Alfie Gildea

Deputy Chief Crown Prosecutor 

HM Senior Coroner, Greater Manchester South 
1 Mottram Street 
Mount Tabor  
Stockport  
SK1 3PA 

Date 5 January 2021 

Our ref: 

Dear Mrs Mutch, 

Re: Regulation 28 Report following the Inquest touching upon the death of Alfie Gildea. 

Thank you for your report sent by email dated 17 November 2020 in respect of Alfie Gildea (deceased) and pursuant 
to  paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013. 

Having carefully considered your report and the matters relating to the Crown Prosecution Service therein, I reply as 
follows: 

Extract from Regulation 28, point 2: 

The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different.  
It  was  unclear  why  this  was  the  case.    However,  as  a  result  there  are  different  points  at  which  an  offender’s 
background triggers the requirement to treat the suspect as a serial/serious DA perpetrator. 

The  CPS  Domestic  Abuse  Guidelines  describe  a  serial  perpetrator  as  someone  who  ‘has  committed  an  act  of 
domestic abuse against two or more different victims’.  Therefore, had all available information been provided to the 
Crown Prosecution Service on 10 July 2018 then Gildea ought properly to have been identified as a serial perpetrator 
within the terms of the CPS definition. Had the prosecutor then followed the appropriate CPS Policy he would have 
been directed to think about building the case without the support of the victim and to consider whether or how to 
bring other potential victims on board. 

By contrast, according to the College of Policing website: 

‘A serial perpetrator is someone who has been reported to the police as having committed or threatened domestic 
abuse against two or more victims. This includes current or former intimate partners and family members.’ 

Although broadly similar to the CPS definition it appears to specifically require there to have been reports to the 
police from or about two different victims. Via email correspondence with Greater Manchester Police’s Public 
Protection and Serious Crime Directorate I have confirmed that this is the definition used by them in managing 
Domestic Abuse investigations.   

Crown Prosecution Service, CPS North West, Sunlight House, Quay St, Manchester, M3 3LU 
DX: 744372 Manchester 53      Tel: 0161 827 4700 
 www.cps.gov.uk 

 
 
 
   
 
 
 
 
                    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I am not able to say how different descriptions have been developed.  There is obvious sense in the police and CPS 
definitions  aligning  so  that  it  is  clear  for  everyone  involved  in  the management  of  criminal  Domestic  Abuse  cases 
when a suspect should be regarded as a serial perpetrator.   

Although the CPS definition is wider than that used by the police because it doesn’t specifically require a report to 
the  police  to  have  been  made,  it  ought  to  be  acknowledged  that,  in  reality,  the  most  likely  source  of  such 
information will be held by the police following a report by a victim or third party on their behalf. 

I confirm that the disparity between the definitions has been highlighted to the Crown Prosecution Service’s national 
policy team so that they may consider further. 

Samuel Gildea clearly fitted the description of a ‘serial DA perpetrator’ on either of the CPS and Police’s definitions 
of the term and therefore information relating to reports by previous victims ought properly to have been provided 
to the Crown Prosecution Service in July 2018. 

Extract from Regulation 28, point 10: 

(10) The evidence to the inquest was that although there is a clear policy regarding information sharing between 
the CPS and Police that was not followed.  The file that was submitted omitted key information available to GMP 
that would have been important to the Decision Maker.  The CPS Decision Maker did not follow CPS Guidance, set 
an Action Plan or document any detailed assessment of proceeding without the direct evidence of the victim.  The 
inquest was told it was likely that there was a conversation between the officer and the CPS Decision Maker.  This 
was  not  documented  by  either  of  them  and  there  was  no  evidence  that  such  conversations  are  routinely 
documented despite the fact that they may contain key information.   

As part of the evidence to the inquest the Crown Prosecution Service acknowledged that the prosecutor (a) failed to 
consider or apply their Guidance (b) should have set an action plan and (c) gave no proper consideration to whether 
this was a case capable of being built as a victimless prosecution. 

All CPS Direct prosecutors have been recently trained on ‘Case Analysis and Strategy’.  This training focussed on the 
importance of recording the rationale for decisions and the selection of charge. It included a detailed case study on a 
coercive  and  controlling  case  involving  a  serial  Domestic  Abuse  perpetrator.  The  training  also  involved  a 
comprehensive analysis of available evidence and the suspect’s previous Domestic Abuse history with other partners 
and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from 
the outset. This training took place from December 2019 to June 2020 and is part of the induction program for new 
lawyers joining CPS Direct. 

CPS Direct have also trained all prosecutors on ‘Domestic Abuse Evidence Led Prosecutions’. This built on the Case 
Analysis  and  Strategy  training  focussing  on  the  importance  of  case-building  DA  cases  from  the  very  start,  where 
possible strengthening the case to ensure that it could proceed without the victim. It also gave refresher guidance 
on the available legislation and gateways for the admission of evidence without calling the victim, stressing the need 
to ensure scrupulous policy compliance before an ‘NFA’ decision is reached. This training was completed between 
July-October 2020 and is also part of the induction program for new lawyers joining CPS Direct. 

In  CPS  North  West  over  the  course  of  August  and  September  2020  prosecutors  underwent  training  about  the 
structure  and content of a good review which included a specific section on the  need to carefully record decision 
making  in Domestic  Abuse  cases  and to think  about  whether  it  is  possible to  proceed  without  the  support  of  the 
victim.  The Evidence Led Prosecutions course which has been delivered by CPS Direct will also be rolled out locally 
to Magistrates’, Crown Court and RASSO prosecutors as soon as we are able to do so.  I am not able to commit to a 
date at the present time because of other national training commitments which are required to be delivered first.  I 
have  held  a  preliminary  meeting  with  Detective  Superintendent 
  and  confirmed  with  him  that  a  number  of 
GMP officers involved in Domestic Abuse investigations will also be invited to attend so that they can deliver similar 
training in force.   

2 

  
 
 
   
 
 
 
 
   
 
 
 
 We  also  take  on  board  the  importance  of  a  consistent  and  transparent  approach  to  recording  whether  there  has 
been  a  telephone  call  with  the  police  as  part  of  the  charging  decision.  Senior  managers  within  CPS  Direct  have 
confirmed that guidance has been re-issued to all of their prosecutors on the need to include within the MG3 details 
of  any  conversation  relevant  to  an  issue  in  the  case,  where  it  is  not  already  included  within  the  documentation 
submitted.   

Finally,  although  not  a  formal  recommendation,  I  would  like  to  comment  on  the  reference  within  Section  4 
paragraph 7 concerning reasonable lines of enquiry especially in the light of the newly issued Director Guidance 6 
which comes into force on 31 December 2020.   

Within  my  original  witness  statement  I  explained  the  role  of  the  prosecutor  in  relation  to  the  identification  of 
reasonable lines of enquiry.  It remains the case, however, that there is no power for a prosecutor to formally direct 
the police to undertake such enquiries and their role in this is advisory.  From the Director’s Guidance on Charging 
6th Edition:  

Paragraph 3.1 (concerning the responsibility of the police): 

•  Complying  with  the  decision  of  the  prosecutor  to  charge,  caution,  obtain  additional  material  or 
information or take no action, with appropriate expedition, unless the case is escalated for  review. 
The police will notify the prosecutor if the case cannot so proceed, explaining why; and 

•  Complying  with  action  plans  and  providing  any  further  evidence,  material,  or  other  information 

within agreed time periods. 

The process therefore ought to be that where there are  identifiable outstanding reasonable lines of enquiry these 
should be included in an action plan by the prosecutor.   Where the police do not comply with the action plan then 
consideration  needs to  be  given  to  any  reason  for  such  failure  (for  example  where  the  material  is  not  capable  of 
being obtained by them or where they refuse to carry out such enquiry).  Prosecutors are expected to be proactive 
in their use of locally agreed escalation processes in order to obtain the requested material so as to give the best 
possible chance to build a case to the point of charge. 

I hope that this response is helpful in outlining the actions that we are taking to address the issues that were raised 
by the tragic death of Alfie Gildea and in demonstrating our commitment to learning lessons so that we can do our 
utmost to prevent such incidents from occurring in future. 

Yours faithfully, 

Deputy Chief Crown Prosecutor 
CPS North West 

3

Corporate Director 
Children’s Services 
Trafford Council 
Trafford Town Hall, Talbot Road, 
Stretford, Manchester M32 0TH  

Email 

Telephone 

www.trafford.gov.uk 

Date:  26 November 2020 
Ref:  Case 

Alison Mutch OBE 
HM Senior Coroner 
HM Coroner’s Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Via email: 

Dear Ms Mutch 

Re: Death of Alfie Ian Samuel GILDEA  

Thank you for your letter dated 18 November 2020 enclosing your Regulation 28 report. 

As  was  confirmed  and  accepted  at  the  inquest,  the Council  has made  significant  improvements  to  its  policies  and 
procedures since 2018.  The full details of these changes and improvements were set out in detail in the Council’s 
evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating 
to  the  Council.    In  relation  to  the  possible  national  issue  identified  in  point  15  of  your  listed  concerns,  our 
understanding  was  that  it  was  your  intention  to  write  to  central  government,  specifically  the  Department  for 
Education. 

If the Council is able to assist further or if there is any additional information that you require, please do not hesitate 
to contact me”. 

Yours sincerely. 

J
Corporate Director, Children’s Services

From Jo Churchill MP 
Parliamentary Under Secretary of State for Prevention, 
Public Health and Primary Care 

39 Victoria Street 
London 
SW1H 0EU 

12 March 2021 

Your Ref: 

Our Ref: 

Ms Alison Mutch 
HM Senior Coroner, Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1 3AG

Dear Ms Mutch, 

Thank you for your correspondence of 18 November 2020 to Matt Hancock, relating to the 
death of Alfie Gildea.  I am responding as Minister responsible for health visiting services 
and I am grateful for the additional time in which to do so.  

Firstly, I would like to take this opportunity to offer my sincere condolences to baby Alfie’s 
mother and family. 

I wish to assure you that this Government is committed to ending violence against women 
and children and recognises the important role all statutory agencies play in helping to 
prevent the deaths of children in circumstances such as those suffered by Alfie and his 
family.  

I have noted carefully your concerns about the actions of the Trafford health visiting 
service and the poor information sharing between Greater Manchester Police, Trafford 
Council and the health visiting service in this case, as well as your concerns about the 
numbers of health visitors nationally.  

I have been made aware that the Trafford Strategic Safeguarding Partnership (TSSP), 
initiated a serious case review (SCR) into Alfie’s case, published in December 2019.  This 
recommended a number of actions for local agencies, including NHS providers and the 
local clinical Commissioning group, as well as actions for the TSSP itself, including an 
update of the multi-agency domestic abuse policy and guidance.  I am also aware that the 
Greater Manchester Health and Social Care Partnership (GMHSCP), in its response to 
you, has advised that in light of the inquest findings, local agencies are reviewing the SCR 
action plan to ensure all local learning is ascertained, acted upon and shared. 

I understand detailed information on the improvement actions that individual local 
organisations are taking to address the matters of concern in your report will be provided 
to you separately.  In its response, the GMHSCP provided assurance that the actions will 
be closely monitored.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 Health professionals, including health visitors and their teams, are in a unique position to 
identify and, where appropriate, support children and families with safeguarding issues.  
As professionals they are required to be competent in child protection and are expected to 
regularly participate in training to update and maintain their skills. 

In March 2017, the Department published a resource for health professionals, Responding 
to domestic abuse [1], an update to a handbook for healthcare professionals published in 
2005. 

The resource drew on previous public health guidance published in 2014 by the National 
Institute for Health and Care Excellence (NICE) on Domestic Violence and Abuse: Multi  
agency working [2], and the accompanying 2016 guide, Quality Standard, Domestic 
Violence and Abuse [3].  

The Department’s resource set out the responsibilities of providers and commissioners of 
health services, and of practitioners in responding to victims of domestic abuse.  It 
included a new section offering practical guidance to healthcare professionals on dealing 
with the perpetrators of domestic abuse. 

On confidentiality and sharing information, the guide acknowledges that while it is vital that 
information on domestic abuse is kept confidential to protect victims from injury or death, in 
some instances, failure to share information can put victims at risk.  

Professionals may lawfully share information, without patient consent, if this can be 
justified in the public interest, or where they are required by law or court order.  For 
example: 

•  Where there is risk of harm to the victim, any children involved or somebody else if 

information is not passed on as a referral; 

•  To inform a risk assessment (where the definition of 'harm' to a child includes 
impairment caused by seeing or hearing the abuse of another person); or 

•  When the courts request information about a specific case. 

In order that organisations, agencies and practitioners collaborate effectively, it is vital that 
everyone working with children and families, including those who work with parents/carers, 
understands the role they play.  

The inter-agency guide Working Together to Safeguard Children [4] (2018) strengthened 
the arrangements in this area.  I would expect practitioners to be aware of, and comply 

1 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/597435/Do
meticAbuseGuidance.pdf  
2 https://www.nice.org.uk/guidance/ph50/resources/domestic-violence-and-abuse-multiagency-working-pdf-
1996411687621  
3 https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381  
4 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Workin
g_together_to_safeguard_children_inter_agency_guidance.pdf  

 
 
 
 
 with, the published arrangements set out by the local safeguarding partners as detailed in 
the inter-agency working guide.   

The multi-agency guidance sets out specific details for practitioners on being aware of and 
developing their understanding of domestic abuse, which includes controlling and coercive 
behaviour from perpetrators of domestic abuse, and the impact this has on children. 

Health visitors as leaders of the Healthy Child Programme (HCP) deliver the HCP zero to 
five and are equipped to work at community, family and individual levels.  They are skilled 
in identifying issues early, determining potential risks, and providing early intervention to 
prevent issues escalating.  

Since 2015, local authorities have been responsible for the commissioning of services for 
children between the ages of 0-5 and it is for local authorities to determine the required 
numbers of health visitors based upon local needs.  All commissioning should be based on 
a robust Joint Strategic Needs Assessment and supported by local workforce plans.  In 
this financial year, local authorities will receive a £3.279 billion public health grant for their 
public health duties for all ages [5]. 

There is no single source that counts health visitors across all the bodies local authorities 
commission services from.   We do know that NHS workforce statistics for hospital trusts 
and clinical commissioning groups show 6,753 full-time equivalent health visitors deployed 
by Hospital and Community Health Services in September 2020.  

Universal reviews provided by Health Visitor Services have been mandated, following the 
transfer of zero-to-five services to local authorities.  This is to enable services to be 
delivered in the context of a national, standard format to ensure consistent delivery. 

Finally, you may wish to note that we are awaiting a report from the Early Years Health 
Adviser, Andrea Leadsom MP, who has been leading a major review into improving health 
outcomes in babies and young children [6].  The review will consider the barriers that 
impact on early-years development, including social and emotional factors and early 
childhood experiences, and seek to show how to reduce the impacts of vulnerability and 
adverse childhood experiences in this stage of life. 

I hope this response is helpful.  Thank you for bringing these concerns to my attention.  

JO CHURCHILL 

5 https://www.gov.uk/government/publications/public-health-grants-to-local-authorities-2020-to-2021 
6 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches

Greater Manchester  Health and Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London  Road 
Manchester  M1 3BN 

T: 

E: 

26 November 2020   

Ms A Mutch OBE 
HM Senior  Coroner 
Coroner’s  Court 
1 Mount Tabor  Street 
Stockport 
SK1 3AG   

Dear Ms Mutch  

Re: Regulation  28 Report to Prevent Future Deaths – Alfie Ian Samuel Gildea 
18.11.2020     

Thank you for your Regulation  28 Report dated  18 November 2020  concerning the 
sad death  of Alfie Gildea  on 14 September  2018.  Firstly, I would  like to express  my 
deep  condolences  to Alfie Gildea’s  family.  

The inquest  concluded that Alfie’s death  was a result of 1a) Head Injury.  

Following  the inquest  you raised  concerns in your Regulation  28 Report  to Greater 
Manchester  Health and Social Care Partnership  (GMHSCP) that there is a risk future 
deaths  will occur unless  action is taken. 

I have noted  that your Regulation  28 letter  has also  been sent  to Greater Manchester 
Police, Trafford Metropolitan  Borough Council,  Greater Manchester Mental  Health 
NHS Foundation  Trust,  Pennine  Care NHS Foundation  Trust, The Crown 
Prosecution  Service, the Home Office and the Department  of Health and Social Care  
and I will leave it to the named respondents  to address  the concerns which you have 
expressed.  My letter therefore addresses  the issues  that fall within  the remit of 
GMHSCP more widely around  how we can share  the learning  from this case. 

NHS England  / Improvement Regional  Safeguarding  and Quality Team use  a variety 
of approaches  to share  learning  and good  practice across the North West and North 
East & Yorkshire  Regions.   This  includes  a weekly safeguarding  bulletin  which is 
disseminated  to CCG Designated  Professionals  and dissemination  of “7 minute 
briefings”  following published  serious  case reviews (SCR), domestic homicide 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 reviews and serious  adult reviews across  the regional  footprint  to promote  learning 
and share  good practice. 

An SCR was completed  and published  in December 2019  which resulted  in the 
identification  of a number of actions  that are being  overseen  by the Trafford Strategic 
Safeguarding  partnership.  In light  of the findings  of the inquest  the SCR action plan 
is being  reviewed and scrutinised  with a view to ensuring  that all local learning  is 
ascertained,  acted upon and shared.  Further details  on this will be within the 
individual  responses  to the regulation  28 from other partners. 

- 

Actions taken  or being taken to prevent reoccurrence  across  Greater 
Manchester. 

1.  Learning  to be presented/shared  with the Greater Manchester Quality Board.   

This  meeting is attended  by commissioners,  including  commissioners  of 
specialist  services, regulators,  Healthwatch  and NICE. 

2.  Learning  to be shared  with the Greater Manchester  commissioners  of 

services to consider  the findings  of the investigation  within the context of the 
services they commission 

The Greater Manchester  Health and Social Care Partnership  (GMHSCP) is 
committed to improving outcomes for the population  of Greater Manchester.  In 
conclusion  key learning  points  and recommendations  will be monitored  to ensure 
they are embedded  within  practice. 

I hope  this response  provides  the relevant  assurances  you require.  Thank you for 
bringing  these important  patient  safety issues  to my attention  and please  do not 
hesitate  to contact me should  you need any further information. 

Yours sincerely 

Chair of GM Medical Executive, GMHSCP

A/Chief Constable 

HM Senior Coroner Ms Alison Mutch 
HM Coroner's Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch 

8 January 2021 

Re: Regulation 28 Report following the inquest into the death of Alfie Ian Samuel Gildea 

Thank you for your report sent by email dated 18 November 2020 in respect of the events which led to 
the tragic death of Alfie Gildea and pursuant to Regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013 and paragraph 7, Schedule 5, of the Coroners and Justice Act 2009. 

Having  carefully  considered  your  report,  Greater  Manchester  Police  (GMP)  accepts  in  full  the  points 
raised.  As  a  consequence,  your  report  has  already  led  to  detailed  discussions  within  GMPs 
Professional Standards Branch as to the issues which have arisen in this and other cases, with a view 
to taking further co-ordinated action to address the concerns identified. I have provided more detail of 
these measures below and reply to the specific issues raised as follows: 

1.  The  inquest  was  told  that  at  the  time  of  the  allegation  of  assault  in  July  2018  suspects  in 
domestic  abuse  cases  were  not  placed  on  bail  with  conditions,  to  protect  alleged  victims, 
where further investigation was required. Instead they were placed under investigation. 

At the time of the allegation of assault on the 10 July 2018, GMP was complying with the Policing and 
Crime Act 2017 which was implemented on the 3 April 2017. The biggest change was that there was a 
presumption  of  release  without  bail  in  almost  all  cases.  National  Police  Chiefs  Council  (NPCC) 
guidance  was  issued  to  all  Forces  in  relation  to  the  new  legislation,  but  Forces  were  encouraged  to 
reduce  the  use  of  bail  conditions  due  to  concerns  around  how  long  individuals,  who  had  not  been 
charged with any offences, were subject to those conditions. 

The  GMP  policy  in  place  at  the  time  of  Alfie's  death  did  not  stipulate  that  bail  should  not  be  used  in 
domestic abuse cases. It is recognised, however, that the significant change in approach to police bail 
that followed the introduction of the Policing and Crime Act 2017 meant that there was a potential for 
misunderstanding in relation to the application of the legislation to police bail at that time. 

In  May  2019,  the  NPCC  issued  updated  operational  guidance  regarding  the  use  of  bail  to  all  Forces. 
This operational guidance followed a review undertaken by Her Majesty's Inspectorate of Constabulary 
and  Fire  &  Rescue  Services  (HMICFRS)  which  identified  that  the  use  of  bail  across  the  UK  had 
decreased since the new Bail Act changes were implemented. The operational guidance supported the 
use of bail in domestic abuse cases and other safeguarding investigations. GMP's Criminal Justice and 
Custody branch have recently conducted a review of bail and released under investigation (RUI), which 
includes  domestic  abuse  cases.  The  results  of  this  review  are  being  discussed  with  the  Public 
Protection Governance Unit with a view to ensuring robust compliance across the force. 

2.  The  inquest  was  told  that  the  GMP/CPS  definitions  of  a  serious/serial  domestic  abuse 
perpetrator were different. It was unclear why that was the case. However, as a result there 
are different points at which an offender's background triggers the requirement to treat the 
suspect as a serial/serious DA perpetrator. 

GMP has liaised with Deputy Chief Crown Prosecutor 

 in relation to this matter.   

 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
     
 
 
 
 
 Cont.t pg 2…….. 

The  current  definition  of  a  serial  domestic  abuse  perpetrator  used  by  GMP,  which  is  aligned  with  the 
definition used by the College of Policing, is:  'A serial perpetrator is someone who has been reported to 
the  police  as  having  committed  or  threatened  domestic  abuse  against  two  or  more  victims.  This 
includes current or former intimate partners and family members.' 

The CPS definition is: 'Where a suspect has committed an act of domestic abuse against two or more 
different victims they should be considered a serial perpetrator.' 

The difference is the inclusion in the police definition of the previous incidents having been reported to 
the  police  which  is  not  present  in  the  CPS  definition.  It  stands  to  reason  that  the  CPS  would  not  be 
aware of incidents reported to the police that did not either result in a crime being recorded or referred 
to  the  CPS.  GMP  are  currently  seeking  clarification  that,  whilst  the  CPS  have  the  ability  to  flag  a 
particular case file as a domestic case, they potentially cannot, or do not, flag the individuals involved in 
that case as repeat or serial and rely on the police to share this information. Neither GMP nor the CPS 
uses the terminology of serious domestic abuse perpetrator. 

The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation.  
It  will  provide  clear  definitions  on  the  application  and  use  of  the  serial  domestic  abuse  perpetrator 
marker.    Guidance  will  be  shared  with  police  officers  and  police  staff  based  in  safeguarding  units 
around the correct application of this information marker on a person's record. 

A  whole  system  approach  to  offender  management  has  been  agreed  in  principle  at  the  Justice  and 
Rehabilitation  Executive  Board  by  the  Deputy  Mayor  which  will  include  GMP,  National  Probation 
Service  (NPS),  and  Community  Rehabilitation  Company  (CRC).  This  will  include  management  of 
domestic abuse perpetrators. 

3.  It  was  unclear  where  the  information  that  an  individual  met  the  criteria  for  a  serial  and 
serious DA Perpetrator should or did sit in GMP's systems. Officers giving evidence did not 
understand how such information could be accessed or recorded. 

At  the  time  of  GMP’s  involvement  with  Alfie's  parents,  GMP  used  OPUS  which  is  a  records 
management  system.  The  domestic  abuse  policy  at  that  time  stipulated  that  a  serial  domestic  abuse 
perpetrator was: 'Someone who has committed domestic abuse against three or more different partners 
or an offender who has committed five or more domestic abuse offences against one partner. In these 
circumstances  officers  should  utilise  the  PPI  (Public  Protection  Incident)  and  FIS  (Force  Intelligence 
System)  to  identify  additional  risk  factors  to  a  victim  and  consider  use  of  the  Domestic  Violence 
Disclosure Scheme. Consideration should be given to flag the perpetrator via the FIS OPUS system as 
a domestic abuse serial perpetrator.' 

When  a  serial  domestic  abuse  perpetrator  was  identified,  they  would  be  flagged  as  such,  which  was 
immediately visible on the person's record held in OPUS as per the example below: 

At  the  time  of  GMP’s  involvement  with  Alfie's  parents,  the  expectation  was  that  multi  agency 
safeguarding  hubs  would,  in  the  main,  identify  and  add  relevant  information  markers  to  people  who 
required it. However, it was not their sole responsibility and the marker could be applied by anyone who 
identified it.  

Had  the  GMP  policy  been  followed,  Samuel  Gildea  should  have  had  a  serial  domestic  abuse 
perpetrator marker added, but he did not. It is possible that there may have been a lack of  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 3…….. 

understanding  around  when  a  person  was  considered  a  serial  domestic  abuse  perpetrator  as  the 
definition at that time was less clear than the definition in the new domestic abuse policy. 

Information  markers  can  be  added  in  iOPS  in  a  very  similar  manner.  At  present,  there  are  some 
enhancements  planned  for  Spring/Summer  2021  which  will  further  improve  the  information  markers 
available in iOPS, however both high risk and serial victims and perpetrators can now be added by all 
users. These information markers are presented/visible as per the example below: 

4.  There  was  a  lack  of  understanding  amongst  police  witnesses  about  the  GMP  policy  in 
relation  to  serial/serious  DA  perpetrators  and  the  actions  that  were  required  under  GMPs 
policy. 

At the time of Alfie's death, the domestic abuse policy stipulated the following on serial domestic abuse 
perpetrators: 'In these circumstances officers should utilise the PPI (Public Protection Incident) and FIS 
(Force  Intelligence  System)  to  identify  additional  risk  factors  to  a  victim  and  consider  use  of  the 
Domestic  Violence  Disclosure  Scheme.  Consideration  should  be  given  to  flag  the  perpetrator  via  the 
FIS OPUS system as a domestic abuse serial perpetrator.' 

The presence of an information marker is just that; it provides information to officers around potential 
risk factors that they may wish to consider when dealing with incidents. The presence of these markers 
rarely stipulates that a subsequent action should be followed and it is not intended that this should be 
the case. Information markers are used to guide officers in making appropriate decisions in accordance 
with the National Decision Model. Whilst the serial domestic abuse perpetrator marker was not applied 
in  the  case  of  Samuel  Gildea,  the  incidents  that  he  had  been  linked  to  as  a  perpetrator  of  domestic 
abuse were visible and accessible to all and officers are expected to assess previous history in coming 
to assessments about risk factors. 

The definitions for repeat and serial victims and perpetrators have been revised since Alfie's death to 
simplify them. Where automation of markers can occur, this is being explored, however clear direction 
on the application and use of the serial domestic abuse perpetrator marker will be shared  with police 
officers and staff when the domestic abuse policy is agreed. The Public Protection Governance Unit is 
currently  working  with  iOPS  and  Capita  to  ensure  visibility  and  understanding  of  when  information 
markers should be applied and how to do this. 

5.  Evidence  at  the  inquest  suggested  that  the  majority  of  officers  had  received  very  limited 
training in relation to DA and in particular coercive and controlling behaviour. Understanding 
of how coercive and controlling behaviour in a relationship could be identified was limited. 

When coercive and controlling behaviours came into legislation in 2015, a train-the-trainer model was 
used  in  order to  efficiently  train  as  many  GMP  staff  as  possible.  At this  time,  over  800 front  line  staff 
were  trained.  This  training  provided  an  understanding  of  the  legislation  and  application  of  it,  with  key 
features of coercive and controlling behaviours highlighted. 

 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 4…….. 

GMP's student officers receive a full day’s domestic abuse input which gives an overview of the various 
strands of  domestic  abuse,  including  coercive  and  controlling  behaviours.  In  addition,  student  officers 
also complete a two-week consolidation training course prior to going out on independent patrol. Within 
this course, the students receive a full day’s safeguarding input, which is heavily focused on domestic 
abuse and child protection. 

Between  2015  and  2020,  2773  PCs  completed  the  Safeguarding  for  Constables  course  at  Sedgley 
Park  which  incorporated  coercive  and  controlling  behaviours  within  a  relationship.  Further  CPD  was 
due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual 
CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition 
and  typology;  the  'murdered  by  my  boyfriend'  film;  coercion  and  control;  stalking  and  harassment; 
identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and 
incident closing codes. 

DCI 
  from  the  Public  Protection  Governance  Unit  has  been  seconded  to  the  People  and 
Development  Branch  to  review  all  GMP  vulnerability  training  in  the  first  instance.  Following  initial 
scoping, she will design, establish, and test a new vulnerability training offer for the force. 

6.  The inquest was told that the DASH risk assessment is a national tool. However training of 

GMP officers on understanding how to evaluate risk and score risk was limited. 

GMP's People and Development Branch has advised that all officers now receive training on the DASH 
risk model and coercive controlling behaviour as part of their initial student officer training. This includes 
highlighting certain questions on the DASH risk assessment which can indicate escalated risk of harm, 
such as non-fatal strangulation. At the time OPUS was in use, these higher risk questions were denoted 
by being in a bolder print than other questions. Training on the DASH risk model was also delivered on 
the aforementioned Safeguarding for Constables course. 

At  the  time  of  GMP’s  involvement  with  Alfie's  parents,  the  force  policy  stipulated  that  officers  should 
take into account the circumstances of the incident, the vulnerability of the victim, and the history of the 
perpetrator  when  making  a  risk  assessment.  The  new  force  policy  offers  more  guidance  to  officers 
around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, 
such as standard risk, would not be appropriate.  This includes: 

•  Three or more domestic abuse incidents in the last 12 months. 
•  Are  there  warning  markers  for  child  protection,  high  risk  domestic  abuse  serial  perpetrator,  or 

violence? 

•  Pattern of coercive or controlling behaviour? 
• 
• 
•  Has the perpetrator abused one or more previous victims? 

Is there a pattern of stalking and harassment? 
Is there any report of non-fatal strangulation? 

It is envisioned that this will be shared with officers on a regular basis during continuous professional 
development inputs and identified training courses. Additionally, the Public Protection Governance Unit 
has recently designed some refresher presentation for safeguarding teams around risk identification.  

This Unit is also working with the People and Development Branch to support a newly designed course 
which is aimed at officers and staff in the organisation who work in a safeguarding role where they need 
to  evaluate  risk  and  provide  formal  training  to  support  those  staff  in  understanding  risk  factors  and 
identifying them at the earliest opportunity. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 5…….. 

7.  Recognition  of  when  and  how  Clare's  Law  should  be  used  and  the  understanding  of  its 

importance in DA cases was limited amongst the officers giving evidence. 

The Domestic Violence Disclosure Scheme (DVDS) policy has recently been submitted to GMP's Policy 
and Strategy team for rework. The revised policy has made a number of enhancements to ensure that 
Clare's Law is considered by safeguarding teams on every domestic abuse incident they receive. The 
revised policy has also re-instated that a Detective Inspector should review and authorise the form of 
words that is to be disclosed to the victim. 

In Spring/Summer 2021, there will be a specific DVDS marker available in iOPS which will be applied to 
a  person's  record  to  reflect  that  they  have  made  an  application  under  Clare's  Law.  The  information 
marker  will  denote  whether  a  disclosure  was  made  or  not  and  where  further  information  about  the 
disclosure can be located. This will also make it far more visible to all officers that concerns have been 
raised by either an individual, a third party, or by GMP. 

In  2019,  the  People  and  Development  Branch  delivered  training  to  all  first  responders  at  the  rank  of 
Constable, Sergeant, and Inspector to raise awareness of the DVDS and their responsibilities to identify 
when a disclosure may be appropriate, as well as how to share information with the safeguarding team 
that will ultimately oversee the disclosure process. All new recruits are made aware of the background 
to the DVDS and the aims and objectives of the scheme. 

It  is  intended  that  when  the  revised  policy  is  agreed,  estimated  to  be  in  February  2021,  there  will  be 
accompanying training material to raise awareness of the key changes and of the process itself. 

8.  The  limited  training  and  understanding  of  GMP  officers  meant  that  lines  of  further  enquiry 

that would allow for a victimless prosecution were not followed. 

It is recognised that GMP's previous domestic abuse policy did not fully explore or explain 'victimless' or 
evidence-led  prosecutions.  The  revised  domestic  abuse  policy  provides  clear  definitions  and 
responsibilities for officers investigating domestic abuse offences to consider evidence-led prosecutions 
where appropriate to do so. 

GMP recognise that this area needs further development and are currently in discussions with the CPS 
who are delivering training to prosecutors on this topic. It is intended that GMP will attend this training 
with a view to delivering something similar to the wider GMP workforce. By having a joint training event, 
this  will  ensure  that  the  CPS  and  police  are  aligned  in  the  delivery  and  expectations  of  evidence-led 
prosecutions. 

9.  The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU 
units. However the inquest heard that as a result the limited specialist support and oversight 
offered  to  neighbourhood/response  officers  had  further  reduced  in  low/medium  risk  DA 
cases. 

These  areas  of  concern  are  recognised  by  the  Investigation  Safeguarding  Review  2  (ISR2)  project. 
Recommendations  have  been  made  by  the  ISR2  team  for  GMP  to  restructure  their  vulnerability  and 
safeguarding  model  by  introducing  specialist  Child  Protection  Investigation  and  Adult  Safeguarding 
Units. These are only recommendations and are currently being discussed at Chief Officer level against  

budgeting restraints going forward. Until a decision around ISR2 has been reached, interim mitigations 
have been put in place, including: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 6…….. 

• 

• 

• 

ISR2 project team to complete a dip-sampling exercise on each district to ensure that the children's 
crime allocation and triage (C-CAT) is being applied correctly and child protection crimes are being 
reviewed by an appropriately trained officer and allocated to the correct resource. 

ISR2 project team to speak to each district and ensure that as a minimum each high risk domestic 
abuse victim has telephone contact from officer within the MASH. 

ISR2 project team will establish whether district Independent Domestic Violence Advocate provision 
has  capability  to  support  high  risk  domestic  abuse  victims  within  24/48  hours  of  an  incident  being 
reported. Where gaps are identified, GMCA will be contacted to ensure these gaps are addressed 
through their commissioning. 

•  Districts will be required to complete the triage process within the 24 hour timescale set and triage 

against set standards developed by the Public Protection Governance Unit. 

•  Each  district  to  instigate  a  daily  /  twice  weekly  meeting  (virtual  or  physical)  with  adult  social  care, 
mental health services, and drugs and alcohol services to discuss adult protection incidents within 
the last 24/48 hours. 

•  The  ISR2  recommendations  in  relation  to  DCI  roles  and  responsibilities  to  be  implemented  giving 

district DCIs greater capacity to fulfil their core role. 

•  A  review  of  the  management  of  vulnerability  inbox  to  ensure  that  this  is  managed  by  the  correct 

resource who understands the requirements under NCRS. 

•  Each  district  to  introduce  a  monthly  /  bi-monthly  partnership  meeting  to  discuss  tactical  issues  / 

blockages. 

Updates in relation to the progress of the ISR2 project are being communicated internally and externally 
to provide clarity around the proposals, timescales, and the interim measures. 

10. The evidence to the inquest was that although there is a clear policy regarding information 
sharing  between  the  CPS  and  Police  that  was  not  followed.  The  file  that  was  submitted 
omitted  key  information  available  to  GMP  that  would  have  been  important  to  the  decision 
maker.  The  CPS  decision  maker  did  not  follow  CPS  guidance,  set  an  action  plan,  or 
document any detailed assessment of proceeding without the direct evidence of the victim. 
The inquest was told it was likely that there was a conversation between the Officer and CPS 
decision maker. This was not documented by either of them and there was no evidence that 
such  conversations  are  routinely  documented  despite  the  fact  that  they  may  contain  key 
information. 

GMP has liaised with Deputy Chief Crown Prosecutor 

 in relation to this matter. 

GMP  is  aware  that  ‘Case  Analysis  and  Strategy’  training  was  delivered  to  all  CPS  Direct  prosecutors 
between  December  2019  and  June  2020,  and  now  forms  part  of  the  induction  programme  for  new 
lawyers joining CPD Direct. The training involved a comprehensive analysis of available evidence and 
the  suspect’s  previous  domestic  abuse  history  with  other  partners  and  emphasised the  importance of 
setting  a  detailed  action  plan  to  ensure  early  and  effective  case  progression  from  the  outset.  This 
training  also  focused  on  the  importance  of  recording  the  rationale  for  decisions  and  the  selection  of 
charge. 

GMP  is  also  aware  that  ‘Domestic  Abuse  Evidence  Led  Prosecutions’  training  was  delivered  to  all 
prosecutors  by  CPS  Direct  between  July  and  October  2020,  and  also  forms  part  of  the  induction 
programme for new lawyers joining CPS Direct. This training built upon the aforementioned Case  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 7…….. 

Analysis and Strategy training, focusing on the importance of case-building domestic abuse cases from 
the very start to ensure that it could proceed without the victim.  GMP has confirmed with Deputy Chief 
 that a number of GMP officers involved in domestic investigations 
Crown Prosecutor 
will be invited to attend this training so that similar training can be delivered across GMP. 

11. The  GMP  policy  on  notification  of  DVPN/DVPOs  to  alleged  victims was  not followed.  There 
was  no  evidence  of  a  clear  and  effective  system  of  notification  on  the  Trafford  Division  of 
GMP. 

Since the death of Alfie, GMP has recruited two police staff to permanently and solely perform the role 
of DVPO officers. This has enabled a new process whereby the team now has extra flexibility to contact 
the victim as soon as the DVPO has been granted and offer additional support. If this contact fails, then 
the  new  process  outlines  the  clear  responsibilities  for  districts  to  make  contact  with  the  victim  and 
conduct compliance checks within specified timeframes. 

A revised DVPN/DVPO  policy has been signed-off and launched alongside an accompanying training 
package to reflect the changes to the process. The following changes to the DVPN/DVPO process have 
now been implemented force wide: 

•  Applications for a DVPN are reviewed by an Inspector prior to submission to the Superintendent. 
•  Any refused applications will be documented with a full rationale and collated by the DVPN/O team. 
•  Guidance on timescales to complete both offender compliance and victim engagement visits. 

12. Information  sharing  between  all  of  the  statutory  agencies  in  particular  health,  Local 
Authority, and Police was poor. As a result there was no holistic overview of the situation or 
shared  recognition  of  the  risk  posed  by  the  perpetrator.  Opportunities  to  use  the  MARAC 
framework were not taken. 

Each  GMP  district  has  a  multi-agency  safeguarding  hub  and  a  key  partner  within  that  hub  includes 
children's social care. It is understood that children's health is generally well represented in many hubs, 
albeit they may not be co-located in every district. Adult health representation in the safeguarding hubs 
is generally less  well represented. Some districts have representatives from adult social care, but the 
differences  in  primary  and  secondary  care  in  health  settings  makes  it  difficult  to  capture  all  facets  of 
mental health provision in the community or understand who may be accessing which services. 

GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in 
the triage process of six district safeguarding teams, including information sharing between agencies. 
The purpose of the review  was to understand the methodology and information considered as part of 
the triage decision making process and how this was recorded. This review identified good practice and 
areas for  development moving forward. Triage expectations  for  domestic  abuse,  child  protection,  and 
adults at risk have been circulated to districts to set out the standards expected during triage. Moving 
forward, the Public Protection Governance Unit is working with the People and Development Branch to 
establish a specific triage training course which will include guidance on information sharing. 

It  is  the  aim  of  the  Public  Protection  Governance  Unit  to  agree  consistency  across  the  district  teams 
and  ensure  that  information  sharing  agreements  and  protocols  which  have  been  established  are 
aligned with each other. 

MARACs  are  set  up  on  each  of  the  districts  with  a  local  case  management  team  employed  by  GMP 
providing the administration for the meetings. A Domestic Abuse Coordinator has been recruited and is  
currently  awaiting  authority  to  be  appointed. The  new  appointee  will  take  responsibility  for  ensuring  a 
consistent approach to MARAC is taken across the force. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Cont.t pg 8…….. 

Additionally,  when  the  newly  formed  training  course  for  safeguarding  teams  is  implemented,  this  will 
support improved identification of cases which need to be referred to MARAC. 

I hope that this response is helpful in outlining the actions that we are taking to address the issues that 
you raised, and in demonstrating our total commitment to learning lessons from tragic events such as 
those  which  led  to  the  death  of  Alfie  Gildea,  so  that  we  can  do  our  utmost  to  prevent  such  incidents 
from occurring in future. 

Yours sincerely 

A/Chief Constable

Direct Communications Unit 
2 Marsham Street 
London 
SW1P 4DF 

Tel: 
www.homeoffice.gov.uk 

David Jones 

DECS Reference: 

Dear David 

5 Feb  

Thank you for your letter of 18 November which shared the Regulation 28 report pertaining 
to Alfie Gildea’s death and please accept my apologies for the delayed response. 

The Report raised several matters of concern relating to Greater Manchester Police’s 
response to the management of Alfie’s father. I would like to share what has been done at 
a national level to address some of these issues. 

The management of serial and serious perpetrators of abuse is key to preventing further 
abuse and we are keen to ensure that we have the right systems in place to enable the 
police and agencies to accurately identify the risks posed by perpetrators.  As part of this 
work, the College of Policing issued guidance to police forces in last Summer on the 
‘Identification, assessment and management of serial or potentially dangerous domestic 
abuse and stalking perpetrators’.  The key principles set out that forces should have 
processes in place to identify serial or potentially dangerous domestic abuse or stalking 
perpetrators and ensure that information about the perpetrator is recorded on the Police 
National Computer, the Police National Database or ViSOR as appropriate. 

The Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law, is an 
important tool designed to keep people safe and we are working with the police to review 
the guidance used by forces.  Under Clause 70 of the Domestic Abuse Bill, we are seeking 
to place the guidance that underpins DVDS onto a statutory footing to drive greater use 
and consistent application of the scheme by placing an express duty on the police to have 
regard to the guidance.  Alongside legislation, we are reviewing the content of the 
guidance to ensure they are applied consistently across the country and are as effective 
as possible in helping to protect victims.  This review will consider the timelines involved in 
the process and the use of risk assessments and safety planning. 

The coercive and controlling behaviour offence is increasingly being used by police, but 
we continue to consider how best to work with forces to ensure they understand it and 
enforce the laws with maximum effect. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Finally, the Domestic Abuse Bill will introduce new Domestic Abuse Protection Orders 
(DAPOs).  Once the Bill receives Royal Assent, we intend to pilot the Orders before rolling 
it out more widely.  Police training will be an integral part of the rollout of DAPOs and we 
will produce detailed statutory guidance and a programme of training and toolkits for 
professionals to ensure there is a strong understanding of the new orders. 

Email: