Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0114, written 28 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2024 |
|---|---|
| Reference | 2024-0114 |
| Deceased | Sylvia Crowther |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Constable 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 2 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. 3 INVESTIGATION and INQUEST On 20 January 2023 I commenced an investigation into the death of Sylvia Dawn CROWTHER aged 58. The investigation concluded at the end of the inquest on 25 January 2024. The Conclusion of the Inquest was that the Deceased died as result of Suicide. 4 CIRCUMSTANCES OF THE DEATH The Deceased suffered with physical disabilities, mental health issues, and alcoholism. Her husband of 39 years was her main carer. At around 19.15 hours on 3 January 2023, the Deceased reported to Police that her husband was being violent towards her. On attending, the Police could see no visible marks or cuts but arrested her husband; the Deceased made it clear that she did not support any criminal action against him. On 4 January 2023, her husband was bailed until 28 February 2023 with conditions that he was not to return to the marital home. Police also made a Safeguarding Referral to Social Services who organised an urgent welfare visit to the Deceased that same evening. The Deceased refused all care services offered during the visit and stated that she would kill herself if her husband did not return home (but not that evening). The Deceased continued to refuse care when contacted by Social Services the following morning but was provided with the telephone number for the Safeguarding Team. Sometime between 14.45 and 15.45 on 6 January 2023 and, in a distressed state, Sylvia left a message on the Safeguarding Team’s phone requesting help. At 15.06 hours, she also sent a text to her Victim Engagement Officer stating that she could not cope on her own and requesting a call. Although a member of the Safeguarding Team spoke briefly to her on the phone at 16.30 hours, they requested Police to make an urgent welfare visit; a ‘prompt response’ was organised by Police Control Room at 16.56 hours but, owing to service demand, they arrived at 19.24 hours and found the Deceased unresponsive on the living room floor. Despite all resuscitation efforts, paramedics confirmed her death at 20.25 hours. and notes to her husband and to Police were found at the scene. The notes confirmed an intention to end her life and the note to Police indicated that she felt that they had not listened to her. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Although the Domestic Homicide Review (DHR) carried out in this case has already recommended a number of issues for agencies to consider, additional matters have been observed by the Court in relation to Police action: (i) (ii) (iii) Whilst some officers carried out their tasks effectively and appropriately, overall important steps in the Deceased's husband's arrest and subsequent conditional pre-charge bail did not appear to have been followed. In particular, S47ZZA PACE 1984 requires the investigating officer to seek the views of the alleged victim on whether relevant conditions should be imposed on the person's bail and then to inform the custody officer of these views but this was not done in this case: the first time that the Deceased was made aware of the nature of her husband's bail conditions was when the Police brought him home after his release on bail to collect his belongings. An earlier discussion between Police and the Deceased might have highlighted the Deceased’s deep emotional and physical dependence on her husband and the need to consider alternative options to criminal investigation with potentially more supportive care attached to them, such as the use of a DVPN/DVPO as highlighted by the DHR. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 24, 2024. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons - Head of Social Care, Central Bedfordshire Council I have also sent it to – DHR Report Author who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 9 Dated: 28/02/2024 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Assistant Chief Constable of Bedfordshire Police By Email Only Emma Whitting Senior Coroner for Bedfordshire & Luton 15th April 2024 Dear Ms Whitting, RE: Regulation 29 response to Coroners’ regulation 28 report to prevent future deaths in relation to the inquest into the death of Sylvia Crowther I write in my capacity as the Assistant Chief Constable of Bedfordshire Police and in response to the regulation 28 notice dated 28 February 2024. I understand this matter involves a vulnerable female who built up the courage to contact Bedfordshire Police on 3 January 2023, to report being the victim of domestic abuse (“DA”) by her husband. Statistics taken from the National Centre for Domestic Violence inform us that a domestic related call is made to the police every 30 seconds. Less than 24% of all domestic victims ever report their abuse to the Police. It is estimated that around 3 women per week die by suicide as a result of Domestic Violence (“DV”). There is a national strategic policing requirement for forces to tackle Violence Against Women and Girls (“VAWG”), supported by a delivery framework. Tackling VAWG, in particular domestic abuse, is a Bedfordshire Police priority. Officers and staff within Bedfordshire Police have undertaken ‘DA matters’ training and the force now have a total of 38 DA champions across a variety of Policing functions. When a victim contacts Bedfordshire Police, it is crucial that my Officers are seen to be trustworthy, compassionate, and sympathetic to ensure they gain the victim’s trust. At a time of heightened national concern about VAWG, Officers and Staff within Bedfordshire Police are encouraged to deal proactively with alleged perpetrators of DV. We understand from the charity Refuge that leaving an abusive partner is a process rather than a single act, which takes on average seven attempts. On 3 January 2023, Mrs Crowther made serious DA allegations, naming her husband as the perpetrator. I would expect my Officers to act on such allegations and arrest where appropriate. I understand that happened in this case and, subsequently, safeguarding needs were identified and actioned to prevent further harm. Safeguarding was especially important in this case as Mrs Crowther was classed as vulnerable due to her disabilities. Safeguarding concerns were heightened because the identified perpetrator was listed as her main carer. Policing involves the identification, balance and mitigation or management of competing risks., a process that involves gathering information from multiple sources, including from victims. Having considered the concerns you raise, I am satisfied our force has necessary procedures in place to ensure victims of DA are involved in conversations regarding important decisions, such as police bail. I appreciate that on this occasion the investigating Officer overlooked the requirement for interaction with the victim regarding imposing bail conditions on her husband. This meant that engagement did not take place until after the bail conditions had been imposed. However, I believe the Officer and his supervisor felt bail was necessary due to serious safeguarding concerns and I cannot see that the consultation would have made a material impact on the decision in the circumstances as they presented on this occasion. Nevertheless, reflective feedback has been provided to the individual Officer as well as to the wider Emerald Team in respect of the requirement for victim consultation regarding bail. To reassure you, a process is embedded across the force where upon the conclusion of the criminal interview, contact is made with the victims to discuss the status of the case, the proposed outcomes - including discussions regarding what bail conditions are appropriate (if bail is decided) - and next steps in the investigation. During these discussions, victims are encouraged to discuss any additional bail conditions they feel would be appropriate. Unfortunately, victims of DA investigations are not always supportive of Police action and over the years it has been found that over a third of DA cases are discontinued for this reason. In such circumstances, and when significant concern is still held regarding the welfare of the victim, Police can proceed without the victim’s support in what is called an evidence led prosecution. In Mrs Crowther’s case, after considering all records held on file, this was the decision made. The overarching concern throughout this investigation, was the risk posed to Mrs Crowther by her husband, who was also her main carer. The process during an evidence led prosecution is still for the investigating officer to engage with the victim regarding the investigation, including any potential bail conditions. Proceeding in these circumstances often means we impose bail conditions which are not agreed to by the victim but are deemed necessary to protect their personal safety and mental wellbeing. This approach prevents repeat offending and escalation of violence. The use of DVPN/DVPO’s are specifically for domestic violence perpetrators, over the age of 18, when violence has been used or threatened. As with evidence led prosecutions, the victim’s consent and engagement is not required for an order to be applied for and granted. Approved orders are in effect for a minimum of 14 days to a maximum of 28 days. Once a DVPO is ordered the responding party can request the order be modified or terminated, but the Court is unlikely to terminate the order unless the respondent can demonstrate there has been a substantial change in circumstances which shows they are not likely to resume acts of domestic violence. Within Bedfordshire we promote the consideration of a DVPO in investigations. Once a DVPO is ordered, it is the responsibility of the individual to comply with the prohibitions. In the event of a breach of a DVPO, the individual is open to arrest, leading to a possible fine of £50 for every day whilst in breach, up to a maximum of £5,000 or two-months imprisonment. In the case of Mrs Crowther, although the investigating officers considered a DVPO, with her additional complex needs, a decision was made that police bail would be more appropriate in terms of safeguarding. This is because with police bail, we have more flexibility in terms of decision making. At any stage during a police bail period, a determination can be made to cancel current conditions once any outstanding enquires have been completed. In conclusion, we consider ourselves to be a learning organisation and are always looking to improve our processes both within our Emerald Department and across the wider force, to ensure we are providing the very best safeguarding for Bedfordshire’s most vulnerable people. Yours sincerely Assistant Chief Constable
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