Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Lee-Ann Sarah Ince Thank you for your Regulation 28 Report dated 20/06/2024 concerning the sad death of Ms Lee-Ann Sarah Ince on 09/05/2023. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms. Ince’s family for their loss. Thank you for highlighting your concerns during Mr. Ince’s Inquest which concluded on 22nd May 2024. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention. We recognise it is also very important to ensure we make the necessary improvements to the quality and safety of future services. Further to the notice issued to the Greater Manchester Integrated Care Board in respect of the above, partners in Trafford have agreed to file a joint response to ensure that the action we take is as robust and as effective as it can be. Following receipt of the notice, partners convened a working group which consisted of colleagues from Health, Adult Social Care, Children’s Services, Greater Manchester Police and Community Safety and consulted with Trafford Domestic Abuse Services throughout. We welcome the comments and observations made by HM Coroner and are resolute in ensuring that recommendations are translated into tangible actions which made a difference to victims of domestic abuse. We remain committed as always to a journey of continuous improvement and we submit the attached document which sets out what we intend to do as a partnership, and timescales for action. The Community Safety Partnership Board which has commissioned the Domestic Homicide Review will retain local governance to ensure that these actions are met and to report back to the HM Coroner on progress upon request.

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 1 of 10 Preventing Future Deaths – Response Template (LI) A ‘RegulaƟon 28: Report to prevent future deaths’ was issued to the Greater Manchester Integrated Care Board (ICB) by the HM Coroner in relaƟon to the inquest into the death of Lee-Ann Sarah Ince. The following extract is taken from the report which highlights the idenƟfied concerns: During the course of the inquest the evidence revealed maƩers giving rise to concern. In my opinion there is a risk that future deaths will occur unless acƟon is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.
1. The inquest heard evidence that agencies involved in supporƟng her in the months leading up to her death had a limited understanding of how behaviours could be twisted in a coercive and controlling relaƟonship to make it appear as if the vicƟm was part of the problem. In this situaƟon it was clear that Lee-Ann was the vicƟm of so called “love bombing” which meant that she was barraged with messages from the perpetrator. The impact of that on a vicƟm’s mental health was not recognised.
2. Her children had expressed their concerns to their school. The school had been proacƟve in sharing those concerns but there was liƩle evidence that other agencies were then listening to “the voice of the child”. This meant that agencies who had direct contact with her did not have a full grasp of the situaƟon or her vulnerability. The inquest was told that if informaƟon is not effecƟvely shared and the voice of the child is lost there is an increased risk to the vicƟm.
3. A feature of her vulnerability was her physical health and how dependent she was, as a consequence, on the perpetrator to help care for her. The addiƟonal vulnerability and impact of this was not recognised by agencies involved in supporƟng her. The inquest was told that where vulnerability is not properly understood the risk presented to a vicƟm of domesƟc abuse increases. You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th August 2024. I, the coroner, may extend the period. In response to the above, the table below sets out the acƟons that will be taken forward to address those highlighted concerns with respecƟve Ɵmescales for the specified acƟons. Please refer below

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 2 of 10 Matter of Concern 1 The inquest heard evidence that agencies involved in supporting her in the months leading up to her death had a limited understanding of how behaviours could be twisted in a coercive and controlling relationship to make it appear as if the victim was part of the problem. In this situation it was clear that Lee- Ann was the victim of so called “love bombing” which meant that she was barraged with messages from the perpetrator. The impact of that on a victim’s mental health was not recognised. Action Progress to date Next Steps Timescales Responsible Agency
1.1 - We will work collaboratively to develop or commission specialist training for practitioners to better understand the dynamics where coercion and control is present. We will develop and deliver specialist training that focuses on the dynamics of control and coercion and how this needs to be understood by practitioners who are working with victims and their families. This aims to bring clarity on who is the abuser and who is the victims and support effective decision making and action Whilst there has already been training on Control & Coercion this has been more focused on the legal framework and definitions rather than an understanding around the dynamics and how this may impact. . Identify number of individuals to be trained. Agree scope of training and content Commission sessions to be funded by the Community Safety Partnership Bookings, advertising and monitoring to be collated through Safeguarding Learning & Development. Progress against this will be reported to the Community Safety Partnership who will retain governance of our partnership approach and delivery in respect of domestic abuse. Training to commence September 2024 with the first courses being rolled out in the latter half of the year. This will then be an ongoing training offer. Trafford Community Safety Partnership
1.2 - We will routinely make it usual practice to invite Independent Domestic Violence Advocates (IDVAs) to initial Case Discussions with Trafford Domestic Abuse Service (TDAS) have already taken place in respect of existing capacity, and this has been agreed Best practice and approach to be agreed with all partners. October 2024 Trafford Council

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 3 of 10 Conferences or other safeguarding meetings where they are supporting the victim. The purpose of this is so that they can advocate on behalf of the victim and bring their specialism and expertise. This approach is to be embedded within the council so that opportunities to better support victims is not missed. in principle subject to capacity and demand pressures. The multi-agency risk assessment (MARAC) process is well embedded across the partnership and Trafford Domestic Abuse Services are a key stakeholder at these meetings and actions are inclusive of considering support needs to the victim. IDVAs are routinely invited to meetings were domestic abuse is a feature but we will strengthen our approach in respect of support at Child Protection conferences. Agreed changes to Safeguarding procedures to be endorsed by Trafford Strategic Safeguarding Partnership (TSSP) and CSP. Adult Social Care and Children’s Social Care to update their procedures in line with agreed changes. Performance reporting against this to be developed and reported to Strategic Safeguarding Partnership and Community Safety partnership. Briefings to be rolled out across Adult and Children Services to embed requirements and expectations across the service. IDVA service to attend CSC Leadership Forum (for all Practice Managers and Head of Service) and present in respect of their role as advocates and support to victims of violence to support embedding of this practice requirement. Children’s Safeguarding Unit to amend current score card to monitor invitation and attendance of IDVA as advocate at Child Protection Conference.

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1.3 – We will develop plans to raise awareness of coercion and the impact and harm of coercive and controlling behaviour so that it is better understood by professionals and members of the public alike. Plans are already in place for awareness raising campaign. Budget has been identified and made available to support this. Community Safety to work with TDAS & Communications Team to develop a public awareness campaign on control and coercion. Use of existing budget on campaigns to fund a social media campaign in Trafford on ‘control and coercion’ Launch on White Ribbon Day 2024 (25th November 2024) Trafford Community Safety Partnership Matter of Concern 2 Her children had expressed their concerns to their school. The school had been proactive in sharing those concerns but there was little evidence that other agencies were then listening to “the voice of the child”. This meant that agencies who had direct contact with her did not have a full grasp of the situation or her vulnerability. The inquest was told that if information is not effectively shared and the voice of the child is lost there is an increased risk to the victim. Action Progress to date Next Steps Timescales Responsible Agency
2.1 – We will continue to progress the dedicated multi- agency Domestic Abuse Action Plan that is detailed within Trafford’s Ambitions for Children’s Plan (Ambition 6) There is a dedicated Domestic Abuse priority within Trafford's Ambitions for Children Plan (Ambition 6). The priority has a detailed action plan that sits beneath it. The focus of this plan has been to strengthen the early identification of domestic abuse by developing our approach that supports our understanding of children's lived experience and to inform our interventions. Key actions that are being taken forward under the auspices of that plan include: Ongoing and being progressed. September 2024 Children’s Social Care Children’s Social Care to lead but model and approach will need endorsement from Trafford Strategic

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 5 of 10 Review of the Domestic Abuse Practitioner role within First Response Team (FRT Children’s Social Care Point of Entry). Discussions with TDAS to further enhance their role and presence within FRT building on the existing
0.5 days per week are already taking place to further strengthen initial response to domestic abuse / violence concerns. Embed Domestic Abuse practitioners within our localities to support early identification and intervention. Research and roll out an agreed evidence-based approach to the management of risk in respect of DA across the partnership. Researching models of intervention has already been undertaken and an options paper will formally be presented to the Ambitions work stream for endorsement and will include roll out and implementation plan. This options appraisal will include consideration of Safe and Together Model. The Safe and Together Model is licensed and offers a suite of tools and interventions designed Safeguarding Partnership

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 6 of 10 to help child welfare professionals become domestic violence informed. The model aims to move away from professionals focusing survivor’s behaviour and moving towards concentrating on the actions of perpetrators.
2.2 We will roll out ‘Voice of the Child’ Training across the partnership Victim Voice facilitator from TDAS has been meeting with children and young people within Trafford, who have experienced domestic abuse to understand their experiences of seeking support from services. This work is being used to inform learning and practice across the partnership. The next steps will include how this can be incorporated into existing training. A pilot training programme delivered by Access 27 has been implemented with 2 sessions held and 25 social care practitioners attending the training. The programme involves a powerful theatre performance that highlights experiences of children of living in a household where domestic abuse is a feature as well as considering the legislation, identifying children as victims in their own right. Progress the business case to roll out this training and then present to the relevant partnership decision making forums. September 2024 Childrens Social Care and Trafford Domestic Abuse Services

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 7 of 10 A dedicated resource pack specific to Trafford has been developed as part of this programme. Evaluation of the session using questionnaires to evaluate learning had been used to inform impact of the training.
2.3 – We will further strengthen and enhance Children’s Social Care (CSC) & Greater Manchester Police triage and decision making at the point of entry in respect of Domestic Abuse GMP and CSC have a joint triage front door process in place (MASH) that involves screening of all referrals to CSC at point of entry. Recent inspections have identified the Front door arrangements as an area of strength, A meeting has been held on Tuesday 16 July 2024 between Senior leaders within CSC and GMP to scope further strengthening these arrangements the work with particular focus on the joint role and decision-making practice of GMP and TDAS role within triage. Dedicated daily triage arrangements for partners to be implemented specifically in relation to incidents of domestic abuse. This will need to be aligned and reviewed in accordance current daily risk meetings that take place as part of Adult Social Care decision making. Policies and procedures to updated following any changes and endorsed through partnership routes. In progress to be completed October 2024 Children’s Social Care & Greater Manchester Police
2.4 We will continue to strengthen our Family Help services in respect of response to incidents domestic abuse and coercive control Trafford Family Help services have been reshaped and the model within Trafford Family Support Service is inclusive of having dedicated adult practitioner expertise in respect of domestic abuse, substance misuse Progress the work that is ongoing to review the Reducing Parental Conflict (RPC) Offer and its use as a key intervention, within Family Help. The review will inform an updated action plan, held by the Reducing In place and ongoing Review of RPC to be completed Dec 2024 Children’s Social Care

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 8 of 10 A dedicated training programme is supporting our service redesign and inclusive of Trafford Team Together and Family Hub practitioners. The Reducing Parental Conflict (RPC)programme is in place across Trafford as part of Family Help approach. To date 323 people across the partnership have been trained in RPC toolkit since outset. Parental Conflict Steering Group attended by key partners and VCFE. Learning from the evaluation and any good practice learning to be cascaded across the partnership Matter of Concern 3 - A feature of her vulnerability was her physical health and how dependent she was, as a consequence, on the perpetrator to help care for her. The additional vulnerability and impact of this was not recognised by agencies involved in supporting her. The inquest was told that where vulnerability is not properly understood the risk presented to a victim of domestic abuse increases. Action Progress to date Next Steps Timescale Responsible Agency
3.1 - Any victim of domestic abuse who comes into contact with agencies who has care/support needs due to their health or disability will be routinely referred to Adult Social Care for assessment of their needs under The Care Act 2014. Victims are being identified and referred through our Daily Risk Management Meetings (DRMM) and MARAC and this is well attended by partners. Members of MARAC and the DRMM will be reminded to consider disability and ethical needs when considering levels of risk to potential victims. Policies and Procedures to be updated in line with this recommendation and cascaded across the partnership. The identified training programmes that are in place and due to be rolled out will be inclusive of this expectation for appropriate referrals to be made. 12 months – whilst some departments or agencies may be able to effect change quickly to ensure that this is implemented and embedded, we also need to work with wider partners to ensure a consistent approach. Adult Social Care, Community Safety Partnership and GM ICB

Trafford Council / NHS GM FINAL PFDLI 09082024 Page 9 of 10 A Primary Care IDVA role has been implemented and the postholder provides direct advice, guidance and support to the sector and professionals where there is domestic abuse and victims have health needs. Performance reporting and partnership reporting arrangements to be strengthened. Reporting in respect of MA training is already operational through formal partnership arrangements and the Strategic Safeguarding partnership is currently updating its score card. Specific reporting in respect of compliance in respect of this training to be included so that impact and effectiveness can be considered. The Domestic Abuse Partnership Board to receive updates on the work of the primary care IDVA and the difference that this role is making for victims at the quarterly Board Meeting
3.2 – Adult Social Care to work with specialist agencies such as TDAS to develop bespoke training around Domestic Abuse and The Care Act 2014. A programme of legislative requirements and familiarisation is already being rolled out across adult services as part of the Improving Lives Everyday Board This is inclusive of all aspects of the Care Act and statutory requirements. A programme of familiarisation of Care Act requirements when working with parents who have care needs. This work is being ed by the Designated Social Care Officer and will include considering whether vulnerability and risk is enhanced as a consequence of any adult needs. Specialist training course to be developed and rolled out in respect of The Care Act & Domestic Abuse Attendance and reach of the training to be reported and formally monitored through Safeguarding Learning & Development so that any issues and actions needed can be reported and progressed through single agency and multi-agency meetings. To be launched within 12 months. Our objective is to develop the content of this course throughout Q3&Q4 of 2024/25 to be launched and delivered from April 2025 onwards. Trafford Council / Trafford Domestic Abuse Services

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3.3 A dedicated task & finish group (underneath the Domestic Abuse Partnership Board) to specifically develop our approach and response to supporting victims of domestic abuse who have physical disabilities/health needs. Invites to be sent in August and for the group to commence work in September 2024 The Domestic Abuse Partnership Board is well established and has membership from across the partnership. The Board meeting starts with lived experience and the voice of survivors. Consideration to be given to how we can hear form survivors with health needs to better inform our work. Agreed Task & Finish Group to include Adult Social Care, Children’s Services, Health, Strategic Safeguarding, Police and Community Safety representatives Group to ensure that there are robust plans in place to ensure provision around accessible accommodation, support for victims who need tailored interventions due to ill health or disability. Plans to be presented back to the Domestic Abuse Partnership Board August 2024 Trafford Council