Prevention of Future Deaths reports · 2024

Angela Mittal

Regulation 28 report to prevent future deaths, reference 2024-0446, written 13 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Aug 2024
Reference2024-0446
DeceasedAngela Mittal
CoronerHeidi Connor
Coroner areaBerkshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:
1 Chief Constable for Thames Valley Police,
2 Chair of National Police Chiefs’ Council,

1

CORONER

I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire

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.

It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner
for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails
no more than the coroner bringing some information regarding a public safety concern to the
attention of the recipient. The report is not punitive in nature and engages no civil or criminal
right or obligation on the part of the recipient, other than the obligation to respond to the
report in writing within 56 days.

3

INVESTIGATION and INQUEST

The family requested me to refer to the deceased as Angela. I will reflect that in this report. I
conducted an inquest into the death of Angela Mittal which concluded on 26th of July 2024.

The conclusion of the jury was as follows:
Angela was unlawfully killed. The following Thames Valley Police findings have been admitted:
a. The officers who spoke to Angela on 29th of November 2018 did not recognise that

she was reporting the crime of coercive control.

b. The officers who spoke to Angela on 29th of November 2018 did not record the

crimes she reported, either of assault or coercive control.

c. The officers who spoke to Angela on 29th of November 2018 accepted that the risk
grading on the DOM-5 risk assessment form should have been medium rather than
standard.

d. The senior officer who saw Angela on 29th November 2018 accepted that he did not

fully review the DOM-5 risk assessment form before signing it.

e. The officers who spoke to Angela on 29th November 2018 did not take information

available to them (on the command and control system used then, from a call Angela
had made to the police earlier that morning) into account in their assessment of risk.
This was despite the call handler identifying domestic violence and coercive control in
the course of that 16 minute telephone call.

f.

The officers who spoke to Angela on 29th November 2018 did not investigate the
crimes Angela reported to them that day.

Regulation 28 – Before Inquest
Document Template Updated 30/07/2020

 Based on all the evidence heard in court, we the jury conclude that the admitted failings of
Thames Valley Police, on the balance of probabilities, did not contribute to Angela’s death.

4

CIRCUMSTANCES OF THE DEATH

Angela was murdered at her home address by her husband on 26th of December 2018. She was
41 years old at the time of her death.

We heard in evidence that Angela had spoken to Thames Valley Police by telephone and in
person on the 29th of November 2018. She reported an allegation of assault around a month
prior to that, and also many of the elements of coercive control. She also reported an assault
on her young child to the call handler, but this was not recorded as a crime, nor handed over
to the police officers who saw her that day.

Because of the involvement of a child in the family home, a referral was made to the Multi-
Agency Safeguarding Hub within Wokingham Borough Council Children’s Services. A decision
was made to carry out a Child and Family Assessment under Section 17 of the Children Act of
1989.

Angela had moved out of the marital home whilst she was in contact with the social worker at
Wokingham Borough Council. Although she had discussed the possibility of returning to the
marital home, she did not tell the social worker of a definite plan to do so.

Tragically, and against her family’s advice, Angela returned home on the evening of 25th of
December 2018. Her husband rang Thames Valley Police the following morning to tell them
that he had murdered his wife.

Before this inquest took place, a criminal trial and a domestic homicide review had been
undertaken. It is important to acknowledge, in relation to the concerns listed below, that the
death occurred some five and a half years ago.

5

CORONER’S CONCERNS

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

In the

Given the likelihood that the areas of concern relate not just to the police force in my
jurisdiction, I have addressed this report to the National Police Chiefs’ Council. I note that the
website of the NPCC currently lists violence against women and girls as the first area of work
that they are focusing on.

Thames Valley Police’s own training confirms that coercive and controlling behaviour is a major
risk factor in domestic homicide.

Regulation 28 – Before Inquest
Document Template Updated 30/07/2020

 The MATTERS OF CONCERN are as follows:
(Brief summary of matters of concern)

1. Whether sufficient steps have been taken to ensure that frontline staff have a clear
understanding of domestic abuse and coercive and controlling behaviour – to think
not just about physical abuse, but also about controlling behaviour and how that may
escalate.

2.

3.

I am concerned that Thames Valley Police’s DASH risk assessment form (called a
DOM5) does not make it sufficiently clear that the definition of “serious harm” can
include psychological harm from coercive and controlling behaviour. It may be that
other formulations of this document nationally do make this clear – I have looked only
at the form used by Thames Valley Police.

I heard evidence about a new tool for risk assessing domestic abuse, created by the
College of Policing. Both the senior Thames Valley Police officer and the College of
Policing witness gave evidence that this system is likely to result in better risk
assessment for domestic abuse. As I understand it, this new tool has not been adopted
by Thames Valley Police at this time, because of competing financial priorities, and an
issue with compatibility with the Niche system.

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 the 8th of October.

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 Angela’s family, via their legal
representative.

I have also sent this report to the following recipients, who have an interest in this matter:

1. Legal representatives for Thames Valley Police.
2. Legal representative for Wokingham Borough Council.
3. College of Policing.

who may find it useful or of interest. The above recipients are not expected to respond to this

Regulation 28 – Before Inquest
Document Template Updated 30/07/2020

 report.

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.

9

Dated: 13/08/2024

HEIDI J CONNOR
Senior Coroner for Berkshire for
Berkshire

Regulation 28 – Before Inquest
Document Template Updated 30/07/2020

Responses

2 responses 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 Npcc (PDF)
HM Coroner H J Connor  
Berkshire Coroner’s Office  
Blagrave Street  
Reading 
RG1 1QH 

Dear Ms Connor, 

3rd  October 2024 

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 
5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC 
dated 13th August 2024.  

The notice sets out concerns that arose from the information received during the inquest into the 
death  of  Angela  Mittal.  I  am  very  sorry  to  read  of  the  circumstances  of  Angela’s death.  My 
sympathies are with her family and friends. 

Domestic Abuse (DA) is a priority for the NPCC and key partners and much work has taken place in 
this area to drive improvements and consistency in the policing response. The College of Policing 
sets national standards for learning and development for UK Policing and provides guidance and 
advice in various forms including Authorised Professional Practice (APP).  

A programme of work was developed to improve the policing response to DA, including a project to 
examine  existing  risk  assessment  processes  for  victims  of  DA,  a  review  of  the  existing  training 
curriculum and the development of APP for this area of work. In  2015 with the inception of  new 
legislation  for  the  offence  of  coercive  and  controlling  behaviour,  several  products  were  made  
available on the College learning network (College Learn) aimed at embedding knowledge of the 
legislation.  Using  a  video  briefing,  two  victims  provide  an  insight  of  their  lived  experience  of 
controlling and coercive behaviour, while advice and guidance is also given on the legislation. In 
addition,  forces  were  provided  with  a  new  training  guide  and  content  for  a  half-day  classroom 
session so that there was an option for face-to-face inputs. Although this was not centrally delivered  
forces  were  encouraged  to  deliver  against  the  national  curriculum  using  the  specific  products 
available. 

Simultaneously,  the  College  of  Policing  used  the  DA  curriculum  to  underpin  a  course  for  first 
responders. The DA Matters course is focussed predominantly on understanding, identifying and 

 
 
 
 
 
 
 
 
 
 
            
 
 
 
 
 
 
   
 
 
 responding  to  coercive  and  controlling  behaviour,  the  impact  of  such  behaviours  on  victims, 
including  the  clear  links  to  victim  suicide  and  the  heightened  risk  posed  by  suspects  who  use 
coercion and control in their abuse of victims.  This consists of a one-day course for responders and 
a  two-day  course  for ‘champions,’  those  with  a  more  involved,  mentoring  role.  DA  Matters  was 
developed  with  the  support  of  ‘Safelives,’  (a  national  service  for  victims  of  DA),  and  other  key 
stakeholders including Women’s Aid, Suzy Lamplugh Trust, and other specialist support services. 
The course was piloted and evaluated in 2016 and a model of delivery, (which included co-delivery 
with  a  DA  specialist)  is  promoted  through  the  licensing  of  the  product  (essentially  outlining  the 
conditions  by  which  forces  must  use  the  training  course).  Safelives,  Welsh  Women’s  Aid  and 
Women’s Aid are now the licensed providers for the course, delivering to 75% of frontline workforce 
and  training  force/partner  trainers  to  continue  delivery  thereafter.  Our  providers  are  part  of  our 
Editorial Board whereby we ensure maintenance of the product. 

This course is highly regarded and included as required learning for the policing of domestic abuse 
within the Government Domestic Abuse Strategy. Many forces have received Government funding 
to deliver the programme, with all but one Home Office force having delivered or under contract to 
deliver the course.  

In 2022 further funding from the Home Office to build on the DA Matters first responder course to 
deliver learning for investigators of ‘course of conduct’ offences including coercive and controlling 
behaviour, stalking and harassment.  This learning will be  delivered through Hydra, an immersive 
learning platform which takes officers through cases in a simulated environment. Train the trainer 
events  were  tested  and  delivered  and  concluded  in  April  2024  before  the  course  was  rolled  out 
nationally. 

More  broadly  DA  is  embedded  in  the  curriculum  for  all  entry  routes  into  policing  with  various 
supporting  products  available  to  deliver  against  the  curriculum  (for  example,  areas  such  as 
Domestic  Violence  Disclosure  Scheme  (DVDS),  Domestic  Violence  Protection  Orders  (DVPOs), 
response to DA /Stalking (Abusive Relationship digital learning, Domestic Abuse Risk Assessment 
(DARA/DASH) are catered for). 

Simultaneous to the learning products, the College carried out a review of the implementation of 
domestic abuse , stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into 
policing in 2009. Working alongside Cardiff University the review findings and report prompted the 
development of a new tool for use by initial responders, more focussed on patterns of behaviour 
with a focus on coercion and control rather than incidences of specific behaviours. The Domestic 
Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with 
subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA 
uncovered  more  cases  of  coercive  and  controlling  behaviour  (CCB),  and  gave  officers  more 
accurate information to use professional judgement to assess and respond to risk. This training also 
provides the information on the harmful impacts of CCB.  

 
 
 
 The DARA was launched nationally in November 2022. Unfortunately, implementation has not been 
as smooth as anticipated due to competing demands for amending the various IT systems used for 
recording  the  risk  assessment  process,  however,  the  NPCC  and  the  College  have  been  working 
closely with forces and relevant IT providers to drive implementation. 

I hope the information provided will go some way to address your concerns. Please do not hesitate 
to contact me if you require further action or information in relation to my response. 

Yours sincerely, 

Chair  
National Police Chiefs’ Council
Response from Thames Valley Police (PDF)
Chief Constable 

Thames Valley Police HQ 
Oxford Road 
Kidlington 
OX5 2NX 

Tel: 

www.thamesvalley.police.uk 

3 October 2024

By Email 
Mrs Heidi J Connor  
Senior Coroner 
HM Coroner's Office 
Reading Town Hall 
Reading  

Dear Mrs Connor 

Inquest into the Death of Angela Mittal 

Preventing Future Deaths response of the Chief Constable of Thames Valley Police 

Thank  you  for  your  report  sent  by  letter  dated  13  August  2024  under  paragraph  7, 
Schedule  5,  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the 
Coroners (Investigations) Regulations 2013 in respect of circumstances surrounding the 
tragic death of Angela.  

Your report contains three matters of concern which I shall address below: 

Response to the Regulation 28 concerns 

Whether sufficient steps have been taken to ensure that frontline staff have a clear 
understanding of domestic abuse and coercive and controlling behaviour 

Detective Superintendent 
 is the Thames Valley Police lead for Domestic 
Abuse and Stalking. In his written and oral evidence  (particularly his  statements dated 
  gave  an 
29  January  2024  and  22  May  2024),  Detective  Superintendent 
explanation of the training police officers received in 2018 regarding coercive control and 
how that training has evolved to the present day. I do not wish simply to repeat information 
of which you are already aware, but will set out in summary our current relevant training 
programme and future plans to raise awareness of the impact of coercive and controlling 
behaviour and the potential for it to lead to tragic consequences. 

We are always seeking to improve our training. Changes to training practice and content 
can  be  brought  about  in  a  number  of  ways.    The  training  of  new  recruits  is  mandated 
through the College of Policing and delivered through a number of courses, collectively 
known as Foundation Training.   All our training inputs have been reviewed and in some 
cases improved by an independent domestic abuse training consultancy.  I am satisfied 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 that our Police Constable Entry Programme, Police Constable  Degree Apprenticeship 
and our Degree Holder Entry Programme all contain inputs covering domestic abuse and 
coercive and controlling behaviour. 

Beyond  Foundation  Training,  front  line  officers  are  subject  to  further  training  inputs 
delivered in a variety of ways.     

Thames  Valley  Police  have  commissioned  the  Safe  Lives  charity  to  deliver  its  ‘DA 
Matters’ training to all front-line officers since January 2020. This includes sessions on 
coercive and controlling behaviour.  This training also includes an input known as ‘Crime 
Data Integrity’.  This is essentially training officers to identify and accurately record crime 
and to that end specific videos have been produced covering behavioural crimes such as 
harassment, stalking and coercive and controlling behaviour. 

Front line staff are also expected to attend 2-3 ‘Teams In Action’ training days per annum.  
The  current  training  underway  on  these  days  includes  communication  with  victims, 
domestic  abuse  risk  assessments,  Domestic  Violence  Protection  Notices  (DVPN)  and 
Domestic Violence Disclosure Schemes (DVDS). 

Contact Management staff (call takers and their supervisors) have received a number of 
training  inputs  on  handling  domestic  abuse  calls.    Their  input  on  crime  data  integrity 
focused on domestic abuse and missed crimes.  The tragic death of Angela was used as 
a case study to reinforce the importance of identifying coercive and controlling behaviour. 

It is of note that in 2019 Contact Management added the following question to the Call 
Handlers’  question  set  (the  list  of  questions  asked  for  every  domestic  abuse  call)  to 
identify Coercive and Controlling Behaviour, recognising that a victim/survivor may not 
use  that  particular  term  but  may  describe  behaviour  amounting  to  Coercive  and 
Controlling Behaviour. 

“Has the victim disclosed anything that could indicate an element of control over them by 
the perpetrator? (If yes, record the detail as this is likely to be an indicator for Coercive 
Control)” 

In  2024  Contact  Management  leaders  commissioned  an  external  training  provider  to 
develop  a  new  training  package  (including  Coercive  Control)  and  asked  for  the 
circumstances of Angela’s death to be included as a case study.  

The training course designed for specialist domestic abuse officers has also recently been 
reviewed and refreshed.  Inputs on coercive and controlling behaviour run throughout the 
programme. 

All training for front line staff is in addition to the Operational Guidance products that are 
available  to  guide  officers  on  how  to  identify  and  deal  with  coercive  and  controlling 
behaviour.  These products can be accessed any time through an officers laptop or via 
mobile phone app.  

I am satisfied frontline staff are equipped with sufficient training to understand domestic 
abuse  and  coercive  and  controlling  behaviour.  Thames  Valley  Police  is  committed  to 
providing ongoing and updated training in these important areas. 

 
 
 
 
 
   
 
 
 
 
 
 
 
 I am concerned that Thames Valley Police’s DASH risk assessment form (called a 
DOM5) does not make it sufficiently clear that the definition of “serious harm” can 
include psychological harm from coercive and controlling behaviour. It may be that 
other formulations of this document nationally do make this clear – I have looked 
only at the form used by Thames Valley Police. 

You  are  right  to  point  out  that  the  current  TVP  Domestic  Abuse  risk  assessment  form 
(Dom5) does not define the term ‘serious harm’.  The College of Policing defines the risk 
of serious harm as follows  - ‘A risk which is life threatening and/or traumatic, and from 
which  recovery,  whether  physical  or  psychological,  can  be  expected  to  be  difficult  or 
impossible.’ This definition is included in the risk assessment model known as the DARA.  
 to include this definition on our current 
I have asked Detective Superintendent 
risk assessment form. 

I heard evidence about a new tool for risk assessing domestic abuse, created by 
the  College  of  Policing.  Both  the  senior  Thames  Valley  Police  officer  and  the 
College  of  Policing  witness  gave  evidence  that  this  system  is  likely  to  result  in 
better risk assessment for domestic abuse. As I understand it, this new tool has 
not  been  adopted  by  Thames  Valley  Police  at  this  time,  because  of  competing 
financial priorities, and an issue with compatibility with the Niche system. 

It  is  important  to  note  that  competing  financial  priorities  are  not  the  issue  here.  The 
principal  challenges  are  compatibility  with  our  NICHE  crime  recording  system  and  the 
delivery of training to front line police and staff. Thames Valley Police require a contractor 
to initiate the changes on the NICHE system. The development of Electronic Case Files 
was  prioritised  over  the  implementation  of  DARA  and  that  project  has  overrun.  Any 
solution to this must also be compatible with other processes such as our ability to refer 
the information captured in our domestic abuse risk assessments in a timely fashion to 
other  agencies  with  responsibilities  for  the  protection  of  victims/survivors  and  their 
children, such as Children’s Social Care and colleagues in the health service. A change 
from DASH to DARA is a significant departure from the current process which has been 
in place for many years. It is crucial that all officers and staff who make use of DARA are 
fully trained in its development and use. In order to do this we will need to train thousands 
of officers’ and staff, which will take some considerable time. It is also important to note 
that our partner agencies also use DASH and any change to the risk assessment model 
must bear this in mind as the police will be using a tool that is unfamiliar to those agencies. 

There  are  challenges  to  implementing  the  DARA  risk  assessment  model  within  our 
current version of the NICHE crime recording system. In the future   TVP will be looking 
to adopt an updated NICHE safeguarding and vulnerability module when available.   In 
  to  explore  an  interim 
the  mean  time  I  have  asked  Detective  Superintendent 
solution.  This will include the replacement of the current questions in the DOM 5 with the 
questions  contained  within  the  DARA  and  include  clear  reference  to  the  College  of 
Policing definition of serious harm which can include psychological harm from coercive 
and controlling behaviour. This will be attached to the crime recording system in the form 
of a template. The DARA includes a number of questions designed to assess the level of 
coercive  and  controlling  behaviour  and  the  level  of  risk  posed.    Included  in  this 
implementation will be the training of every front line officer in its use.  

 
 
 
 
 
 
 
 
 
 The  death  of  Angela  is  yet  another  example  of  the  tragic  consequences  of  domestic 
abuse.  Thames Valley Police is determined to do all it can to learn from this devastating 
event and prevent future deaths in similar circumstances. 

Yours sincerely 

Chief Constable

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