Cherylee Shennan
PFD Report
Partially Responded
Ref: 2019-0244
1 of 3 responded · Over 2 years old
Response Status
Responses
1 of 3
56-Day Deadline
4 Nov 2019
Over 2 years old — no identified published response
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
In the circumstances it is my statutory to report to you; The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator; no detailing of his licence conditions, and no information regarding either his nature or the trigger factors for his olfending: Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendalions that were made as a result of those reviews, in particular centred on the lack of inter-agency communications. My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known; and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1. 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
Responses
Response received
View full response
Dear Mr Newman; Re: Cherrylee Shennan Inquest Regualtion 28 Response Please see below for the Chief Constable'$ response to your regulation 28 report of 19th July 2019. The response deals with each recommendation from the Domestic Homicide Review (DHR) that is directed at the Lancashire Constabulary. A number of the DHR'$ recommendations relate to other parties and not the Constabulary. Where this is the case each has been left out of this response. The number of recommendation as it appears in the DHR is in brackets after the response number: Recommended changes following Domestic Homicide_Review
1. (DHR Recommendation 1) National recommendation When offenders who are released on life license or temporary license following a conviction for a domestic violence associated murder, or manslaughter, disclose that are forming a relationship with a new partner, this should trigger an immediate referral to MARAC Lancashire Constabulary are leading a multi-agency systems thinking review of the MARAC process and this is encompassing the journey from initial referral through to the MARAC meeting itself. This follows recognition of potential inefficiencies, time delays and ineffectiveness in the process_ Currently in 're-design' the multi-agency team is testing new models which are specifically aimed at responding to cases in 'live-time' through information sharing practices, tasking and adoption of a lead professional to cO-ordinate work to safeguard the victim: The team are also recognising that the MARAC process needs to be cognisant of the wider family and are addressing the needs of children/other parties in the household, and also the perpetrator s needs to provide opportunity to address root causes of abuse: Fn UK In case of emergency ca | 999, non-emergency cal 101 H
@LancsPolice facebook com/lancspolice T Commmm SLndd the they
The approach is therefore holistic, public health orientated and focused on problem solving whilst keeping the victim at the heart of the response_ Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question: The guidance is clear that responsibility for the referral lies with the Offender Manager and the cases MUST be prioritised as High Risk: The document produced, outlining the flow and criteria is attached
2. (DHR recommendation 2) Local Recommendation: The local MARAC protocol should be revised to ensure that anyone who is forming an intimate relationship with domestic abuse offenders who have been convicted of murder or manslaughter and are on life licence and are referred by an offender manager are prioritised as high risk cases and immediately heard at MARAC This should include the immediate sharing of information with the NHS and General Practice as an integral part of the MARAC process The attached document "MARAC operating protocol" (LC1) accounts for these criteria following the recommendation of the DHR.
3. (DHR recommendation 8) The learning from this case should be used to review multi agency data sharing for those offenders previously convicted of domestic abuse murder or manslaughter who on life licence The Lancashire Constabulary are a stakeholder in the MASH (Multi-Agency Sharing Hub); which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on nominals subject of safeguarding referrals ~ in particular those with previous convictions and actionable orders such as licence conditions. A perpetrator under a life licence is considered as high risk and would be referred to the MASH Probation staff who identify the perpetrator' $ offender manager to share information the referral to prompt any necessary action for example a recall on licence: MASH shares appropriately in parallel with partner agencies from these referrals in addition to Probation ~ for example with Social Care should children be a factor; This message is be refreshed periodically by the MASH police lead to MASH staff: (DHR recommendation 9) (a) Local Recommendation: are key from
MASH information systems and processes should be audited and tested against the learning from this case to ensure that there are no gaps in the system: Corporate systems thinking review of MASH was conducted from 2016-18 and amongst a number of changes implemented was a move from a process-driven response to safeguarding referrals to a model where MASH staff understood their role in supporting people and keeping them safe, achieving this by considering each case on its merits, including the specific needs of the victim, adult and/or children involved and responding accordingly in partnership. Staff Supervisors/Team Leaders were trained and are now focussed on this approach to recognising the risk, sharing information to achieve early interventions: With specific regard to this DHR and the processes to ensure information intended for sharing lands with it' $ recipient; a statement has been provided to the Coroner by MASH team leader Antonio Angelone: Extracted that statement: "The MASH are responsible for sharing information with partners, to safeguard vulnerable people both within Lancashire and outside: "In 2014 the force recorded vulnerability reports via an IT system called "Sleuth". This was achieved through the submission of a PVP (Protecting vulnerable persons) report, which the MASH would share. At that time, information was predominantly shared by @ system generated email within sleuth. It was identified that sending emails directly through the Sleuth system did not inform the sender if they failed to be delivered: In light of this when the constabulary changed its IT system from "Sleuth to "Connect" on 27h November 2018, the operating practice for sharing information changed with it: It was agreed that when information is shared via email it must be done via @ personal email address rather than 0 system generated address. This means that if an email fails to deliver to the intended recipient; the sender is immediately informed and can therefore take immediate action to ensure delivery: "This is particularly important when sending information to addresses outside of Lancashire as it highlights if an address has been incorrectly inputted or is inaccurate: Whilst this is less likely to occur Locally within Lancashire, (due to the addresses used regularly) it provides the added benefit of highlighting any technical difficulties within email addresses. Since adopting this approach there has been @ number of occasions when technical difficulties have arisen associated to delivering emails, which have, been quickly overcome: "When sharing information with agencies outside of the Lancashire area the process is that the MASH complete research to identify appropriate sharing pathways. Each pathway can vary dependent upon agency structures and unique working practices: It is therefore necessary to adopt bespoke approach to meet the needs of each agency. In the majority of occasions, this involve contacting the local police area's MASH (where this exists) or alternatively the police vulnerability departments. Once the locally agreed pathways are determined, information is shared via agreed emails. In 2014 Lancashire was one of the few force areas which had a MASH, making this process, challenging: The MASH model is now much more widely used nationally and therefore identification of agreed sharing pathways is much easier to determine: (b) Local Recommendation: The mechanism for communication across all agencies involved in the MASH needs quality assurance, in this case email communication alone was not sufficient to ensure the transfer of important information, therefore e-mail communication alone should not be relied upon. from being will
See response above at 4 (a):
5. (DHR recommendation 10) National Recommendation: Specific guidance should be issued to LSCB's in relation to the risks posed by violent offenders on life licence and should be explicitly referenced in the continuum of needs thresholds for Child Protection. The LSCB published report 'Lancashire Continuum of Needs and Thresholds Guidance" (Oct 2018) makes specific reference to children in domestic abuse settings: Domestic abuse and/or violence within the family which is having significant adverse impact on the child/unborn A person convicted for domestic abuse related murder, manslaughter, or serious assault is known to be developing a relationship with a parent or guardian of a child or young person: A child or young person is living in @ home where domestic abuse related assaults and incidents are a regular occurrence for agencies, or @ referral to MARAC has taken place The full report is attached (LC2):
6. (DHR recommendation 11) (a) Local Recommendation: The Domestic Abuse Strategy Group should ensure that local independent sector agencies have 0 robust disclosure and referral policy in place and that suitable training is available to promote compliance: Lancashire commissioning agencies (including Lancashire County Council; OPCC) for victim services groups including IDVA provision include within their contracts policy on compliance with disclosure and referrals including engagement with Domestic Homicide Reviews All locally commissioned IDVA services undergo Domestic Abuse training incorporating referrals and disclosure processes: (b) Local recommendation: All relevant statutory and voluntarylindependent agencies that to support families, should undertake domestic abuse training: In terms of police training around Domestic Abuse: All new recruits receive a full 'programme' of DA, Stalking & Harassment Training: (All DA Training includes Coercive & Controlling behaviour) Additional DA and Stalking and Harassment Training is provided on the Probationers Development Course (Officers with 14-18months service) Additional DA, Stalking and Harassment Training is provided to the new recruits on the "'New Style' new recruits course (2019). living work
DA, Stalking and Harassment; HBV/FMFGM Training provided to all new Contact Management recruits (Force Control Room): DA and Stalking and Harassment Training is provided to the Dedicated Decision Makers ~ Crime Data Integrity Teams_ DA and Stalking and Harassment Training was provided to Investigation Management Unit when they were newly formed (2018). DVDS (Clare's Law) and DVPN/O's Training is provided at regular intervals to BCU/Frontline staff DA, HBV/FM/FGM Training provided to Initial CID (ICIDP) course Multi- Agency Training which includes police staff/officers: DA and HBV/FMFGM Training provided on behalf of Blackpool Safeguarding Children'$ Board: HBV/FMFGM Training provided on behalf of Lancashire Safeguarding Children'$ Board. (Support has also been provided in re-writing LSCB DA 'programme' yet to be delivered ) DA and HBV /FMFGM Training has been provided to Preston based Probation Officers. The attached document (LC3) provides details (as supplied by the OPCC) of training delivered to partner agencies and organisations for domestic abuse in the past 12-18 months: In support of this the OPCC has also provided the following documents (attached):
1. Pan-Lancashire Domestic Abuse Strategy (Feb 2017) (LC4)
2. Lancashire Safeguarding Adults Board _ DA Guidance (Aug 2018) (LCS) The implementation of 'Operation Encompass' (early disclosure to Lancashire-based schools hosting children involved in/party to domestic abuse incidents in the preceding 24 hours to offer silent or active support) during 2018/19 included DA training provision to Dedicated Safeguarding Leads (DSL/ADSLs) from over 800 Lancashire County Council Schools, over 60 Blackburn with Darwen Schools and over 40 Blackpool schools. This training was delivered jointly by police and education: This training was supplemented by awareness raising inputs of Op Encompass to Police Officers and staff. Op Encompass has been 'live' in Lancashire since May 2019_ The constabulary through its Public Protection Unit has adopted a force-wide model of "SIP" Safeguarding; Investigation & Prevention which is for officers/staff to apply to all incidents deal with and will help appreciate wider vulnerabilities of the individuals, families, groups and environments come into contact with and instil 'professional curiosity' in dealing with vulnerability, not least domestic abuse: SIP is incorporated into vulnerability training in all related courses/inputs recently been delivered at 'Vulnerability Coach Iaunch sessions to over 250 frontline police officers/staff which has seen the recruitment of over 100 Vulnerability coaches in these roles to support; and coach their colleagues: they they and has guide
1. (DHR Recommendation 1) National recommendation When offenders who are released on life license or temporary license following a conviction for a domestic violence associated murder, or manslaughter, disclose that are forming a relationship with a new partner, this should trigger an immediate referral to MARAC Lancashire Constabulary are leading a multi-agency systems thinking review of the MARAC process and this is encompassing the journey from initial referral through to the MARAC meeting itself. This follows recognition of potential inefficiencies, time delays and ineffectiveness in the process_ Currently in 're-design' the multi-agency team is testing new models which are specifically aimed at responding to cases in 'live-time' through information sharing practices, tasking and adoption of a lead professional to cO-ordinate work to safeguard the victim: The team are also recognising that the MARAC process needs to be cognisant of the wider family and are addressing the needs of children/other parties in the household, and also the perpetrator s needs to provide opportunity to address root causes of abuse: Fn UK In case of emergency ca | 999, non-emergency cal 101 H
@LancsPolice facebook com/lancspolice T Commmm SLndd the they
The approach is therefore holistic, public health orientated and focused on problem solving whilst keeping the victim at the heart of the response_ Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question: The guidance is clear that responsibility for the referral lies with the Offender Manager and the cases MUST be prioritised as High Risk: The document produced, outlining the flow and criteria is attached
2. (DHR recommendation 2) Local Recommendation: The local MARAC protocol should be revised to ensure that anyone who is forming an intimate relationship with domestic abuse offenders who have been convicted of murder or manslaughter and are on life licence and are referred by an offender manager are prioritised as high risk cases and immediately heard at MARAC This should include the immediate sharing of information with the NHS and General Practice as an integral part of the MARAC process The attached document "MARAC operating protocol" (LC1) accounts for these criteria following the recommendation of the DHR.
3. (DHR recommendation 8) The learning from this case should be used to review multi agency data sharing for those offenders previously convicted of domestic abuse murder or manslaughter who on life licence The Lancashire Constabulary are a stakeholder in the MASH (Multi-Agency Sharing Hub); which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on nominals subject of safeguarding referrals ~ in particular those with previous convictions and actionable orders such as licence conditions. A perpetrator under a life licence is considered as high risk and would be referred to the MASH Probation staff who identify the perpetrator' $ offender manager to share information the referral to prompt any necessary action for example a recall on licence: MASH shares appropriately in parallel with partner agencies from these referrals in addition to Probation ~ for example with Social Care should children be a factor; This message is be refreshed periodically by the MASH police lead to MASH staff: (DHR recommendation 9) (a) Local Recommendation: are key from
MASH information systems and processes should be audited and tested against the learning from this case to ensure that there are no gaps in the system: Corporate systems thinking review of MASH was conducted from 2016-18 and amongst a number of changes implemented was a move from a process-driven response to safeguarding referrals to a model where MASH staff understood their role in supporting people and keeping them safe, achieving this by considering each case on its merits, including the specific needs of the victim, adult and/or children involved and responding accordingly in partnership. Staff Supervisors/Team Leaders were trained and are now focussed on this approach to recognising the risk, sharing information to achieve early interventions: With specific regard to this DHR and the processes to ensure information intended for sharing lands with it' $ recipient; a statement has been provided to the Coroner by MASH team leader Antonio Angelone: Extracted that statement: "The MASH are responsible for sharing information with partners, to safeguard vulnerable people both within Lancashire and outside: "In 2014 the force recorded vulnerability reports via an IT system called "Sleuth". This was achieved through the submission of a PVP (Protecting vulnerable persons) report, which the MASH would share. At that time, information was predominantly shared by @ system generated email within sleuth. It was identified that sending emails directly through the Sleuth system did not inform the sender if they failed to be delivered: In light of this when the constabulary changed its IT system from "Sleuth to "Connect" on 27h November 2018, the operating practice for sharing information changed with it: It was agreed that when information is shared via email it must be done via @ personal email address rather than 0 system generated address. This means that if an email fails to deliver to the intended recipient; the sender is immediately informed and can therefore take immediate action to ensure delivery: "This is particularly important when sending information to addresses outside of Lancashire as it highlights if an address has been incorrectly inputted or is inaccurate: Whilst this is less likely to occur Locally within Lancashire, (due to the addresses used regularly) it provides the added benefit of highlighting any technical difficulties within email addresses. Since adopting this approach there has been @ number of occasions when technical difficulties have arisen associated to delivering emails, which have, been quickly overcome: "When sharing information with agencies outside of the Lancashire area the process is that the MASH complete research to identify appropriate sharing pathways. Each pathway can vary dependent upon agency structures and unique working practices: It is therefore necessary to adopt bespoke approach to meet the needs of each agency. In the majority of occasions, this involve contacting the local police area's MASH (where this exists) or alternatively the police vulnerability departments. Once the locally agreed pathways are determined, information is shared via agreed emails. In 2014 Lancashire was one of the few force areas which had a MASH, making this process, challenging: The MASH model is now much more widely used nationally and therefore identification of agreed sharing pathways is much easier to determine: (b) Local Recommendation: The mechanism for communication across all agencies involved in the MASH needs quality assurance, in this case email communication alone was not sufficient to ensure the transfer of important information, therefore e-mail communication alone should not be relied upon. from being will
See response above at 4 (a):
5. (DHR recommendation 10) National Recommendation: Specific guidance should be issued to LSCB's in relation to the risks posed by violent offenders on life licence and should be explicitly referenced in the continuum of needs thresholds for Child Protection. The LSCB published report 'Lancashire Continuum of Needs and Thresholds Guidance" (Oct 2018) makes specific reference to children in domestic abuse settings: Domestic abuse and/or violence within the family which is having significant adverse impact on the child/unborn A person convicted for domestic abuse related murder, manslaughter, or serious assault is known to be developing a relationship with a parent or guardian of a child or young person: A child or young person is living in @ home where domestic abuse related assaults and incidents are a regular occurrence for agencies, or @ referral to MARAC has taken place The full report is attached (LC2):
6. (DHR recommendation 11) (a) Local Recommendation: The Domestic Abuse Strategy Group should ensure that local independent sector agencies have 0 robust disclosure and referral policy in place and that suitable training is available to promote compliance: Lancashire commissioning agencies (including Lancashire County Council; OPCC) for victim services groups including IDVA provision include within their contracts policy on compliance with disclosure and referrals including engagement with Domestic Homicide Reviews All locally commissioned IDVA services undergo Domestic Abuse training incorporating referrals and disclosure processes: (b) Local recommendation: All relevant statutory and voluntarylindependent agencies that to support families, should undertake domestic abuse training: In terms of police training around Domestic Abuse: All new recruits receive a full 'programme' of DA, Stalking & Harassment Training: (All DA Training includes Coercive & Controlling behaviour) Additional DA and Stalking and Harassment Training is provided on the Probationers Development Course (Officers with 14-18months service) Additional DA, Stalking and Harassment Training is provided to the new recruits on the "'New Style' new recruits course (2019). living work
DA, Stalking and Harassment; HBV/FMFGM Training provided to all new Contact Management recruits (Force Control Room): DA and Stalking and Harassment Training is provided to the Dedicated Decision Makers ~ Crime Data Integrity Teams_ DA and Stalking and Harassment Training was provided to Investigation Management Unit when they were newly formed (2018). DVDS (Clare's Law) and DVPN/O's Training is provided at regular intervals to BCU/Frontline staff DA, HBV/FM/FGM Training provided to Initial CID (ICIDP) course Multi- Agency Training which includes police staff/officers: DA and HBV/FMFGM Training provided on behalf of Blackpool Safeguarding Children'$ Board: HBV/FMFGM Training provided on behalf of Lancashire Safeguarding Children'$ Board. (Support has also been provided in re-writing LSCB DA 'programme' yet to be delivered ) DA and HBV /FMFGM Training has been provided to Preston based Probation Officers. The attached document (LC3) provides details (as supplied by the OPCC) of training delivered to partner agencies and organisations for domestic abuse in the past 12-18 months: In support of this the OPCC has also provided the following documents (attached):
1. Pan-Lancashire Domestic Abuse Strategy (Feb 2017) (LC4)
2. Lancashire Safeguarding Adults Board _ DA Guidance (Aug 2018) (LCS) The implementation of 'Operation Encompass' (early disclosure to Lancashire-based schools hosting children involved in/party to domestic abuse incidents in the preceding 24 hours to offer silent or active support) during 2018/19 included DA training provision to Dedicated Safeguarding Leads (DSL/ADSLs) from over 800 Lancashire County Council Schools, over 60 Blackburn with Darwen Schools and over 40 Blackpool schools. This training was delivered jointly by police and education: This training was supplemented by awareness raising inputs of Op Encompass to Police Officers and staff. Op Encompass has been 'live' in Lancashire since May 2019_ The constabulary through its Public Protection Unit has adopted a force-wide model of "SIP" Safeguarding; Investigation & Prevention which is for officers/staff to apply to all incidents deal with and will help appreciate wider vulnerabilities of the individuals, families, groups and environments come into contact with and instil 'professional curiosity' in dealing with vulnerability, not least domestic abuse: SIP is incorporated into vulnerability training in all related courses/inputs recently been delivered at 'Vulnerability Coach Iaunch sessions to over 250 frontline police officers/staff which has seen the recruitment of over 100 Vulnerability coaches in these roles to support; and coach their colleagues: they they and has guide
Report Sections
Investigation and Inquest
On the 21s March 2014 an investigation into the death of Cherylee Yvette Shennan aged 40 was opened: The investigation concluded at the end of the inquest on 15ih 2019. The conclusion of the inquest was: Unlawful The death of Cherylee on 71h March 2014 was more than minimally contributed to by the following: The failure to recall the perpetrator to prison once reports were made of violence to Cherylee and the perpetrator drinking The following possible contributed to the death of Cherylee on 17h March 2014: The lack of inter-agency management or appropriate sharing of information prior to the 15 March 2014. The lack of inter-agency management or appropriate sharing of information following the 1st March 2014.
Circumstances of the Death
In brief the deceased was a 40 year old woman who was murdered by the perpetrator on the 17th March 2014. perpetrator was an individual who was on licence" having murdered his previous partner in 1998. He was released on licence" in April 2012. His licence was managed by the Greater Manchester Probation Trust and had been assessed as a high risk to known individuals with trigger points for offending including relationship breakups, jealousy and alcohol and substance misuse He began a relationship with Cherylee at sometime in the summer of 2013. Evidence was heard that Cherylee was the victim of domestic abuse, manifesting across the range of forms of abuse, including violenceat the hands of the perpetrator from a5 early as late October 2013 Coroncr'$ Court, 2 Furuduy Court; Furuduy Drivd; Fulwood, Prestun, Luncashire; PRZ 9NB Tel 01772 536536 Fux 01772 530752 July killing The "life "life The violence included a broken nose, multiple accounts Of facial bruising, a fractured jaw, and being held hostage at knife point on at least two occasions Although a previous relationship had led to communication between agencies not only locally but also across into neighbouring counties, there was no such communication when the relationship with Cherylee started: In particular there was no contact with the Lancashire Constabulary, in whose jurisdiction, Cherylee lived: On the 1st March 2014 Cherylee disclosed the abuse to a family member, which resulted in a visit initially by uniform officers and subsequently by specialist Domestic Abuse officers, however the deceased did not directly report the abuse, and subsequently denied that the abuse had occurred_The perpetrator_was however identified buLno_information was held on him by Lancashire Constabulary: On the 12ih March 2014 the perpetrator reported to his offender manager that an allegation had been made against him, but withdrawn: On the 14h March 2014 details of the police's visits was provided to the offender manager by the domestic abuse officers On the 17ih March 2014 Cherylee informed the offender manager that the allegations had in fact been true: This was communicated to Lancashire Constabulary and two officers attended Cherylee's address. The officers who attended carried either none of their personal protective equipment or an incomplete set: Whilst there the perpetrator assaulted not only Cherylee but also the two officers and subsequently proceeded to stab Cherylee repeatedly in the street. The perpetrator was subsequently charged and convicted of Cherylee's murder:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.