‘Teresa’ - Leeds · perpetrator. Teresa had four children. Her two eldest children were born during Teresa’s relationship with a man who was much older than Teresa and from

DHRM+Executive+Summary+v1.1.docx

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THE EXECUTIVE SUMMARY

DOMESTIC HOMICIDE REVIEW (DHR) UNDER SECTION 9 OF

THE DOMESTIC VIOLENCE CRIME AND VICTIMS ACT 2004

IN RESPECT OF THE DEATH OF 26 YEAR OLD

‘Teresa’

IN MAY 2017

PETER MADDOCKS

INDEPENDENT AUTHOR

Commissioned by

SAFER LEEDS

October 2018


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Index

The review process....................................................................................... 3

1.1 Contributors to the review ............................................................... 3

1.2 The review panel members .............................................................. 5

1.3 Author of the overview report .......................................................... 5

1.4 Terms of reference ......................................................................... 6

1.5 Summary chronology ...................................................................... 8

Key issues arising from the review ............................................................. 10

Conclusions and recommendations ............................................................ 13

1.6 Extending and improving opportunities for risk identification and

assessment ............................................................................................ 14

1.7 Cognitive influences and processing of information............................. 16

1.8 Policy and training ........................................................................ 17

1.9 Recommendations ........................................................................ 19

1.10 National policy ............................................................................. 19


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The review process

1. This summary outlines the process undertaken by Safer Leeds1 in reviewing the homicide of Teresa2 who was a resident in their area.

2. To protect the identities of the victim and of the respective family members the following pseudonyms have been in used in this domestic homicide review (DHR); Teresa for the 26 year old victim and Dabir for the 26 year old perpetrator. Teresa had four children. Her two eldest children were born during Teresa’s relationship with a man who was much older than Teresa and from whom Teresa had fled from domestic violence and abuse. Those two children are referred to as Imran and Sayiba aged 8 and 7 years respectively when Teresa was killed. Her two youngest children were born during their marriage with Dabir. Those two children are Basir and Emily and were aged 19 months and 6 months respectively when Teresa was killed by Dabir. Teresa had two halfsiblings who provided information for the DHR. Two friends also provided information. Teresa was white British and Dabir is British Asian and English their language of communication. Professionals are referred to by their roles such as health visitor, GP, police officer or social worker for example.

3. Dabir was convicted of murder along with a female friend of his. Two other people who include two of Dabir’s relatives were also convicted of assisting Dabir. He was sentenced to 22 years imprisonment.

4. The decision to commission a review was made in May 2017. The first meeting

of the DHR panel was in December 2017. Three further meetings of the panel were held. The panel met for the final time in June 2018.

5. Twenty of the more than 40 agencies contacted as part of the initial scoping

for the review confirmed that they had varying levels of contact with Teresa and/or Dabir and provided information as described in section 1.1.

1.1 Contributors to the review

6. A scoping meeting reviewed responses from the services who had contact or

knowledge about the victim and/or perpetrator. All were asked to provide chronological information. Most of the organisations were required to complete an individual management review (full report) that required analysis

1 Safer Leeds is the community safety partnership set up under the Crime and Disorder Act 1998. 2 These are not the true names of either the victim or the perpetrator. Teresa had converted to Islam and had adopted a Muslim name although had continued to be known by her original name by some people and organisations. The criminal trial and associated processes have referred to her by her non-Muslim name and therefore the name Teresa has been used for the purpose of this report.


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of their contact whilst other organisations who had less significant involvement provided a short report.

a) Clinical Commissioning Group (in regard to GP services provided

through Practice 1 until May 2016 and then Practice 2 when Teresa

transferred after moving home);

b) Children’s Social Work Services; the two older children were subject of

child protection plans between November 2013 and June 2015 due to

concerns about their emotional and physical harm as well as neglect

and they were also subject of preliminary Family Court proceedings;

there has been more recent involvement in December 2015 and again

in March 2017 when Teresa had been misusing alcohol;

c) Housing Leeds; provided landlord and tenancy services including

response to complaints regarding noise and nuisance from Teresa’s

property;

d) Learning for Life Service provide Children’s Centre services; Teresa

participated in three sessions of a 0-6 Parenting programme in 2013;

e) Learning Improvement Services in respect of education for the two

older children at School A from early 2013 when Teresa had moved to

Leeds and at School B after the family moved in early 2016;

f) Leeds Anti-Social Behaviour Team (LASBT); Teresa was the subject of

complaints about noise nuisance from her property;

g) Leeds Community Healthcare provided health visiting and school

nursing services; Teresa was known from July 2003 when she moved

into a rented home in the city

h) Leeds Teaching Hospitals Trust; provided health care to all of the family

at various times which included maternity care as well as presentations

for out-patient and accident treatment;

i) West Yorkshire Police; had contact in regard to reports of domestic

violence and abuse; the last contact that Teresa had was the subject of

the referral to the Independent Office for Police Conduct (IOPC).

7. Information was also provided from Cafcass, the Crown Prosecution Service,

Families First, Housing Leeds, Leeds and York Partnership Foundation Trust,

Together Women Project, The National Probation Service and West Yorkshire

Community Rehabilitation Company, Victim Support and the Yorkshire

Ambulance Service. None of these services had any substantial involvement

and therefore no agency report was requested from them. The local 2gether

Cluster Services had brief contact with Teresa. The service received a referral

from the primary school in June 2016 for support to the family in respect of

her eldest child, Imran. The service completed four sessions of work between

20th July 2016 and the 17th October 2016 before Teresa disengaged.


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8. Additionally, the chair of the panel spoke with the leaving care worker

employed by the local authority who had been in contact with and supported

Teresa (and Lacy).

9. All of the authors providing reports to the review were independent of any direct involvement or supervision of decision making regarding Teresa or Dabir.

1.2 The review panel members

10. A suitably experienced and independent person chaired the panel; details are

provided in section 1.3. All of the panel members were independent of any involvement or decision making in regard to the events and people concerned with the circumstances examined by the review. The membership of the panel is listed below.

Organisation Job title or role

Leeds Community Healthcare NHS Trust

Head of Service – Safeguarding

Leeds City Council - Children's Social Work Services

Head of Children's Social Work

Leeds Teaching Hospital Trust Lead Professional Safeguarding Adults/Deputy Head Safeguarding

NHS Leeds Clinical Commissioning Groups Partnership

Deputy Designated Nurse Safeguarding children and adults

Detective Chief Inspector for Safeguarding and IOM

West Yorkshire Police

Safer Leeds, Domestic Violence Domestic Violence Team Manager

Leeds City Council - Resources & Housing

Head of Housing Management

Leeds Community Healthcare Head of Service for Safeguarding

Leeds City Council - Children & Families

Head of Service Learning for Life

1.3 Author of the overview report


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11. Peter Maddocks is the independent author of the overview report. He has over forty years’ experience of social care services, the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has completed domestic homicide reviews with other community safety partnerships in England. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales. In compliance with national guidance he has used the online toolkit and online learning provided by the Home Office. He has also participated in training in relation to serious case reviews including the use of systems learning as developed by SCIE (social care institute for excellence) in regard to serious case reviews and participated in masterclass training for independent reviewers. He has undertaken one serious case review (SCR) and one combined DHR and SCR previously in Leeds. He has never been employed by any of the organisations participating in the review, has not held any elected office in Leeds or West Yorkshire and has no personal or other relationship with any individual who has a professional or elected position in Leeds or in West Yorkshire.

12. Kathy Shaw was the independent chair of the review panel. Kathy is an independent safeguarding consultant and trainer; an experienced NSPCC children services manager and registered social worker qualified to advanced level and MSc advanced professional practice in social work. Kathy has extensive experience in operational and strategic development and delivery of family centred services, including refuge provision and direct support to families bereaved by murder or manslaughter. She has completed a number of domestic homicide reviews and safeguarding adult reviews across the region and has been active in the field of violence against women and children for over thirty years. Kathy has had no involvement in the delivery of identified services, or line management for any service or individual mentioned in the report.

1.4 Terms of reference

13. The time period under review is from the September 2015 until the date of death in May 2017. The timeline for detailed information and analysis is as close to the start of the relationship as can be determined. Agencies contributing reports or information to the domestic homicide review used the following terms of reference to provide information and analysis for the domestic homicide review.


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a) What contact and knowledge did the agency have that indicated Teresa

could be vulnerable or at risk, including from domestic abuse and violence and what response was there? This includes the opportunities for assessment and the quality of risk identification from any information or observations recorded at the time and to also consider any additional factors of vulnerability (such as previous exposure to domestic abuse, any cognitive or other difficulty, substance misuse, absence of appropriate family or social support).

b) What contact, knowledge and information did the agency have to indicate that Dabir could be a risk as a perpetrator of domestic abuse and violence or from other risk and what response was there by the agency? This should include any relevant history including lifestyle, substance misuse or mental health for example as well a propensity for coercion or control that would indicate an enhanced level of risk to a household with children?

c) What opportunities and services were available to help meet the needs of Teresa or her children? In particular was action taken in accordance with agency and interagency safeguarding children protocols, legislation and relevant professional standards? Was the help accessible, appropriate, empathetic and empowering in addressing risk? Was action taken by the agency to help identify whether Teresa or her children were at risk of significant harm or in need of services in securing appropriate protection and support?

d) What action was taken by the agency to establish whether there were any particular issues arising from age, culture, disability, ethnicity, gender, language, marriage or civil partnership, pregnancy and maternity or religion? Attention is drawn to the nine protected characteristics set out in the Equality Act 2010 (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation) and whether there are any lessons to be identified in regard to agency practice or policy.

e) Was there ever any cause to escalate any issues to senior managers in the agency or with any other specialist professionals or organisations? If so, were there any barriers or evidence of delay in terms of escalating issues? What outcome was there?

f) Were there issues in regard to the capacity or resources of services that had an impact on the ability to help Teresa or her children, Dabir or


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other family members; or an impact on the ability to work with other services? This should include comment about the quality of supervisory or management oversight, the extent to which professionals in your agency have enough training and understanding about domestic abuse and safeguarding and workload.

g) Were there any issues in regard to the impact of any organisational changes covered by the period under review that influenced how your agency or partnership arrangements were operating?

h) Even in the most difficult and complex of circumstances there can be good practice. What can be identified as good practice in this case?

i) What action(s) by the agency in retrospect might have led to better outcomes in this particular case? Why were these not considered/not taken at the time from the agency’s perspective?

j) Identify any lessons to be learnt from the review for the agency. This should be explicit if any shortfalls in meeting standards have been identified as well as any gaps in policy, protocols or professional practice and understanding. This section should also link to any action being taken by the agency or recommendations being made.

1.5 Summary chronology

14. Teresa moved to Leeds having left a violent and abusive relationship with the father of her two eldest children. Children’s Social Work Services were involved and the two children were the subject of child protection plans which were stepped down to child in need (CIN) in February 2015. Teresa had met Dabir in September 2014 although the first occasion when social workers met Dabir was in April 2015. Teresa had begun converting to Islam before meeting Dabir whom she married under Sharia law. Teresa had become pregnant with the first of their two children in the spring of 2015.

15. Children’s Social Work Services closed their involvement in June 2015 when it appeared that Teresa was in a stable relationship and the children were safe.

16. By November 2015 Imran’s behaviour at school was beginning to cause concern.

17. In December 2015 Dabir phoned the police to report that Teresa was in drink and was ‘smashing up the house’. The police arrested Teresa for breach of the peace and the incident was discussed at the daily safeguarding hub meeting; Children’s Social Work Services reopened their involvement to complete an


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assessment which focussed on the safety and well-being of the children. At this stage Teresa reported that Dabir’s family were supportive and although she saw Dabir daily he was not living at the house.

18. Teresa moved to a property rented from the local authority’s housing service in January 2016. This meant that a new health visitor had to be allocated; it also meant that Teresa was no longer in contact with people at the local children’s centre that she had been using. Teresa also moved to a new GP practice.

19. In February 2016 there was an anonymous phone call to the police from a female reporting that her boyfriend was ‘battering’ her. The caller gave a post code and property number; the house number was non-existent although the postcode was the location where Teresa lived. The mobile was not registered to an owner although after her death the phone was linked to Teresa.

20. From March 2016 there were regular complaints about noise and disturbance from Teresa’s property. These reports were made to the housing service who over the following weeks organised for written logs to be kept by members of the community who were being disturbed. Reports in general were never made to the police and the anti-social behaviour team became involved from later 2016.

21. In those records a member of the public overheard Teresa asking a male why he was being violent to her. This was not reported the police or to any other service at the time. The Children’s Social Work Service closed their involvement in April 2016 unaware of the complaints being made.

22. The police were called to deal with a party that was causing nuisance in June 2016. This contact was not referred to the safeguarding hub or to Children’s Social Work Services having been processed as a noise nuisance incident.

23. Imran had moved to a new school because of the family move and his behaviour continued to cause concern. The school were unaware of the complaints being logged or the violence that can now be seen to have been occurring from Dabir.

24. Teresa continued to deny that there was any disturbance being caused from her property. In February 2017 Dabir called the police after a confrontation between Teresa and a female friend. Teresa was arrested when she became aggressive towards the police officers.

25. In early March 2017 Teresa told a primary health care professional that she felt low and had no family support. In late March 2017 Dabir called the police to report a disturbance at the house involving Teresa; this call came just before a


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member of the public called in the disturbance to the police. Dabir presented himself as being the victim of an assault by Teresa.

26. Shortly after this Teresa confided in a primary health care worker that Dabir was controlling and ‘messing with (her) head’. The following day Teresa told a social worker that she and Dabir were ‘taking a break’ and that Dabir tried to control the contact that Teresa had with her family. Teresa was continuing to decline any support from Children’s Social Work Services who closed their involvement for the final time in April 2017 before Teresa was killed.

27. In early May 2017 Teresa told school that she would be spending time with family due to ‘trouble with the baby’s dad’. Less than 24 hours later Teresa made a 999 call to the police to report being afraid of going home to her property in case Dabir was waiting for her. This call was the subject of an independent investigation by the Independent Office for Police Conduct who confirmed that the police handling of the call and the follow up had complied with legal and police professional standards and procedures. The police were continuing to follow up the incident when Teresa’s body was located four days later.

Key issues arising from the review

28. Teresa had experienced significant neglect and inconsistent care in her early

years. The legacy of that adverse early childhood was reflected in the behaviour and needs that she displayed during adolescence when she was vulnerable to exploitative relationships. She had a disrupted education and spent several years living in local authority care although this was not in Leeds. She did have the support of a leaving care worker with whom she remained in contact with although had lost contact after she began her relationship with Dabir. Given Dabir controlled the contact that Teresa sought with her family and friends it may well be that the loss of contact with a significant professional was part of the same behaviour.

29. By the time that Teresa had moved to Leeds she had developed a mistrust of many agencies which was reinforced by the views of some friends. This contributed to Teresa never wanting to disclose information that for example could have an impact in raising concerns about the care of children. Teresa’s physical care of her children did not raise concerns and the school found Teresa to be supportive of her children’s school work.

30. The two significant intimate relationships that Teresa had were both

characterised by abuse and violence. Teresa’s first partner was much older and for several years they moved to different parts of the country resulting in Teresa becoming even more isolated from any friends or family contact. Teresa


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eventually left this relationship spending some time living in a refuge with support from various services.

31. At this stage Teresa had two young children and was drinking heavily with consequent impact on her emotional and mental well-being. She was experiencing low mood and depression. Whilst in the refuge she became friendly with another young female who was Muslim and this appears to have encouraged Teresa to become interested in Islam; it is thought that part of this might have been the Islamic prohibition on the use of alcohol being an encouragement to make changes to her own life.

32. Given that Teresa had become pregnant at an early age, had experienced abusive and exploitative relationships, and was educationally and economically disadvantaged she was at a higher risk of suffering abuse and violence in her intimate relationships.

33. The relationship with Dabir was initially good according to Teresa’s account at the time to friends. He appeared to offer the prospect of improved stability and it seems that a combination of his family and cultural network offered Teresa the prospect of a community where she could feel that she belonged. She attended the Mosque.

34. Dabir’s presentation to professionals was consistently of a polite and reasonable man who was on occasions the victim of Teresa’s verbal and physical violence when she had been drinking. This combined with Teresa’s antipathy and fear of the consequences of losing her children if services became concerned about abuse and violence contributed to Teresa remaining isolated from potential advice and support.

35. It has become apparent that Teresa was planning to leave the relationship certainly from the early months of 2017. This was reflected in her discussions with some friends which were not disclosed to any professional at the time as well as some partial disclosures to various professionals that did not explicitly describe what was happening. Even in March 2017 Teresa was giving contradictory messages about Dabir and this reflected the internal conflict that Teresa was no doubt experiencing. She used phrases such as ‘messing with my head’ to describe Dabir’s behaviour. The psychological and emotional abuse and control associated with men who use control and coercion in their intimate relationships is far less visible than physical abuse.

36. Key areas of learning include;

a) Domestic violence and abuse remains a widespread public health and

safeguarding issue; it needs good strategic responses that deliver


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effective help and interventions across all public services that have

contact with adults and children, to recognise and to respond to

indicators of abuse; evidence and information about anti-social

behaviour or disturbance may for example represent domestic

violence and abuse; children’s behaviour can represent changing or

adverse home circumstances;

b) Ensuring vulnerable women have contact and information about

advice and support services following the birth of their children is an

important part of creating pathways to advice and help; it remains

important for all births and particularly when the birth is occurring at

a relatively early stage in a relationship and there has been previous

history of abuse;

c) Annual tenancy visits and routine contacts such as for maintenance

and repair can provide important opportunity for identifying

potential safeguarding and vulnerability; similarly, routine contact

with primary health and education services are where victims will first

provide information rather than going to the police or to social care

services;

d) The purpose and circumstances for completing a DASH should

continue to be promoted with all public services that have contact

with adults and children;

e) Any information, observed or disclosed, about domestic violence and

abuse or separation is potentially significant; victims may not wish to

admit or be able to acknowledge that they are in fear of an intimate

partner; an acknowledgement that the victim feels frightened is

always a clear indicator for an escalated level of concern and may

contrast with previous contact or presentations with services; if a

DASH assessment has not been completed, the information should

be processed as a report of domestic violence and abuse for the

multi-agency hub to consider;

f) Withdrawal of children from school or nurseries during usual term

times should be discussed with the designated teacher to include

consideration as to whether there is any evidence to suggest concern

about domestic abuse or violence;

g) The framing or coding of information can critically determine the risk

level that is allocated for determining professional follow up; for

example malicious communication is a very different issue from

harassment particularly within the context of intimate partner

violence; euphemistic language such as having ‘trouble’ or ‘messing

with my head’ deserve exploring and clarifying as far as possible;


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h) Economic and social disadvantage combined with poor educational

achievement or participation at school and disruption in childhood

are significant factors for increasing the risk of domestic violence and

abuse and isolation from sources of advice and help;

i) Men who control their partners will seek to influence and manage

how information is presented to professionals and is processed by

them; this includes controlling the narrative about who is victim and

who is the perpetrator; it is an extension of their control over the

victim and isolating them from advice and help;

j) For many young adults who have experienced living in care and have

had to overcome adverse early childhood experiences or neglect can

leave them unable to form trusting relationships ; they have great

difficulty using other people’s help; they have difficulties in

developing alliances with helpful people and this can place them at a

disadvantage ; low self-esteem associated with experience of abusive

relationships and low educational participation can exacerbate this;

k) Culture can enable self-respect and social status and provide support,

protection and security; it also has the power to harm. Culture and

any religion can be used inappropriately as a means to control the

behaviour of women and to keep them ‘disciplined’;

l) Strong cultural attitudes and beliefs for example about the use of

alcohol and mental health risks shame and stigma that can create

greater isolation for women who are in an abusive relationship;

m) Any risk assessment and its subsequent management has to take

account of any damage and deficits that impair cognitive capacity and

other functioning of victims arising for example from dependence on

or excessive use of substances;

Conclusions and recommendations

37. The services who provided a written report for the review identifying learning

for their own organisations have implemented action and recommendations

to support that learning in their services. The key findings and

recommendations in this overview report to address and support learning

from the review are grouped as follows:

a) Extending and improving opportunities for risk identification

and assessment;

b) Cognitive influences and processing of information;

c) Policy and training.


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1.6 Extending and improving opportunities for risk identification and assessment

38. Victims are generally less likely to tell the police or social workers about

domestic violence and abuse. The value of providing antenatal and postnatal

contact has health and social benefits for the mother and for the child. Given

the strong correlation between the onset of violence and abuse during

pregnancy, creating a point of contact to develop a relationship of support

offers an important opportunity to identify women who are in abusive

relationships. Teresa had previously used a children’s centre although had

moved out of that centre’s area. The review is a reminder of the importance

of following up mothers and proactively offering contact and support.

39. Violence against women continues to be under-reported. Victims are most

likely to talk to people they know rather than to any professional or

organisation; this is what Teresa had been doing for several months. Teresa

and many of her friends shared a common antipathy about services that could

have been a source of advice.

40. Teresa was especially vulnerable given her personal history of previous abuse

from an intimate partner, her fear of her children going into care, no doubt

exacerbated by her own childhood experience and her problems with alcohol

and low mood.

41. The Crime Survey provides data on people aged 16 and over who experience

domestic abuse. There were an estimated 2 million adults aged 16 to 59 who

said they were a victim of domestic abuse in the previous year (March 2016)

and this is substantially higher than the number of incidents reported to the

police (434,095 in the 12 months to March 2016 ). The survey found that over

27 per cent of women reported being a victim of domestic abuse since 16 years

of age and that women aged between 16 and 24 years old were more likely to

be victims of domestic abuse compared with those who are older. The survey

found that only 23 per cent of female victims made reports to the police. The

survey found that there was a high reliance by victims on talking with people

they knew rather than with a professional or an organisation able to help them

such as the police.

42. Low academic achievement, neglect and abuse and early sexual activity and

teenage pregnancy are not predictors of an abusive relationship but are high

risk indicators. As with adult victims, there are many factors that increase risk

and discourage disclosing information or seeking help. They include fear of

escalating the violence, issues of confidentiality where disclosing information


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means sharing with other services, not being taken seriously, fear of losing a

baby or child to care. A lack of confidence that the violent partner can be

managed, exacerbated in this case by Dabir presenting as the calm and

responsible partner; having support from peers who may themselves be

isolated from services and other support and can reinforce the normalisation.

Many of these were factors that Teresa was contending with.

43. Previous domestic homicide reviews in the city have highlighted the

importance of not only improving how signs and indicators are identified prior

to or even despite any disclosure being made by a victim, but distinguishing

between the different types of domestic violence and abuse; in particular,

identifying control and coercion. In this particular case, it seems evident that

Dabir exploited Teresa’s difficulty with alcohol and her struggles to manage her

emotions and stress. The extent to which Dabir was controlling Teresa as well

as the various contact and interactions with professionals represents

considerable calculation and cunning that he continued to display after he had

killed Teresa. Representing the violence as being a result of Teresa’s use of

alcohol and loss of control and him being the innocent party had the effect of

making Teresa even more isolated and powerless.

44. Children’s behaviour is often an early indicator of changed circumstances.

Imran’s behaviour at school began to cause concern from around the time that

Dabir and Teresa began their relationship. With the benefit of hindsight, some

of the behaviours that Imran was presenting was probably symptomatic of the

abuse. It is acknowledged that Teresa was supportive of the school and of her

children’s education and spoke positively about Dabir. It is less clear what

opportunities were sought to talk with Imran on his own. The learning point is

that the behaviour of a child can be an essential pointer to undisclosed issues

at home. Separation, the formation of new relationships, adults joining the

household as well as exposure to chaotic adult behaviour are all sources of

stress for children. Asking children about their home circumstances and letting

them talk about things that might be causing distress are important sources of

information.

45. Removing children from school during term time is discouraged. Although

many such requests or occurrences are associated with families taking a

holiday or example, this review is an example of where Teresa was attempting

to flee an abusive relationship. School governing bodies and head teachers

have an important role in helping identify circumstances where domestic

violence and abuse is the underlying factor leading to a child being removed

during term time or not returning after a holiday.


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1.7 Cognitive influences and processing of information

46. The report has described how Dabir was able to manipulate Teresa and the

contact with services. It would have been very difficult for any police officer

for example to have seen what was happening based on the presentation of

information during the three contacts of most relevance to this review.

47. The review offers general learning for all services about how information and

events are framed, described and reported.

48. The most explicit information about domestic violence and abuse was never

made to any professionals but was the overheard information from members

of the public who were being disturbed by the noise from Teresa’s home. The

learning is that behaviour being reported to the local authority as noise

nuisance may in fact be evidence about potential domestic violence and abuse.

Matters were compounded by the delays in collecting and collating the diary

sheets that contained the information.

49. Another example of how information was misleadingly framed was the coding

of Dabir’s messaging of Teresa as malicious communication rather than

harassment. Although it had little or no impact on how Teresa’s last contact

with the police was managed and was in compliance with national policy, there

is compelling evidence about harassment (along with stalking) being important

indicators of higher risk behaviour in domestic violence and abuse and in

particular control and coercion.

50. Other examples of how the framing of information occurred with other

services included Teresa’s description of Dabir ‘messing with (her) head’ and

describing ‘trouble’ with Dabir. Whilst this was no doubt how Teresa was

describing what was happening, it remains important for professionals to have

the confidence and understanding to try to gain the confidence and further

information from the individual at the time of the conversation.

51. Teresa appeared to straddle contrasting cultures and groups of friends. The

case has highlighted the additional complexity that strong cultural or religious

traditions can represent in identifying and supporting adult victims of domestic

abuse to disclose information or access and accept help when women are

expected to comply with cultural and religious practices and to follow the

traditions of their family or community in order to be accepted.


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52. Culture describes a range of different factors that include patterns of

behaviour and customs, values and attitudes, implicit rules of conduct,

patterns of social organisation and taboos or sanctions, which are shared

across people with a common identity.

53. Some cultural traditions that include South Asia relies on the family structure

to provide support and to resolve personal problems and difficulties. It is a

tradition that believes strongly in the privacy and primacy of the family and

encourages family members to be loyal to the family and to not look to

external people and agencies to intervene. It is a tradition that encourages the

family and its various members to take care and responsibility, supporting

couples to maintain their marriages for the sake of their children and a

patriarchal view about the role and status of husbands and has implications for

how wives and children should behave. Conversely, Teresa spent much of her

childhood as a looked after child and although continued to be in contact with

members of her family there is a less identifiable and structured tradition

about family during her formative years.

54. Amongst Asian communities, the family (extended over numerous

households) is a fundamental and influential foundation, providing financial

support and emotional security. The accomplishments of an Asian family are

often judged in terms of the family as a whole, so privacy or independence is

seen as undesirable. Gender stereotypes are highly conventional and since

women are held responsible for maintaining family honour, known as izzat,

and avoiding sharam (shame) the family may justify women being guarded

and considered not as individuals but as property.

1.8 Policy and training

55. The value, and therefore the use, of DASH by professionals in addition to the

police has been highlighted in previous recent and as yet unpublished DHRs in

the city. The learning point has come through in this review. Although there is

no guarantee that Teresa would have felt able to participate in a DASH when

for example the primary health worker was listening to Teresa’s comments

about Dabir or would have been any more forthcoming about giving

information, the DASH provides a structure for collating information and

reflecting on the significance of immediate behaviour and concerns within the

context of other factors such as vulnerability and personal history.

56. The review has been an opportunity to examine the local response to concerns

about anti-social behaviour and how this can be symptomatic of other issues

such as domestic violence and abuse. Action has already been taken to address


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staff training and development and the analysis and collation of information

being provided for example through nuisance logs.

57. It has not been custom and practice for services such as Children’s Social Work

Services (CSWS) to routinely contact the anti-social behaviour team or housing

when conducting statutory enquiries and assessments in regard to a child in

need or safeguarding. This case has highlighted that potentially, there may be

information that is not known to other services such as the police but is

relevant to establishing whether there are concerns about the household that

are relevant to assessing risk to children and vulnerable adults. Although the

police had several contacts with Teresa and with Dabir, they were not aware

of the level of reported anti-social behaviour and along with the other services

were never made aware of the information about apparent assaults on Teresa

by Dabir that were overheard in the community.

58. The final contact that Teresa had with the police was still open when she died.

The decision making and actions taken by the police were the subject of an

independent investigation by the IOPC which found that procedures had been

applied correctly. The fact that Teresa made a clear statement of being afraid

of Dabir was a significant new factor. This is borne out in evidence from other

domestic homicide reviews and research; a victim acknowledging they could

be at risk is a very clear warning of risk.

59. Although the police had continued to follow up contact with Teresa, the fact

that that the incident had not been resolved prevented it from being processed

any further such as referring to the multi-agency front door safeguarding hub

or the daily domestic violence meeting. Policy making based on one case is

generally to be resisted. There was sufficient evidence from the phone call to

have indicated further screening and follow up was likely to occur but was

delayed whilst the police attempted to close their inquiries in regard to the

crime report. Given the volume of reports being received and processed the

police and associated services need to deploy systematic processes for

prioritising their respective responses. Reviewing the circumstances and

associated criteria under which a crime report of domestic violence and abuse

that has not been signed off within 24 hours due to the inability to complete a

DASH or to take a statement would be indicated as a potential area for further

development.

60. Leeds public housing services have a programme of annual visits to tenants.

The visits are guided with specific questions designed to identify vulnerabilities

and support needs which can which can include domestic violence and abuse


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and result in referral to other support services. It is an example of good practice

that the review panel wanted to see extended to other significant landlord

organisations in the city.

1.9 Recommendations

1. Safer Leeds should satisfy itself that enduring changes have been

achieved in the recording and associated processing of information

about anti-social behaviour for the purpose of identifying and making

appropriate referrals regarding domestic violence and abuse.

2. The Leeds Education Safeguarding Team should consider whether schools require further encouragement in developing policy and practice guidelines specific to children living with domestic violence and abuse. In particular, the importance of considering factors that might be contributing to behavioural presentation at school as well as how requests for children to be removed from school during term time or fail to return to school are screened.

3. Safer Leeds should refer the report to the Leeds Strategic Housing Board to consider if any further work is indicated in regard to enhancing the role of housing providers in identifying households that are potentially vulnerable to domestic violence and abuse.

4. Children’s Social Work Services and West Yorkshire Police should

ensure that when enquiries are being undertaken in regard to

safeguarding children or linked to reports of domestic violence and

abuse that consideration is given to checks being made for information

from the anti-social behaviour services.

5. Safer Leeds to consider if any further development in training and professional development is indicated by the review, so that if and when a victim expresses fear in regard to an intimate partner or family member, it is properly recognised and responded to as an indicator of high risk and is processed accordingly.

1.10 National policy

1. The Home Office should consider if the review indicates a need for any

further guidance to anti-social behaviour services and housing

providers regarding the processing and response to reports or

complaints of anti-social behaviour representing potential domestic

abuse and action to be considered.

2. The Home Office should consider if any further national guidance in regard to the circumstances under which the offence of malicious


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communication is used in regard to contact that represents harassment to signify the potential evidence of control and coercion and implications for assessing risk.

Documents

‘Teresa’ - Leeds · perpetrator. Teresa had four children. Her two eldest children were born during Teresa’s relationship with a man who was much older than Teresa and from