writing in response to your Regulation 28 report of 27 August following the tragic 
death of Kay Richardson. Your report raised a concern regarding the protection in place for 
the victim. 

I am acutely aware of issues regarding the use of pre-charge bail, particularly in relation to 
vulnerable victims and witnesses. As such I am working closely with criminal justice 
partners on what further mitigations can be put in place. A significant amount of further 
work is already in train on this matter, including to ensure the robustness of current 
frameworks and greater oversight of the use of pre-charge bail in high harm cases.  

However, it is important to be clear that pre-charge bail, including conditions, continues to 
be available to the police where it is necessary and proportionate, including to prevent 
further offences and protect victims and witnesses. 

To date, the Home Office has coordinated the implementation of a number of actions on 
this issue. For example, the National Police Chiefs’ Council (NPCC) has published 
operational guidance that provides clear advice on domestic abuse and high harm cases, 
specifying that if a suspect has been arrested in connection with an offence involving 
vulnerable people or domestic abuse, there should be documented decision-making as to 
why pre-charge bail has not been used and serious consideration given to the imposition 
of bail with conditions in order to safeguard the victim. The guidance also advises that a 
detective inspector should be consulted before a domestic abuse or high harm offense 
suspect is released under investigation.  

In addition, HMICFRS are inspecting all forces on their use of pre-charge bail. The reports 
will be key in building our evidence base for what wider changes may be necessary and 
as such the Government will give serious consideration to its findings. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You also raised concerns about the decision of the police to return to the perpetrator his 
home keys. As I gather you are aware, the Independent Office for Police Conduct 
investigated this matter in order to understand why such a decision would have been 
taken and to help prevent such events occurring in the future, and I expect the police to 
act on the findings. 

More broadly, you may be aware that earlier this year the government introduced its 
landmark Domestic Abuse Bill and alongside this has published a comprehensive package 
of other measures following the domestic abuse consultation that took place in 2018.  The 
government is committed to transform the response to this abhorrent crime that affects so 
many people in society, particularly women and sometimes with tragic consequences, 
such as the death of Kay Richardson.  The package of legislative and non-legislative 
measures puts prevention and protection at the heart of the government’s approach to 
combat domestic abuse.  

I hope my response is reassuring and I am grateful to you for writing and bringing this 
important matter to our attention.   

Yours sincerely, 

Rt Hon Priti Patel MP

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