Alfie Gildea
PFD Report
All Responded
Ref: 2020-0242
Child Death (from 2015)
Community health care and emergency services related deaths
Police related deaths
All 6 responses received
· Deadline: 18 Feb 2021
Sent To
Response Status
Responses
6 of 7
56-Day Deadline
18 Feb 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
_ 1_ The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required. Instead were placed under investigation.
2. The inquest was told that the GMPICPS definitions of a seriouslserial domestic abuser perpetrator were different: It was unclear why that was the case_ However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a seriallserious DA perpetrator:
3. It was unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems: Officers giving evidence did not understand how such information could be accessed or recorded.
4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to seriallserious DA perpetrators and the actions that were required under GMPs policy:
5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour: Understanding of how coercive and controlling behaviour in a relationship could be identified was limited.
6. The inquest was told that the DASH risk assessment is a national tool: However training of GMP officers on understanding how to evaluate risk and score risk was limited. they Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. 9_ The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhoodlresponse officers had further reduced in lowlmedium risk DA cases:
10.The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed: The file that was submitted omitted key information available to GMP that would have been important to the decision maker: The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim; The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that may contain key information:
11.The GMP policy on notification of DVPNIDVPOs to alleged victims was not followed: There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
12.Inforation sharing between all of the statutory agencies in particular health; Local Authority and Police was poor: As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator: Opportunities to use the MARAC framework were not taken:
13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident: Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed Iittle real opportunity for disclosure.
14.The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies.
15.The inquest was told that at the time the MARAT _ front line service was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority they have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th January 2021. !, 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: COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Alfie's mother the Children's Commissioner and HM Inspectorate of Constabulary who find it useful or of interest: 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: Alison Mutch HM Senior Coroner Ko Akt 18.11.2020 may
2. The inquest was told that the GMPICPS definitions of a seriouslserial domestic abuser perpetrator were different: It was unclear why that was the case_ However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a seriallserious DA perpetrator:
3. It was unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems: Officers giving evidence did not understand how such information could be accessed or recorded.
4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to seriallserious DA perpetrators and the actions that were required under GMPs policy:
5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour: Understanding of how coercive and controlling behaviour in a relationship could be identified was limited.
6. The inquest was told that the DASH risk assessment is a national tool: However training of GMP officers on understanding how to evaluate risk and score risk was limited. they Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. 9_ The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhoodlresponse officers had further reduced in lowlmedium risk DA cases:
10.The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed: The file that was submitted omitted key information available to GMP that would have been important to the decision maker: The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim; The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that may contain key information:
11.The GMP policy on notification of DVPNIDVPOs to alleged victims was not followed: There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
12.Inforation sharing between all of the statutory agencies in particular health; Local Authority and Police was poor: As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator: Opportunities to use the MARAC framework were not taken:
13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident: Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed Iittle real opportunity for disclosure.
14.The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies.
15.The inquest was told that at the time the MARAT _ front line service was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority they have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th January 2021. !, 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: COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Alfie's mother the Children's Commissioner and HM Inspectorate of Constabulary who find it useful or of interest: 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: Alison Mutch HM Senior Coroner Ko Akt 18.11.2020 may
Responses
Greater Manchester Police fully accepted the concerns, issuing a force-wide directive on using bail with conditions in domestic abuse cases and incorporating bail training for new recruits. They also conducted a deep-dive review of triage processes, circulated new triage expectations, and provided Domestic Violence Disclosure Scheme training to all officers.
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View full response
Dear Ms Mutch
Re: Regulation 28 Report following the inquest into the death of Alfie Ian Samuel Gildea
Thank you for your report sent by email dated 18 November 2020 in respect of the events which led to the tragic death of Alfie Gildea and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7, Schedule 5, of the Coroners and Justice Act 2009.
Having carefully considered your report, Greater Manchester Police (GMP) accepts in full the points raised. As a consequence, your report has already led to detailed discussions within GMPs Professional Standards Branch as to the issues which have arisen in this and other cases, with a view to taking further co-ordinated action to address the concerns identified. I have provided more detail of these measures below and reply to the specific issues raised as follows:
1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required. Instead they were placed under investigation.
At the time of the allegation of assault on the 10 July 2018, GMP was complying with the Policing and Crime Act 2017 which was implemented on the 3 April 2017. The biggest change was that there was a presumption of release without bail in almost all cases. National Police Chiefs Council (NPCC) guidance was issued to all Forces in relation to the new legislation, but Forces were encouraged to reduce the use of bail conditions due to concerns around how long individuals, who had not been charged with any offences, were subject to those conditions.
The GMP policy in place at the time of Alfie's death did not stipulate that bail should not be used in domestic abuse cases. It is recognised, however, that the significant change in approach to police bail that followed the introduction of the Policing and Crime Act 2017 meant that there was a potential for misunderstanding in relation to the application of the legislation to police bail at that time.
In May 2019, the NPCC issued updated operational guidance regarding the use of bail to all Forces. This operational guidance followed a review undertaken by Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) which identified that the use of bail across the UK had decreased since the new Bail Act changes were implemented. The operational guidance supported the use of bail in domestic abuse cases and other safeguarding investigations. GMP's Criminal Justice and Custody branch have recently conducted a review of bail and released under investigation (RUI), which includes domestic abuse cases. The results of this review are being discussed with the Public Protection Governance Unit with a view to ensuring robust compliance across the force.
2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuse perpetrator were different. It was unclear why that was the case. However, as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator.
GMP has liaised with Deputy Chief Crown Prosecutor in relation to this matter.
A/Chief Constable
HM Senior Coroner Ms Alison Mutch HM Coroner's Office 1 Mount Tabor Street Stockport SK1 3AG
8 January 2021
Cont.t pg 2……..
The current definition of a serial domestic abuse perpetrator used by GMP, which is aligned with the definition used by the College of Policing, is: 'A serial perpetrator is someone who has been reported to the police as having committed or threatened domestic abuse against two or more victims. This includes current or former intimate partners and family members.'
The CPS definition is: 'Where a suspect has committed an act of domestic abuse against two or more different victims they should be considered a serial perpetrator.'
The difference is the inclusion in the police definition of the previous incidents having been reported to the police which is not present in the CPS definition. It stands to reason that the CPS would not be aware of incidents reported to the police that did not either result in a crime being recorded or referred to the CPS. GMP are currently seeking clarification that, whilst the CPS have the ability to flag a particular case file as a domestic case, they potentially cannot, or do not, flag the individuals involved in that case as repeat or serial and rely on the police to share this information. Neither GMP nor the CPS uses the terminology of serious domestic abuse perpetrator.
The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person's record.
A whole system approach to offender management has been agreed in principle at the Justice and Rehabilitation Executive Board by the Deputy Mayor which will include GMP, National Probation Service (NPS), and Community Rehabilitation Company (CRC). This will include management of domestic abuse perpetrators.
3. It was unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMP's systems. Officers giving evidence did not understand how such information could be accessed or recorded.
At the time of GMP’s involvement with Alfie's parents, GMP used OPUS which is a records management system. The domestic abuse policy at that time stipulated that a serial domestic abuse perpetrator was: 'Someone who has committed domestic abuse against three or more different partners or an offender who has committed five or more domestic abuse offences against one partner. In these circumstances officers should utilise the PPI (Public Protection Incident) and FIS (Force Intelligence System) to identify additional risk factors to a victim and consider use of the Domestic Violence Disclosure Scheme. Consideration should be given to flag the perpetrator via the FIS OPUS system as a domestic abuse serial perpetrator.'
When a serial domestic abuse perpetrator was identified, they would be flagged as such, which was immediately visible on the person's record held in OPUS as per the example below:
At the time of GMP’s involvement with Alfie's parents, the expectation was that multi agency safeguarding hubs would, in the main, identify and add relevant information markers to people who required it. However, it was not their sole responsibility and the marker could be applied by anyone who identified it.
Had the GMP policy been followed, Samuel Gildea should have had a serial domestic abuse perpetrator marker added, but he did not. It is possible that there may have been a lack of
Cont.t pg 3……..
understanding around when a person was considered a serial domestic abuse perpetrator as the definition at that time was less clear than the definition in the new domestic abuse policy.
Information markers can be added in iOPS in a very similar manner. At present, there are some enhancements planned for Spring/Summer 2021 which will further improve the information markers available in iOPS, however both high risk and serial victims and perpetrators can now be added by all users. These information markers are presented/visible as per the example below:
4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy.
At the time of Alfie's death, the domestic abuse policy stipulated the following on serial domestic abuse perpetrators: 'In these circumstances officers should utilise the PPI (Public Protection Incident) and FIS (Force Intelligence System) to identify additional risk factors to a victim and consider use of the Domestic Violence Disclosure Scheme. Consideration should be given to flag the perpetrator via the FIS OPUS system as a domestic abuse serial perpetrator.'
The presence of an information marker is just that; it provides information to officers around potential risk factors that they may wish to consider when dealing with incidents. The presence of these markers rarely stipulates that a subsequent action should be followed and it is not intended that this should be the case. Information markers are used to guide officers in making appropriate decisions in accordance with the National Decision Model. Whilst the serial domestic abuse perpetrator marker was not applied in the case of Samuel Gildea, the incidents that he had been linked to as a perpetrator of domestic abuse were visible and accessible to all and officers are expected to assess previous history in coming to assessments about risk factors.
The definitions for repeat and serial victims and perpetrators have been revised since Alfie's death to simplify them. Where automation of markers can occur, this is being explored, however clear direction on the application and use of the serial domestic abuse perpetrator marker will be shared with police officers and staff when the domestic abuse policy is agreed. The Public Protection Governance Unit is currently working with iOPS and Capita to ensure visibility and understanding of when information markers should be applied and how to do this.
5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour. Understanding of how coercive and controlling behaviour in a relationship could be identified was limited.
When coercive and controlling behaviours came into legislation in 2015, a train-the-trainer model was used in order to efficiently train as many GMP staff as possible. At this time, over 800 front line staff were trained. This training provided an understanding of the legislation and application of it, with key features of coercive and controlling behaviours highlighted.
Cont.t pg 4……..
GMP's student officers receive a full day’s domestic abuse input which gives an overview of the various strands of domestic abuse, including coercive and controlling behaviours. In addition, student officers also complete a two-week consolidation training course prior to going out on independent patrol. Within this course, the students receive a full day’s safeguarding input, which is heavily focused on domestic abuse and child protection.
Between 2015 and 2020, 2773 PCs completed the Safeguarding for Constables course at Sedgley Park which incorporated coercive and controlling behaviours within a relationship. Further CPD was due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition and typology; the 'murdered by my boyfriend' film; coercion and control; stalking and harassment; identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and incident closing codes.
DCI from the Public Protection Governance Unit has been seconded to the People and Development Branch to review all GMP vulnerability training in the first instance. Following initial scoping, she will design, establish, and test a new vulnerability training offer for the force.
6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited.
GMP's People and Development Branch has advised that all officers now receive training on the DASH risk model and coercive controlling behaviour as part of their initial student officer training. This includes highlighting certain questions on the DASH risk assessment which can indicate escalated risk of harm, such as non-fatal strangulation. At the time OPUS was in use, these higher risk questions were denoted by being in a bolder print than other questions. Training on the DASH risk model was also delivered on the aforementioned Safeguarding for Constables course.
At the time of GMP’s involvement with Alfie's parents, the force policy stipulated that officers should take into account the circumstances of the incident, the vulnerability of the victim, and the history of the perpetrator when making a risk assessment. The new force policy offers more guidance to officers around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, such as standard risk, would not be appropriate. This includes:
• Three or more domestic abuse incidents in the last 12 months.
• Are there warning markers for child protection, high risk domestic abuse serial perpetrator, or violence?
• Pattern of coercive or controlling behaviour?
• Is there a pattern of stalking and harassment?
• Is there any report of non-fatal strangulation?
• Has the perpetrator abused one or more previous victims?
It is envisioned that this will be shared with officers on a regular basis during continuous professional development inputs and identified training courses. Additionally, the Public Protection Governance Unit has recently designed some refresher presentation for safeguarding teams around risk identification.
This Unit is also working with the People and Development Branch to support a newly designed course which is aimed at officers and staff in the organisation who work in a safeguarding role where they need to evaluate risk and provide formal training to support those staff in understanding risk factors and identifying them at the earliest opportunity.
Cont.t pg 5……..
7. Recognition of when and how Clare's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
The Domestic Violence Disclosure Scheme (DVDS) policy has recently been submitted to GMP's Policy and Strategy team for rework. The revised policy has made a number of enhancements to ensure that Clare's Law is considered by safeguarding teams on every domestic abuse incident they receive. The revised policy has also re-instated that a Detective Inspector should review and authorise the form of words that is to be disclosed to the victim.
In Spring/Summer 2021, there will be a specific DVDS marker available in iOPS which will be applied to a person's record to reflect that they have made an application under Clare's Law. The information marker will denote whether a disclosure was made or not and where further information about the disclosure can be located. This will also make it far more visible to all officers that concerns have been raised by either an individual, a third party, or by GMP.
In 2019, the People and Development Branch delivered training to all first responders at the rank of Constable, Sergeant, and Inspector to raise awareness of the DVDS and their responsibilities to identify when a disclosure may be appropriate, as well as how to share information with the safeguarding team that will ultimately oversee the disclosure process. All new recruits are made aware of the background to the DVDS and the aims and objectives of the scheme.
It is intended that when the revised policy is agreed, estimated to be in February 2021, there will be accompanying training material to raise awareness of the key changes and of the process itself.
8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed.
It is recognised that GMP's previous domestic abuse policy did not fully explore or explain 'victimless' or evidence-led prosecutions. The revised domestic abuse policy provides clear definitions and responsibilities for officers investigating domestic abuse offences to consider evidence-led prosecutions where appropriate to do so.
GMP recognise that this area needs further development and are currently in discussions with the CPS who are delivering training to prosecutors on this topic. It is intended that GMP will attend this training with a view to delivering something similar to the wider GMP workforce. By having a joint training event, this will ensure that the CPS and police are aligned in the delivery and expectations of evidence-led prosecutions.
9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases.
These areas of concern are recognised by the Investigation Safeguarding Review 2 (ISR2) project. Recommendations have been made by the ISR2 team for GMP to restructure their vulnerability and safeguarding model by introducing specialist Child Protection Investigation and Adult Safeguarding Units. These are only recommendations and are currently being discussed at Chief Officer level against
budgeting restraints going forward. Until a decision around ISR2 has been reached, interim mitigations have been put in place, including:
Cont.t pg 6……..
• ISR2 project team to complete a dip-sampling exercise on each district to ensure that the children's crime allocation and triage (C-CAT) is being applied correctly and child protection crimes are being reviewed by an appropriately trained officer and allocated to the correct resource.
• ISR2 project team to speak to each district and ensure that as a minimum each high risk domestic abuse victim has telephone contact from officer within the MASH.
• ISR2 project team will establish whether district Independent Domestic Violence Advocate provision has capability to support high risk domestic abuse victims within 24/48 hours of an incident being reported. Where gaps are identified, GMCA will be contacted to ensure these gaps are addressed through their commissioning.
• Districts will be required to complete the triage process within the 24 hour timescale set and triage against set standards developed by the Public Protection Governance Unit.
• Each district to instigate a daily / twice weekly meeting (virtual or physical) with adult social care, mental health services, and drugs and alcohol services to discuss adult protection incidents within the last 24/48 hours.
• The ISR2 recommendations in relation to DCI roles and responsibilities to be implemented giving district DCIs greater capacity to fulfil their core role.
• A review of the management of vulnerability inbox to ensure that this is managed by the correct resource who understands the requirements under NCRS.
• Each district to introduce a monthly / bi-monthly partnership meeting to discuss tactical issues / blockages.
Updates in relation to the progress of the ISR2 project are being communicated internally and externally to provide clarity around the proposals, timescales, and the interim measures.
10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan, or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
GMP has liaised with Deputy Chief Crown Prosecutor in relation to this matter.
GMP is aware that ‘Case Analysis and Strategy’ training was delivered to all CPS Direct prosecutors between December 2019 and June 2020, and now forms part of the induction programme for new lawyers joining CPD Direct. The training involved a comprehensive analysis of available evidence and the suspect’s previous domestic abuse history with other partners and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from the outset. This training also focused on the importance of recording the rationale for decisions and the selection of charge.
GMP is also aware that ‘Domestic Abuse Evidence Led Prosecutions’ training was delivered to all prosecutors by CPS Direct between July and October 2020, and also forms part of the induction programme for new lawyers joining CPS Direct. This training built upon the aforementioned Case
Cont.t pg 7……..
Analysis and Strategy training, focusing on the importance of case-building domestic abuse cases from the very start to ensure that it could proceed without the victim. GMP has confirmed with Deputy Chief Crown Prosecutor that a number of GMP officers involved in domestic investigations will be invited to attend this training so that similar training can be delivered across GMP.
11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP.
Since the death of Alfie, GMP has recruited two police staff to permanently and solely perform the role of DVPO officers. This has enabled a new process whereby the team now has extra flexibility to contact the victim as soon as the DVPO has been granted and offer additional support. If this contact fails, then the new process outlines the clear responsibilities for districts to make contact with the victim and conduct compliance checks within specified timeframes.
A revised DVPN/DVPO policy has been signed-off and launched alongside an accompanying training package to reflect the changes to the process. The following changes to the DVPN/DVPO process have now been implemented force wide:
• Applications for a DVPN are reviewed by an Inspector prior to submission to the Superintendent.
• Any refused applications will be documented with a full rationale and collated by the DVPN/O team.
• Guidance on timescales to complete both offender compliance and victim engagement visits.
12. Information sharing between all of the statutory agencies in particular health, Local Authority, and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken.
Each GMP district has a multi-agency safeguarding hub and a key partner within that hub includes children's social care. It is understood that children's health is generally well represented in many hubs, albeit they may not be co-located in every district. Adult health representation in the safeguarding hubs is generally less well represented. Some districts have representatives from adult social care, but the differences in primary and secondary care in health settings makes it difficult to capture all facets of mental health provision in the community or understand who may be accessing which services.
GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.
It is the aim of the Public Protection Governance Unit to agree consistency across the district teams and ensure that information sharing agreements and protocols which have been established are aligned with each other.
MARACs are set up on each of the districts with a local case management team employed by GMP providing the administration for the meetings. A Domestic Abuse Coordinator has been recruited and is currently awaiting authority to be appointed. The new appointee will take responsibility for ensuring a consistent approach to MARAC is taken across the force.
Cont.t pg 8……..
Additionally, when the newly formed training course for safeguarding teams is implemented, this will support improved identification of cases which need to be referred to MARAC.
I hope that this response is helpful in outlining the actions that we are taking to address the issues that you raised, and in demonstrating our total commitment to learning lessons from tragic events such as those which led to the death of Alfie Gildea, so that we can do our utmost to prevent such incidents from occurring in future.
Re: Regulation 28 Report following the inquest into the death of Alfie Ian Samuel Gildea
Thank you for your report sent by email dated 18 November 2020 in respect of the events which led to the tragic death of Alfie Gildea and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7, Schedule 5, of the Coroners and Justice Act 2009.
Having carefully considered your report, Greater Manchester Police (GMP) accepts in full the points raised. As a consequence, your report has already led to detailed discussions within GMPs Professional Standards Branch as to the issues which have arisen in this and other cases, with a view to taking further co-ordinated action to address the concerns identified. I have provided more detail of these measures below and reply to the specific issues raised as follows:
1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required. Instead they were placed under investigation.
At the time of the allegation of assault on the 10 July 2018, GMP was complying with the Policing and Crime Act 2017 which was implemented on the 3 April 2017. The biggest change was that there was a presumption of release without bail in almost all cases. National Police Chiefs Council (NPCC) guidance was issued to all Forces in relation to the new legislation, but Forces were encouraged to reduce the use of bail conditions due to concerns around how long individuals, who had not been charged with any offences, were subject to those conditions.
The GMP policy in place at the time of Alfie's death did not stipulate that bail should not be used in domestic abuse cases. It is recognised, however, that the significant change in approach to police bail that followed the introduction of the Policing and Crime Act 2017 meant that there was a potential for misunderstanding in relation to the application of the legislation to police bail at that time.
In May 2019, the NPCC issued updated operational guidance regarding the use of bail to all Forces. This operational guidance followed a review undertaken by Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) which identified that the use of bail across the UK had decreased since the new Bail Act changes were implemented. The operational guidance supported the use of bail in domestic abuse cases and other safeguarding investigations. GMP's Criminal Justice and Custody branch have recently conducted a review of bail and released under investigation (RUI), which includes domestic abuse cases. The results of this review are being discussed with the Public Protection Governance Unit with a view to ensuring robust compliance across the force.
2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuse perpetrator were different. It was unclear why that was the case. However, as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator.
GMP has liaised with Deputy Chief Crown Prosecutor in relation to this matter.
A/Chief Constable
HM Senior Coroner Ms Alison Mutch HM Coroner's Office 1 Mount Tabor Street Stockport SK1 3AG
8 January 2021
Cont.t pg 2……..
The current definition of a serial domestic abuse perpetrator used by GMP, which is aligned with the definition used by the College of Policing, is: 'A serial perpetrator is someone who has been reported to the police as having committed or threatened domestic abuse against two or more victims. This includes current or former intimate partners and family members.'
The CPS definition is: 'Where a suspect has committed an act of domestic abuse against two or more different victims they should be considered a serial perpetrator.'
The difference is the inclusion in the police definition of the previous incidents having been reported to the police which is not present in the CPS definition. It stands to reason that the CPS would not be aware of incidents reported to the police that did not either result in a crime being recorded or referred to the CPS. GMP are currently seeking clarification that, whilst the CPS have the ability to flag a particular case file as a domestic case, they potentially cannot, or do not, flag the individuals involved in that case as repeat or serial and rely on the police to share this information. Neither GMP nor the CPS uses the terminology of serious domestic abuse perpetrator.
The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person's record.
A whole system approach to offender management has been agreed in principle at the Justice and Rehabilitation Executive Board by the Deputy Mayor which will include GMP, National Probation Service (NPS), and Community Rehabilitation Company (CRC). This will include management of domestic abuse perpetrators.
3. It was unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMP's systems. Officers giving evidence did not understand how such information could be accessed or recorded.
At the time of GMP’s involvement with Alfie's parents, GMP used OPUS which is a records management system. The domestic abuse policy at that time stipulated that a serial domestic abuse perpetrator was: 'Someone who has committed domestic abuse against three or more different partners or an offender who has committed five or more domestic abuse offences against one partner. In these circumstances officers should utilise the PPI (Public Protection Incident) and FIS (Force Intelligence System) to identify additional risk factors to a victim and consider use of the Domestic Violence Disclosure Scheme. Consideration should be given to flag the perpetrator via the FIS OPUS system as a domestic abuse serial perpetrator.'
When a serial domestic abuse perpetrator was identified, they would be flagged as such, which was immediately visible on the person's record held in OPUS as per the example below:
At the time of GMP’s involvement with Alfie's parents, the expectation was that multi agency safeguarding hubs would, in the main, identify and add relevant information markers to people who required it. However, it was not their sole responsibility and the marker could be applied by anyone who identified it.
Had the GMP policy been followed, Samuel Gildea should have had a serial domestic abuse perpetrator marker added, but he did not. It is possible that there may have been a lack of
Cont.t pg 3……..
understanding around when a person was considered a serial domestic abuse perpetrator as the definition at that time was less clear than the definition in the new domestic abuse policy.
Information markers can be added in iOPS in a very similar manner. At present, there are some enhancements planned for Spring/Summer 2021 which will further improve the information markers available in iOPS, however both high risk and serial victims and perpetrators can now be added by all users. These information markers are presented/visible as per the example below:
4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy.
At the time of Alfie's death, the domestic abuse policy stipulated the following on serial domestic abuse perpetrators: 'In these circumstances officers should utilise the PPI (Public Protection Incident) and FIS (Force Intelligence System) to identify additional risk factors to a victim and consider use of the Domestic Violence Disclosure Scheme. Consideration should be given to flag the perpetrator via the FIS OPUS system as a domestic abuse serial perpetrator.'
The presence of an information marker is just that; it provides information to officers around potential risk factors that they may wish to consider when dealing with incidents. The presence of these markers rarely stipulates that a subsequent action should be followed and it is not intended that this should be the case. Information markers are used to guide officers in making appropriate decisions in accordance with the National Decision Model. Whilst the serial domestic abuse perpetrator marker was not applied in the case of Samuel Gildea, the incidents that he had been linked to as a perpetrator of domestic abuse were visible and accessible to all and officers are expected to assess previous history in coming to assessments about risk factors.
The definitions for repeat and serial victims and perpetrators have been revised since Alfie's death to simplify them. Where automation of markers can occur, this is being explored, however clear direction on the application and use of the serial domestic abuse perpetrator marker will be shared with police officers and staff when the domestic abuse policy is agreed. The Public Protection Governance Unit is currently working with iOPS and Capita to ensure visibility and understanding of when information markers should be applied and how to do this.
5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour. Understanding of how coercive and controlling behaviour in a relationship could be identified was limited.
When coercive and controlling behaviours came into legislation in 2015, a train-the-trainer model was used in order to efficiently train as many GMP staff as possible. At this time, over 800 front line staff were trained. This training provided an understanding of the legislation and application of it, with key features of coercive and controlling behaviours highlighted.
Cont.t pg 4……..
GMP's student officers receive a full day’s domestic abuse input which gives an overview of the various strands of domestic abuse, including coercive and controlling behaviours. In addition, student officers also complete a two-week consolidation training course prior to going out on independent patrol. Within this course, the students receive a full day’s safeguarding input, which is heavily focused on domestic abuse and child protection.
Between 2015 and 2020, 2773 PCs completed the Safeguarding for Constables course at Sedgley Park which incorporated coercive and controlling behaviours within a relationship. Further CPD was due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition and typology; the 'murdered by my boyfriend' film; coercion and control; stalking and harassment; identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and incident closing codes.
DCI from the Public Protection Governance Unit has been seconded to the People and Development Branch to review all GMP vulnerability training in the first instance. Following initial scoping, she will design, establish, and test a new vulnerability training offer for the force.
6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited.
GMP's People and Development Branch has advised that all officers now receive training on the DASH risk model and coercive controlling behaviour as part of their initial student officer training. This includes highlighting certain questions on the DASH risk assessment which can indicate escalated risk of harm, such as non-fatal strangulation. At the time OPUS was in use, these higher risk questions were denoted by being in a bolder print than other questions. Training on the DASH risk model was also delivered on the aforementioned Safeguarding for Constables course.
At the time of GMP’s involvement with Alfie's parents, the force policy stipulated that officers should take into account the circumstances of the incident, the vulnerability of the victim, and the history of the perpetrator when making a risk assessment. The new force policy offers more guidance to officers around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, such as standard risk, would not be appropriate. This includes:
• Three or more domestic abuse incidents in the last 12 months.
• Are there warning markers for child protection, high risk domestic abuse serial perpetrator, or violence?
• Pattern of coercive or controlling behaviour?
• Is there a pattern of stalking and harassment?
• Is there any report of non-fatal strangulation?
• Has the perpetrator abused one or more previous victims?
It is envisioned that this will be shared with officers on a regular basis during continuous professional development inputs and identified training courses. Additionally, the Public Protection Governance Unit has recently designed some refresher presentation for safeguarding teams around risk identification.
This Unit is also working with the People and Development Branch to support a newly designed course which is aimed at officers and staff in the organisation who work in a safeguarding role where they need to evaluate risk and provide formal training to support those staff in understanding risk factors and identifying them at the earliest opportunity.
Cont.t pg 5……..
7. Recognition of when and how Clare's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
The Domestic Violence Disclosure Scheme (DVDS) policy has recently been submitted to GMP's Policy and Strategy team for rework. The revised policy has made a number of enhancements to ensure that Clare's Law is considered by safeguarding teams on every domestic abuse incident they receive. The revised policy has also re-instated that a Detective Inspector should review and authorise the form of words that is to be disclosed to the victim.
In Spring/Summer 2021, there will be a specific DVDS marker available in iOPS which will be applied to a person's record to reflect that they have made an application under Clare's Law. The information marker will denote whether a disclosure was made or not and where further information about the disclosure can be located. This will also make it far more visible to all officers that concerns have been raised by either an individual, a third party, or by GMP.
In 2019, the People and Development Branch delivered training to all first responders at the rank of Constable, Sergeant, and Inspector to raise awareness of the DVDS and their responsibilities to identify when a disclosure may be appropriate, as well as how to share information with the safeguarding team that will ultimately oversee the disclosure process. All new recruits are made aware of the background to the DVDS and the aims and objectives of the scheme.
It is intended that when the revised policy is agreed, estimated to be in February 2021, there will be accompanying training material to raise awareness of the key changes and of the process itself.
8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed.
It is recognised that GMP's previous domestic abuse policy did not fully explore or explain 'victimless' or evidence-led prosecutions. The revised domestic abuse policy provides clear definitions and responsibilities for officers investigating domestic abuse offences to consider evidence-led prosecutions where appropriate to do so.
GMP recognise that this area needs further development and are currently in discussions with the CPS who are delivering training to prosecutors on this topic. It is intended that GMP will attend this training with a view to delivering something similar to the wider GMP workforce. By having a joint training event, this will ensure that the CPS and police are aligned in the delivery and expectations of evidence-led prosecutions.
9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases.
These areas of concern are recognised by the Investigation Safeguarding Review 2 (ISR2) project. Recommendations have been made by the ISR2 team for GMP to restructure their vulnerability and safeguarding model by introducing specialist Child Protection Investigation and Adult Safeguarding Units. These are only recommendations and are currently being discussed at Chief Officer level against
budgeting restraints going forward. Until a decision around ISR2 has been reached, interim mitigations have been put in place, including:
Cont.t pg 6……..
• ISR2 project team to complete a dip-sampling exercise on each district to ensure that the children's crime allocation and triage (C-CAT) is being applied correctly and child protection crimes are being reviewed by an appropriately trained officer and allocated to the correct resource.
• ISR2 project team to speak to each district and ensure that as a minimum each high risk domestic abuse victim has telephone contact from officer within the MASH.
• ISR2 project team will establish whether district Independent Domestic Violence Advocate provision has capability to support high risk domestic abuse victims within 24/48 hours of an incident being reported. Where gaps are identified, GMCA will be contacted to ensure these gaps are addressed through their commissioning.
• Districts will be required to complete the triage process within the 24 hour timescale set and triage against set standards developed by the Public Protection Governance Unit.
• Each district to instigate a daily / twice weekly meeting (virtual or physical) with adult social care, mental health services, and drugs and alcohol services to discuss adult protection incidents within the last 24/48 hours.
• The ISR2 recommendations in relation to DCI roles and responsibilities to be implemented giving district DCIs greater capacity to fulfil their core role.
• A review of the management of vulnerability inbox to ensure that this is managed by the correct resource who understands the requirements under NCRS.
• Each district to introduce a monthly / bi-monthly partnership meeting to discuss tactical issues / blockages.
Updates in relation to the progress of the ISR2 project are being communicated internally and externally to provide clarity around the proposals, timescales, and the interim measures.
10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan, or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
GMP has liaised with Deputy Chief Crown Prosecutor in relation to this matter.
GMP is aware that ‘Case Analysis and Strategy’ training was delivered to all CPS Direct prosecutors between December 2019 and June 2020, and now forms part of the induction programme for new lawyers joining CPD Direct. The training involved a comprehensive analysis of available evidence and the suspect’s previous domestic abuse history with other partners and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from the outset. This training also focused on the importance of recording the rationale for decisions and the selection of charge.
GMP is also aware that ‘Domestic Abuse Evidence Led Prosecutions’ training was delivered to all prosecutors by CPS Direct between July and October 2020, and also forms part of the induction programme for new lawyers joining CPS Direct. This training built upon the aforementioned Case
Cont.t pg 7……..
Analysis and Strategy training, focusing on the importance of case-building domestic abuse cases from the very start to ensure that it could proceed without the victim. GMP has confirmed with Deputy Chief Crown Prosecutor that a number of GMP officers involved in domestic investigations will be invited to attend this training so that similar training can be delivered across GMP.
11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP.
Since the death of Alfie, GMP has recruited two police staff to permanently and solely perform the role of DVPO officers. This has enabled a new process whereby the team now has extra flexibility to contact the victim as soon as the DVPO has been granted and offer additional support. If this contact fails, then the new process outlines the clear responsibilities for districts to make contact with the victim and conduct compliance checks within specified timeframes.
A revised DVPN/DVPO policy has been signed-off and launched alongside an accompanying training package to reflect the changes to the process. The following changes to the DVPN/DVPO process have now been implemented force wide:
• Applications for a DVPN are reviewed by an Inspector prior to submission to the Superintendent.
• Any refused applications will be documented with a full rationale and collated by the DVPN/O team.
• Guidance on timescales to complete both offender compliance and victim engagement visits.
12. Information sharing between all of the statutory agencies in particular health, Local Authority, and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken.
Each GMP district has a multi-agency safeguarding hub and a key partner within that hub includes children's social care. It is understood that children's health is generally well represented in many hubs, albeit they may not be co-located in every district. Adult health representation in the safeguarding hubs is generally less well represented. Some districts have representatives from adult social care, but the differences in primary and secondary care in health settings makes it difficult to capture all facets of mental health provision in the community or understand who may be accessing which services.
GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.
It is the aim of the Public Protection Governance Unit to agree consistency across the district teams and ensure that information sharing agreements and protocols which have been established are aligned with each other.
MARACs are set up on each of the districts with a local case management team employed by GMP providing the administration for the meetings. A Domestic Abuse Coordinator has been recruited and is currently awaiting authority to be appointed. The new appointee will take responsibility for ensuring a consistent approach to MARAC is taken across the force.
Cont.t pg 8……..
Additionally, when the newly formed training course for safeguarding teams is implemented, this will support improved identification of cases which need to be referred to MARAC.
I hope that this response is helpful in outlining the actions that we are taking to address the issues that you raised, and in demonstrating our total commitment to learning lessons from tragic events such as those which led to the death of Alfie Gildea, so that we can do our utmost to prevent such incidents from occurring in future.
The GMHSCP will review the Serious Case Review action plan in light of the inquest findings to ensure local learning is ascertained, acted upon, and shared. They also plan to present this learning to the Greater Manchester Quality Board and commissioners of services.
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Dear Ms Mutch
Re: Regulation 28 Report to Prevent Future Deaths – Alfie Ian Samuel Gildea
18.11.2020
Thank you for your Regulation 28 Report dated 18 November 2020 concerning the sad death of Alfie Gildea on 14 September 2018. Firstly, I would like to express my deep condolences to Alfie Gildea’s family.
The inquest concluded that Alfie’s death was a result of 1a) Head Injury.
Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.
I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.
NHS England / Improvement Regional Safeguarding and Quality Team use a variety of approaches to share learning and good practice across the North West and North East & Yorkshire Regions. This includes a weekly safeguarding bulletin which is disseminated to CCG Designated Professionals and dissemination of “7 minute briefings” following published serious case reviews (SCR), domestic homicide
reviews and serious adult reviews across the regional footprint to promote learning and share good practice.
An SCR was completed and published in December 2019 which resulted in the identification of a number of actions that are being overseen by the Trafford Strategic Safeguarding partnership. In light of the findings of the inquest the SCR action plan is being reviewed and scrutinised with a view to ensuring that all local learning is ascertained, acted upon and shared. Further details on this will be within the individual responses to the regulation 28 from other partners.
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Actions taken or being taken to prevent reoccurrence across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission
The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.
I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Alfie Ian Samuel Gildea
18.11.2020
Thank you for your Regulation 28 Report dated 18 November 2020 concerning the sad death of Alfie Gildea on 14 September 2018. Firstly, I would like to express my deep condolences to Alfie Gildea’s family.
The inquest concluded that Alfie’s death was a result of 1a) Head Injury.
Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.
I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.
NHS England / Improvement Regional Safeguarding and Quality Team use a variety of approaches to share learning and good practice across the North West and North East & Yorkshire Regions. This includes a weekly safeguarding bulletin which is disseminated to CCG Designated Professionals and dissemination of “7 minute briefings” following published serious case reviews (SCR), domestic homicide
reviews and serious adult reviews across the regional footprint to promote learning and share good practice.
An SCR was completed and published in December 2019 which resulted in the identification of a number of actions that are being overseen by the Trafford Strategic Safeguarding partnership. In light of the findings of the inquest the SCR action plan is being reviewed and scrutinised with a view to ensuring that all local learning is ascertained, acted upon and shared. Further details on this will be within the individual responses to the regulation 28 from other partners.
-
Actions taken or being taken to prevent reoccurrence across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission
The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.
I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Trafford Council stated that significant improvements to its policies and procedures have already been made since 2018. Details of these changes were provided at the inquest, satisfying the coroner regarding the Council's specific concerns.
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Dear Ms Mutch
Re: Death of Alfie Ian Samuel GILDEA
Thank you for your letter dated 18 November 2020 enclosing your Regulation 28 report.
As was confirmed and accepted at the inquest, the Council has made significant improvements to its policies and procedures since 2018. The full details of these changes and improvements were set out in detail in the Council’s evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating to the Council. In relation to the possible national issue identified in point 15 of your listed concerns, our understanding was that it was your intention to write to central government, specifically the Department for Education.
If the Council is able to assist further or if there is any additional information that you require, please do not hesitate to contact me”.
Re: Death of Alfie Ian Samuel GILDEA
Thank you for your letter dated 18 November 2020 enclosing your Regulation 28 report.
As was confirmed and accepted at the inquest, the Council has made significant improvements to its policies and procedures since 2018. The full details of these changes and improvements were set out in detail in the Council’s evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating to the Council. In relation to the possible national issue identified in point 15 of your listed concerns, our understanding was that it was your intention to write to central government, specifically the Department for Education.
If the Council is able to assist further or if there is any additional information that you require, please do not hesitate to contact me”.
The CPS clarified its definition of a serial domestic abuser and highlighted the implementation of Director Guidance 6 on 31 December 2020. This guidance outlines the roles of police and prosecutors regarding lines of enquiry and action plans in domestic abuse cases.
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Dear Mrs Mutch,
Re: Regulation 28 Report following the Inquest touching upon the death of Alfie Gildea.
Thank you for your report sent by email dated 17 November 2020 in respect of Alfie Gildea (deceased) and pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Having carefully considered your report and the matters relating to the Crown Prosecution Service therein, I reply as follows:
Extract from Regulation 28, point 2:
The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why this was the case. However, as a result there are different points at which an offender’s background triggers the requirement to treat the suspect as a serial/serious DA perpetrator.
The CPS Domestic Abuse Guidelines describe a serial perpetrator as someone who ‘has committed an act of domestic abuse against two or more different victims’. Therefore, had all available information been provided to the Crown Prosecution Service on 10 July 2018 then Gildea ought properly to have been identified as a serial perpetrator within the terms of the CPS definition. Had the prosecutor then followed the appropriate CPS Policy he would have been directed to think about building the case without the support of the victim and to consider whether or how to bring other potential victims on board.
By contrast, according to the College of Policing website:
‘A serial perpetrator is someone who has been reported to the police as having committed or threatened domestic abuse against two or more victims. This includes current or former intimate partners and family members.’
Although broadly similar to the CPS definition it appears to specifically require there to have been reports to the police from or about two different victims. Via email correspondence with Greater Manchester Police’s Public Protection and Serious Crime Directorate I have confirmed that this is the definition used by them in managing Domestic Abuse investigations.
2 I am not able to say how different descriptions have been developed. There is obvious sense in the police and CPS definitions aligning so that it is clear for everyone involved in the management of criminal Domestic Abuse cases when a suspect should be regarded as a serial perpetrator.
Although the CPS definition is wider than that used by the police because it doesn’t specifically require a report to the police to have been made, it ought to be acknowledged that, in reality, the most likely source of such information will be held by the police following a report by a victim or third party on their behalf.
I confirm that the disparity between the definitions has been highlighted to the Crown Prosecution Service’s national policy team so that they may consider further.
Samuel Gildea clearly fitted the description of a ‘serial DA perpetrator’ on either of the CPS and Police’s definitions of the term and therefore information relating to reports by previous victims ought properly to have been provided to the Crown Prosecution Service in July 2018.
Extract from Regulation 28, point 10:
(10) The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the Decision Maker. The CPS Decision Maker did not follow CPS Guidance, set an Action Plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the officer and the CPS Decision Maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
As part of the evidence to the inquest the Crown Prosecution Service acknowledged that the prosecutor (a) failed to consider or apply their Guidance (b) should have set an action plan and (c) gave no proper consideration to whether this was a case capable of being built as a victimless prosecution.
All CPS Direct prosecutors have been recently trained on ‘Case Analysis and Strategy’. This training focussed on the importance of recording the rationale for decisions and the selection of charge. It included a detailed case study on a coercive and controlling case involving a serial Domestic Abuse perpetrator. The training also involved a comprehensive analysis of available evidence and the suspect’s previous Domestic Abuse history with other partners and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from the outset. This training took place from December 2019 to June 2020 and is part of the induction program for new lawyers joining CPS Direct.
CPS Direct have also trained all prosecutors on ‘Domestic Abuse Evidence Led Prosecutions’. This built on the Case Analysis and Strategy training focussing on the importance of case-building DA cases from the very start, where possible strengthening the case to ensure that it could proceed without the victim. It also gave refresher guidance on the available legislation and gateways for the admission of evidence without calling the victim, stressing the need to ensure scrupulous policy compliance before an ‘NFA’ decision is reached. This training was completed between July-October 2020 and is also part of the induction program for new lawyers joining CPS Direct.
In CPS North West over the course of August and September 2020 prosecutors underwent training about the structure and content of a good review which included a specific section on the need to carefully record decision making in Domestic Abuse cases and to think about whether it is possible to proceed without the support of the victim. The Evidence Led Prosecutions course which has been delivered by CPS Direct will also be rolled out locally to Magistrates’, Crown Court and RASSO prosecutors as soon as we are able to do so. I am not able to commit to a date at the present time because of other national training commitments which are required to be delivered first. I have held a preliminary meeting with Detective Superintendent and confirmed with him that a number of GMP officers involved in Domestic Abuse investigations will also be invited to attend so that they can deliver similar training in force.
3 We also take on board the importance of a consistent and transparent approach to recording whether there has been a telephone call with the police as part of the charging decision. Senior managers within CPS Direct have confirmed that guidance has been re-issued to all of their prosecutors on the need to include within the MG3 details of any conversation relevant to an issue in the case, where it is not already included within the documentation submitted.
Finally, although not a formal recommendation, I would like to comment on the reference within Section 4 paragraph 7 concerning reasonable lines of enquiry especially in the light of the newly issued Director Guidance 6 which comes into force on 31 December 2020.
Within my original witness statement I explained the role of the prosecutor in relation to the identification of reasonable lines of enquiry. It remains the case, however, that there is no power for a prosecutor to formally direct the police to undertake such enquiries and their role in this is advisory. From the Director’s Guidance on Charging 6th Edition:
Paragraph 3.1 (concerning the responsibility of the police):
• Complying with the decision of the prosecutor to charge, caution, obtain additional material or information or take no action, with appropriate expedition, unless the case is escalated for review. The police will notify the prosecutor if the case cannot so proceed, explaining why; and
• Complying with action plans and providing any further evidence, material, or other information within agreed time periods. The process therefore ought to be that where there are identifiable outstanding reasonable lines of enquiry these should be included in an action plan by the prosecutor. Where the police do not comply with the action plan then consideration needs to be given to any reason for such failure (for example where the material is not capable of being obtained by them or where they refuse to carry out such enquiry). Prosecutors are expected to be proactive in their use of locally agreed escalation processes in order to obtain the requested material so as to give the best possible chance to build a case to the point of charge.
I hope that this response is helpful in outlining the actions that we are taking to address the issues that were raised by the tragic death of Alfie Gildea and in demonstrating our commitment to learning lessons so that we can do our utmost to prevent such incidents from occurring in future.
Re: Regulation 28 Report following the Inquest touching upon the death of Alfie Gildea.
Thank you for your report sent by email dated 17 November 2020 in respect of Alfie Gildea (deceased) and pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Having carefully considered your report and the matters relating to the Crown Prosecution Service therein, I reply as follows:
Extract from Regulation 28, point 2:
The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why this was the case. However, as a result there are different points at which an offender’s background triggers the requirement to treat the suspect as a serial/serious DA perpetrator.
The CPS Domestic Abuse Guidelines describe a serial perpetrator as someone who ‘has committed an act of domestic abuse against two or more different victims’. Therefore, had all available information been provided to the Crown Prosecution Service on 10 July 2018 then Gildea ought properly to have been identified as a serial perpetrator within the terms of the CPS definition. Had the prosecutor then followed the appropriate CPS Policy he would have been directed to think about building the case without the support of the victim and to consider whether or how to bring other potential victims on board.
By contrast, according to the College of Policing website:
‘A serial perpetrator is someone who has been reported to the police as having committed or threatened domestic abuse against two or more victims. This includes current or former intimate partners and family members.’
Although broadly similar to the CPS definition it appears to specifically require there to have been reports to the police from or about two different victims. Via email correspondence with Greater Manchester Police’s Public Protection and Serious Crime Directorate I have confirmed that this is the definition used by them in managing Domestic Abuse investigations.
2 I am not able to say how different descriptions have been developed. There is obvious sense in the police and CPS definitions aligning so that it is clear for everyone involved in the management of criminal Domestic Abuse cases when a suspect should be regarded as a serial perpetrator.
Although the CPS definition is wider than that used by the police because it doesn’t specifically require a report to the police to have been made, it ought to be acknowledged that, in reality, the most likely source of such information will be held by the police following a report by a victim or third party on their behalf.
I confirm that the disparity between the definitions has been highlighted to the Crown Prosecution Service’s national policy team so that they may consider further.
Samuel Gildea clearly fitted the description of a ‘serial DA perpetrator’ on either of the CPS and Police’s definitions of the term and therefore information relating to reports by previous victims ought properly to have been provided to the Crown Prosecution Service in July 2018.
Extract from Regulation 28, point 10:
(10) The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the Decision Maker. The CPS Decision Maker did not follow CPS Guidance, set an Action Plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the officer and the CPS Decision Maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
As part of the evidence to the inquest the Crown Prosecution Service acknowledged that the prosecutor (a) failed to consider or apply their Guidance (b) should have set an action plan and (c) gave no proper consideration to whether this was a case capable of being built as a victimless prosecution.
All CPS Direct prosecutors have been recently trained on ‘Case Analysis and Strategy’. This training focussed on the importance of recording the rationale for decisions and the selection of charge. It included a detailed case study on a coercive and controlling case involving a serial Domestic Abuse perpetrator. The training also involved a comprehensive analysis of available evidence and the suspect’s previous Domestic Abuse history with other partners and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from the outset. This training took place from December 2019 to June 2020 and is part of the induction program for new lawyers joining CPS Direct.
CPS Direct have also trained all prosecutors on ‘Domestic Abuse Evidence Led Prosecutions’. This built on the Case Analysis and Strategy training focussing on the importance of case-building DA cases from the very start, where possible strengthening the case to ensure that it could proceed without the victim. It also gave refresher guidance on the available legislation and gateways for the admission of evidence without calling the victim, stressing the need to ensure scrupulous policy compliance before an ‘NFA’ decision is reached. This training was completed between July-October 2020 and is also part of the induction program for new lawyers joining CPS Direct.
In CPS North West over the course of August and September 2020 prosecutors underwent training about the structure and content of a good review which included a specific section on the need to carefully record decision making in Domestic Abuse cases and to think about whether it is possible to proceed without the support of the victim. The Evidence Led Prosecutions course which has been delivered by CPS Direct will also be rolled out locally to Magistrates’, Crown Court and RASSO prosecutors as soon as we are able to do so. I am not able to commit to a date at the present time because of other national training commitments which are required to be delivered first. I have held a preliminary meeting with Detective Superintendent and confirmed with him that a number of GMP officers involved in Domestic Abuse investigations will also be invited to attend so that they can deliver similar training in force.
3 We also take on board the importance of a consistent and transparent approach to recording whether there has been a telephone call with the police as part of the charging decision. Senior managers within CPS Direct have confirmed that guidance has been re-issued to all of their prosecutors on the need to include within the MG3 details of any conversation relevant to an issue in the case, where it is not already included within the documentation submitted.
Finally, although not a formal recommendation, I would like to comment on the reference within Section 4 paragraph 7 concerning reasonable lines of enquiry especially in the light of the newly issued Director Guidance 6 which comes into force on 31 December 2020.
Within my original witness statement I explained the role of the prosecutor in relation to the identification of reasonable lines of enquiry. It remains the case, however, that there is no power for a prosecutor to formally direct the police to undertake such enquiries and their role in this is advisory. From the Director’s Guidance on Charging 6th Edition:
Paragraph 3.1 (concerning the responsibility of the police):
• Complying with the decision of the prosecutor to charge, caution, obtain additional material or information or take no action, with appropriate expedition, unless the case is escalated for review. The police will notify the prosecutor if the case cannot so proceed, explaining why; and
• Complying with action plans and providing any further evidence, material, or other information within agreed time periods. The process therefore ought to be that where there are identifiable outstanding reasonable lines of enquiry these should be included in an action plan by the prosecutor. Where the police do not comply with the action plan then consideration needs to be given to any reason for such failure (for example where the material is not capable of being obtained by them or where they refuse to carry out such enquiry). Prosecutors are expected to be proactive in their use of locally agreed escalation processes in order to obtain the requested material so as to give the best possible chance to build a case to the point of charge.
I hope that this response is helpful in outlining the actions that we are taking to address the issues that were raised by the tragic death of Alfie Gildea and in demonstrating our commitment to learning lessons so that we can do our utmost to prevent such incidents from occurring in future.
The Department of Health and Social Care noted the concerns and highlighted that the Trafford Strategic Safeguarding Partnership is reviewing a Serious Case Review action plan. DHSC has also commissioned Public Health England to develop a national network of safeguarding leads and ensure local safeguarding expertise.
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Dear Ms Mutch, Thank you for your correspondence of 18 November 2020 to Matt Hancock, relating to the death of Alfie Gildea. I am responding as Minister responsible for health visiting services and I am grateful for the additional time in which to do so. Firstly, I would like to take this opportunity to offer my sincere condolences to baby Alfie’s mother and family. I wish to assure you that this Government is committed to ending violence against women and children and recognises the important role all statutory agencies play in helping to prevent the deaths of children in circumstances such as those suffered by Alfie and his family. I have noted carefully your concerns about the actions of the Trafford health visiting service and the poor information sharing between Greater Manchester Police, Trafford Council and the health visiting service in this case, as well as your concerns about the numbers of health visitors nationally. I have been made aware that the Trafford Strategic Safeguarding Partnership (TSSP), initiated a serious case review (SCR) into Alfie’s case, published in December 2019. This recommended a number of actions for local agencies, including NHS providers and the local clinical Commissioning group, as well as actions for the TSSP itself, including an update of the multi-agency domestic abuse policy and guidance. I am also aware that the Greater Manchester Health and Social Care Partnership (GMHSCP), in its response to you, has advised that in light of the inquest findings, local agencies are reviewing the SCR action plan to ensure all local learning is ascertained, acted upon and shared. I understand detailed information on the improvement actions that individual local organisations are taking to address the matters of concern in your report will be provided to you separately. In its response, the GMHSCP provided assurance that the actions will be closely monitored.
Health professionals, including health visitors and their teams, are in a unique position to identify and, where appropriate, support children and families with safeguarding issues. As professionals they are required to be competent in child protection and are expected to regularly participate in training to update and maintain their skills. In March 2017, the Department published a resource for health professionals, Responding to domestic abuse [1], an update to a handbook for healthcare professionals published in
2005. The resource drew on previous public health guidance published in 2014 by the National Institute for Health and Care Excellence (NICE) on Domestic Violence and Abuse: Multi- agency working [2], and the accompanying 2016 guide, Quality Standard, Domestic Violence and Abuse [3]. The Department’s resource set out the responsibilities of providers and commissioners of health services, and of practitioners in responding to victims of domestic abuse. It included a new section offering practical guidance to healthcare professionals on dealing with the perpetrators of domestic abuse. On confidentiality and sharing information, the guide acknowledges that while it is vital that information on domestic abuse is kept confidential to protect victims from injury or death, in some instances, failure to share information can put victims at risk. Professionals may lawfully share information, without patient consent, if this can be justified in the public interest, or where they are required by law or court order. For example:
• Where there is risk of harm to the victim, any children involved or somebody else if information is not passed on as a referral;
• To inform a risk assessment (where the definition of 'harm' to a child includes impairment caused by seeing or hearing the abuse of another person); or
• When the courts request information about a specific case.
In order that organisations, agencies and practitioners collaborate effectively, it is vital that everyone working with children and families, including those who work with parents/carers, understands the role they play. The inter-agency guide Working Together to Safeguard Children [4] (2018) strengthened the arrangements in this area. I would expect practitioners to be aware of, and comply
1
meticAbuseGuidance.pdf 2 https://www.nice.org.uk/guidance/ph50/resources/domestic-violence-and-abuse-multiagency-working-pdf- 1996411687621 3 https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381 4
g_together_to_safeguard_children_inter_agency_guidance.pdf
with, the published arrangements set out by the local safeguarding partners as detailed in the inter-agency working guide. The multi-agency guidance sets out specific details for practitioners on being aware of and developing their understanding of domestic abuse, which includes controlling and coercive behaviour from perpetrators of domestic abuse, and the impact this has on children. Health visitors as leaders of the Healthy Child Programme (HCP) deliver the HCP zero to five and are equipped to work at community, family and individual levels. They are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. Since 2015, local authorities have been responsible for the commissioning of services for children between the ages of 0-5 and it is for local authorities to determine the required numbers of health visitors based upon local needs. All commissioning should be based on a robust Joint Strategic Needs Assessment and supported by local workforce plans. In this financial year, local authorities will receive a £3.279 billion public health grant for their public health duties for all ages [5]. There is no single source that counts health visitors across all the bodies local authorities commission services from. We do know that NHS workforce statistics for hospital trusts and clinical commissioning groups show 6,753 full-time equivalent health visitors deployed by Hospital and Community Health Services in September 2020. Universal reviews provided by Health Visitor Services have been mandated, following the transfer of zero-to-five services to local authorities. This is to enable services to be delivered in the context of a national, standard format to ensure consistent delivery. Finally, you may wish to note that we are awaiting a report from the Early Years Health Adviser, Andrea Leadsom MP, who has been leading a major review into improving health outcomes in babies and young children [6]. The review will consider the barriers that impact on early-years development, including social and emotional factors and early childhood experiences, and seek to show how to reduce the impacts of vulnerability and adverse childhood experiences in this stage of life. I hope this response is helpful. Thank you for bringing these concerns to my attention.
JO CHURCHILL
5 https://www.gov.uk/government/publications/public-health-grants-to-local-authorities-2020-to-2021 6 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches
Health professionals, including health visitors and their teams, are in a unique position to identify and, where appropriate, support children and families with safeguarding issues. As professionals they are required to be competent in child protection and are expected to regularly participate in training to update and maintain their skills. In March 2017, the Department published a resource for health professionals, Responding to domestic abuse [1], an update to a handbook for healthcare professionals published in
2005. The resource drew on previous public health guidance published in 2014 by the National Institute for Health and Care Excellence (NICE) on Domestic Violence and Abuse: Multi- agency working [2], and the accompanying 2016 guide, Quality Standard, Domestic Violence and Abuse [3]. The Department’s resource set out the responsibilities of providers and commissioners of health services, and of practitioners in responding to victims of domestic abuse. It included a new section offering practical guidance to healthcare professionals on dealing with the perpetrators of domestic abuse. On confidentiality and sharing information, the guide acknowledges that while it is vital that information on domestic abuse is kept confidential to protect victims from injury or death, in some instances, failure to share information can put victims at risk. Professionals may lawfully share information, without patient consent, if this can be justified in the public interest, or where they are required by law or court order. For example:
• Where there is risk of harm to the victim, any children involved or somebody else if information is not passed on as a referral;
• To inform a risk assessment (where the definition of 'harm' to a child includes impairment caused by seeing or hearing the abuse of another person); or
• When the courts request information about a specific case.
In order that organisations, agencies and practitioners collaborate effectively, it is vital that everyone working with children and families, including those who work with parents/carers, understands the role they play. The inter-agency guide Working Together to Safeguard Children [4] (2018) strengthened the arrangements in this area. I would expect practitioners to be aware of, and comply
1
meticAbuseGuidance.pdf 2 https://www.nice.org.uk/guidance/ph50/resources/domestic-violence-and-abuse-multiagency-working-pdf- 1996411687621 3 https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381 4
g_together_to_safeguard_children_inter_agency_guidance.pdf
with, the published arrangements set out by the local safeguarding partners as detailed in the inter-agency working guide. The multi-agency guidance sets out specific details for practitioners on being aware of and developing their understanding of domestic abuse, which includes controlling and coercive behaviour from perpetrators of domestic abuse, and the impact this has on children. Health visitors as leaders of the Healthy Child Programme (HCP) deliver the HCP zero to five and are equipped to work at community, family and individual levels. They are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. Since 2015, local authorities have been responsible for the commissioning of services for children between the ages of 0-5 and it is for local authorities to determine the required numbers of health visitors based upon local needs. All commissioning should be based on a robust Joint Strategic Needs Assessment and supported by local workforce plans. In this financial year, local authorities will receive a £3.279 billion public health grant for their public health duties for all ages [5]. There is no single source that counts health visitors across all the bodies local authorities commission services from. We do know that NHS workforce statistics for hospital trusts and clinical commissioning groups show 6,753 full-time equivalent health visitors deployed by Hospital and Community Health Services in September 2020. Universal reviews provided by Health Visitor Services have been mandated, following the transfer of zero-to-five services to local authorities. This is to enable services to be delivered in the context of a national, standard format to ensure consistent delivery. Finally, you may wish to note that we are awaiting a report from the Early Years Health Adviser, Andrea Leadsom MP, who has been leading a major review into improving health outcomes in babies and young children [6]. The review will consider the barriers that impact on early-years development, including social and emotional factors and early childhood experiences, and seek to show how to reduce the impacts of vulnerability and adverse childhood experiences in this stage of life. I hope this response is helpful. Thank you for bringing these concerns to my attention.
JO CHURCHILL
5 https://www.gov.uk/government/publications/public-health-grants-to-local-authorities-2020-to-2021 6 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches
The Home Office noted that the College of Policing issued guidance last summer on identifying and managing domestic abuse perpetrators. They are also seeking to place Domestic Violence Disclosure Scheme guidance on a statutory footing and plan to introduce and pilot new Domestic Abuse Protection Orders through the Domestic Abuse Bill.
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View full response
Dear David
Thank you for your letter of 18 November which shared the Regulation 28 report pertaining to Alfie Gildea’s death and please accept my apologies for the delayed response.
The Report raised several matters of concern relating to Greater Manchester Police’s response to the management of Alfie’s father. I would like to share what has been done at a national level to address some of these issues.
The management of serial and serious perpetrators of abuse is key to preventing further abuse and we are keen to ensure that we have the right systems in place to enable the police and agencies to accurately identify the risks posed by perpetrators. As part of this work, the College of Policing issued guidance to police forces in last Summer on the ‘Identification, assessment and management of serial or potentially dangerous domestic abuse and stalking perpetrators’. The key principles set out that forces should have processes in place to identify serial or potentially dangerous domestic abuse or stalking perpetrators and ensure that information about the perpetrator is recorded on the Police National Computer, the Police National Database or ViSOR as appropriate.
The Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law, is an important tool designed to keep people safe and we are working with the police to review the guidance used by forces. Under Clause 70 of the Domestic Abuse Bill, we are seeking to place the guidance that underpins DVDS onto a statutory footing to drive greater use and consistent application of the scheme by placing an express duty on the police to have regard to the guidance. Alongside legislation, we are reviewing the content of the guidance to ensure they are applied consistently across the country and are as effective as possible in helping to protect victims. This review will consider the timelines involved in the process and the use of risk assessments and safety planning.
The coercive and controlling behaviour offence is increasingly being used by police, but we continue to consider how best to work with forces to ensure they understand it and enforce the laws with maximum effect.
Finally, the Domestic Abuse Bill will introduce new Domestic Abuse Protection Orders (DAPOs). Once the Bill receives Royal Assent, we intend to pilot the Orders before rolling it out more widely. Police training will be an integral part of the rollout of DAPOs and we will produce detailed statutory guidance and a programme of training and toolkits for professionals to ensure there is a strong understanding of the new orders.
Email:
Thank you for your letter of 18 November which shared the Regulation 28 report pertaining to Alfie Gildea’s death and please accept my apologies for the delayed response.
The Report raised several matters of concern relating to Greater Manchester Police’s response to the management of Alfie’s father. I would like to share what has been done at a national level to address some of these issues.
The management of serial and serious perpetrators of abuse is key to preventing further abuse and we are keen to ensure that we have the right systems in place to enable the police and agencies to accurately identify the risks posed by perpetrators. As part of this work, the College of Policing issued guidance to police forces in last Summer on the ‘Identification, assessment and management of serial or potentially dangerous domestic abuse and stalking perpetrators’. The key principles set out that forces should have processes in place to identify serial or potentially dangerous domestic abuse or stalking perpetrators and ensure that information about the perpetrator is recorded on the Police National Computer, the Police National Database or ViSOR as appropriate.
The Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law, is an important tool designed to keep people safe and we are working with the police to review the guidance used by forces. Under Clause 70 of the Domestic Abuse Bill, we are seeking to place the guidance that underpins DVDS onto a statutory footing to drive greater use and consistent application of the scheme by placing an express duty on the police to have regard to the guidance. Alongside legislation, we are reviewing the content of the guidance to ensure they are applied consistently across the country and are as effective as possible in helping to protect victims. This review will consider the timelines involved in the process and the use of risk assessments and safety planning.
The coercive and controlling behaviour offence is increasingly being used by police, but we continue to consider how best to work with forces to ensure they understand it and enforce the laws with maximum effect.
Finally, the Domestic Abuse Bill will introduce new Domestic Abuse Protection Orders (DAPOs). Once the Bill receives Royal Assent, we intend to pilot the Orders before rolling it out more widely. Police training will be an integral part of the rollout of DAPOs and we will produce detailed statutory guidance and a programme of training and toolkits for professionals to ensure there is a strong understanding of the new orders.
Email:
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