Prevention of Future Deaths reports · 2024

Sylvia Crowther

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 report28 Feb 2024
Reference2024-0114
DeceasedSylvia Crowther
CoronerEmma Whitting
Coroner areaBedfordshire and Luton
CategorySuicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

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 Bedfordshire Police (PDF)
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

Related reports

Other reports by Emma Whitting

See all →

More reports categorised “Suicide (from 2015)”

See all →

Track Suicide (from 2015)

See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.