Kellie Sutton
PFD Report
All Responded
Ref: 2024-0239
All 1 response received
· Deadline: 25 Jun 2024
Coroner's Concerns (AI summary)
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.
View full coroner's concerns
1. There was a lack of understanding of controlling and coercive behaviour, what it is, and the impact on victims.
2. There was a lack of awareness of the link between domestic abuse and suicide.
3. There was a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU.
2. There was a lack of awareness of the link between domestic abuse and suicide.
3. There was a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU.
Responses
Action Taken
Hertfordshire Constabulary details a range of training delivered since 2016 relating to domestic abuse, coercive control and stalking. Future plans include delivering interactive training exercises, rolling out lived experience sessions with survivors and delivering training inputs on protective orders and Clare's Law. (AI summary)
Hertfordshire Constabulary details a range of training delivered since 2016 relating to domestic abuse, coercive control and stalking. Future plans include delivering interactive training exercises, rolling out lived experience sessions with survivors and delivering training inputs on protective orders and Clare's Law. (AI summary)
View full response
Dear Ms Broadfoot,
We write further to the Regulation 28 dated 30th April 2024, and are now in a position to respond to your three areas of concern which shows that many changes have taken place since the very sad death of Kellie Sutton.
1. There was a lack of understanding of controlling and coercive behaviour, what it is, and the impact on victims.
Detective Superintendent (Senior Investigating Officer (SIO) of the Kellie Sutton investigation) completed an officer’s report for the Coroner dated 15th June 2022 which summarised the training provided from 2016 – 2022 covering Force Training Days, NCALT, DA Matters and Partnership Training.
In 2016, Daisu was launched as a new department and this was supported by additional inputs to all officers and the Operation Oak web page provided a one stop shop for information.
report also documents DA training delivered within Hertfordshire Constabulary relative to the inquest of Kellie Sutton. Coercive Control was a relatively new offence in 2017, only introduced as legislation on the 29th December 2015. The report documents coercive control training packages that were delivered to front line officers in 2016. In April 2017, further training was provided to front line responders on coercive control, including how to recognise and investigate it.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
A Domestic Abuse training course was also completed in 2017 which focused specifically on coercive control, stalking offences and investigations. In addition to the above Detective Supt Phillips notes that the Force Control Room received training in coercive control in the summer of 2019.
In 2022 further Domestic Abuse training was delivered by a specialist (Domestic Abuse Investigation and Safeguarding Unit (DAISU) Detective Sergeant including the introduction of the new risk assessment tool, ‘DARA’ which replaced DASH, providing a more detailed and accurate assessment of risk. Within this training package coercive and controlling behaviour is defined and officers are encouraged to establish facts using ‘TED/5WH’ questions. They are also advised to speak to children who are present to obtain further valuable information.
A Vulnerability Information Portal was created in response to the investigation into Kellie’s death in August 2023. This is an ‘App’ installed on officers’ work mobile phones and laptops, where they can easily access information about subjects including coercive control, Domestic Abuse and suicide, including many other safeguarding matters. It gives all officers and staff practical advice on how to provide the best service to a victim at the first point of contact and is accessible 24 hours a day 7 days a week. It is easy to navigate and locate important guidance documents.
A DAISU Detective Sergeant moved to a dedicated training role in September 2022 and was tasked with providing training to increase knowledge to frontline officers on a wide variety of domestic abuse subjects. This included an update on processes, how to identify and investigate coercive and controlling behaviour, how to seek civil orders (including DVPN/DVPO’s) as well as other safeguarding measures including reinforcing the Clare’s Law process.
2. There was a lack of awareness of the link between domestic abuse and suicide.
All SOPs are updated annually. The January 2024 Standard Operating Procedure for Sudden Death Incidents details suicide attendance and investigation and the following information is provided within: ‘In cases of Suicide, investigation by Local Crime Units will be required to understand what could have caused the individual to take their own life. This is particularly evident in Domestic Abuse and therefore investigation by suitably trained PIP Level 2 Investigators will be required and supervised by a Detective Sergeant’. (PIP 2 investigators are officers who have been trained in serious and complex investigations).
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
‘Intervention Officers are mandated to attend every incident (refer to section 7). This will be raised through first line Supervisory to the Duty Inspector or Detective Inspector who is mandated to attend. It is discretionary and a decision for the Duty Inspector for the Detective Inspector to attend, based on the circumstances. The Local Crime Detective Sergeant will take ownership of the investigation and be required to attend the scene. This will ensure an appropriate Investigator is allocated to conduct an appropriate and professional investigation, which will include all reasonable lines of enquiry, including ‘Victimology’ - the background and relationships of the deceased, utilising corporate systems; particularly any relationship between the deceased and potential third party. This will seek to establish the reasons as to why the deceased took their own life and assist in evidencing any potential criminal liability of a third party. This is required in all cases, and particularly prevalent in cases of Domestic Abuse where there may have been undetected or unreported criminal liability, and whether Domestic Abuse was a contributory factor, for example cases of coercive and controlling behaviour/harassment.’
‘A thorough investigation as to why the deceased took their own life should be conducted, identifying whether there was any third-party involvement that could provide for any criminal liability. All circumstances of the suicide should be investigated to ascertain any detail that gives rise to concern – including domestic abuse, see Statutory Guidance for DHR below. Attendance is detailed in 6.8 and the suicide will require PIP Level 2 investigation. Victimology and a review of intelligence on corporate systems will support the investigation assisting the investigators to understand the reasons as to why the deceased committed suicide.’
Further to the above, a section regarding Domestic Abuse is included in the Sudden Death SOP:
‘In certain circumstances a Domestic Homicide Review (DHR) will need to be conducted alongside the investigation into the death itself to identity any lessons learned. Domestic Abuse homicide and suicide prevention and reduction are national policing priorities. The Home Office National Statutory Guidance states that the circumstances in which to consider holding a DHR are:
‘The death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by – a) person to whom he was related or with whom he was or had been in an intimate personal relationship, b) a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
Or: Where a victim took their own life (suicide) and the circumstances give rise to concern, for example it emerges that there was coercive controlling behaviour in the relationship or history of Domestic Abuse’.
Where these criteria appear to be met it is the responsibility of the Inspector / SIO with oversight of the initial investigation to ensure that a DHR notification is submitted to Hertfordshire County Council (HCC)/Head of Safeguarding (Hertfordshire Constabulary) so that an assessment of suitability for a DHR process can begin.’ These are also submitted to the Force Statutory review team who represent the force as statutory partners at DHR reviews.
The area Detective Inspector has to review every suicide and sign off the report to be sent to the Coroner. This policy has been agreed by the Heads of Departments and the Hertfordshire Senior Coroner, Mr Geoffrey Sullivan. Every suicide is also reviewed by the statutory review team to who check for DHR criteria and will go back to the SIO / reporting officer if it appears DHR criteria have been missed. DHR information and reference material has been place don’t the force internet section and is accessible to all officers.
Training regarding this policy has been delivered to all front-line officers and Neighbourhood Policing Teams (NPT) within the last 6-8 weeks. Student officers, Detectives (including sergeants and Inspectors) are captured by the Bedfordshire Police, Cambridgeshire and Hertfordshire Constabularies collaborated Learning and Development team. Further plans are being drafted to deliver wider training to capture the remaining relevant staff. The sudden death training also focuses on the failings identified from the Stephen Port investigation and critically emphasises the need for professional curiosity at unexpected deaths, the risk of categorising a sudden death without a global understanding of the circumstances and the risks of prejudice and bias.
As a Constabulary our use of digital technology has significantly advanced since 2017 and officers have access to personal issue laptops and mobile phones enabling them to access far greater information from the scene. Extensive training was delivered in force, using Kellie’s tragedy, to further highlight the link between DA and suicide. This was fully supported by her mother. This training was delivered by the OIC of the Kellie Sutton investigation who hosted a number of Continual Professional Development (CPD) sessions using the case to highlight the learning, describing how the investigation was progressed, encouraging an investigative mindset at any report of suicide with a focus on how Coercive Control can be evidenced without an account from the victim.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
These sessions were tailored and delivered across the Hertfordshire Domestic Abuse Partnership at a number of events and forums for Professionals from across the county, involving Police, Social services, Health, County and District
Councils and charities. This input has also been delivered to other Police Forces. Hertfordshire Constabulary have worked alongside a specialist organisation ‘DA Matters’, who deliver training to police forces nationally. Kellie’s story is used as a case study to educate all officers on how they should respond to Domestic Abuse incidents in the future. Kellie’s family have supported the Constabulary using Kellie’s story in this way.
Domestic Abuse has a dedicated section within the Vulnerability Portal which refers to the link between DA and suicide.
All Hertfordshire Officers are expected to be briefed daily for top priorities, information, and intelligence on DA. A section has been added to highlight the link between DA and suicides, this is to encourage professional curiosity, evidence led prosecutions and coercive behaviours. This is now a regular item within briefings where we have a rolling DA focus which is driven by the key trends / intel at the time. The Statutory review team now attend all Force and Safeguarding weekday DMM. The DMM structure has changed ensuring a key focus on vulnerability including any sudden deaths that require SIO oversight.
As part of initial training, all officers receive a DA Matters First Response training package. This is supported by the College of Policing and contains an input on being able to identify domestic abuse in suspected suicides. The following advice and guidance is provided:
• ‘The College of Policing has made clear that a police investigation into a suspected suicide may reveal evidence suggestive of controlling or coercive behaviour or other forms of domestic abuse as background to the suicide’.
• The report makes the following recommendations for frontline officers: o ‘The first responding officer must use an investigative mindset and professional curiosity when attending the scene of a suspected suicide or unexpected death’.
o The attending officer must conduct checks on local force, PNC and PND systems for a recorded history of abuse including crimes, non-crime incidents, intelligence reports and DA flags.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
o These checks should be carried out either prior to, or at, the scene (not after leaving the scene), to ensure that any DA history is identified at the point where it can inform initial scene handling and effective assessment of risk.
3. There was a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU.
Hertfordshire Constabulary has improved both processes and guidance in relation to DVPN’s and other civil orders. There is a specialist team dedicated to processing Civil Orders established within DAISU to review all DA reports and look for opportunities to proactively use DVPO’s. We recognised that as a force we were not using these sufficiently and a collective push within the safeguarding departments and the LPC has led to a vastly improved picture.
A dedicated DVPN/DVPO officer has been placed in Daisu for intimate DA, and one in CIT for non-intimate DA. These officers will prepare the cases identified and present the DVPN to the Magistrates Court to obtain DVPOs. DAISU review all DVPOs across the county, these are listed on a SharePoint page and Chief Inspectors are held accountable for ensuring that regular checks are conducted during the 28-day period of the DVPO. This is reported on daily at the Force Daily Management Meeting.
New guidance and training of DVPN, Clare’s Law and Stalking Protection Orders has been delivered to all Frontline and Neighbourhood Policing Teams including Supervisors, and there are dedicated sections within the Vulnerability Information Portal. This can provide detailed information and advice on the process, including a simple visual flowchart. Further to this, officers are guided to information provided by the College of Policing, to re-enforce that these can be obtained without the need for arrest:
‘Officers have a duty to take or initiate steps to make a victim as safe as possible. Officers should consider domestic violence protection notices (DVPN) and domestic violence protection orders (DVPO) at an early stage following a domestic abuse incident as part of this duty. These notices and orders may be used following a domestic incident to provide short-term protection to the victim when arrest has not been made but positive action is required, or where an arrest has taken place but the investigation is in progress. This could be where a decision is made to caution the perpetrator or take no further action (NFA), or when the suspect is bailed without conditions’.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
To highlight the improvement in this area, the following are figures relating to DVPO’s obtained by Hertfordshire Constabulary:
2022- 4 orders 2023- 29 orders 2024- 156 orders (as of 4th June) and rising This highlights that between 2022 and 2023 there has been a 624% increase and between 2023 and 2024 a 259% increase.
Hertfordshire DA Training
Athena was introduced in Hertfordshire Constabulary on the 23rd May 2018. This system allows a coordinated approach to repeat offenders and victims and links crime reports and non-crime reports with intelligence.
The DARA risk assessment tool replaced DASH in 2023. DARA is a risk tool for frontline police practitioners responding to domestic abuse. The DARA was designed as an alternative to the Domestic Abuse, Stalking, Harassment and Honour-Based Violence Assessment (DASH) risk checklist, for first responders specifically. A review (undertaken in partnership between Cardiff University, the College of Policing and University College London) provided evidence that the DASH model was implemented inconsistently.
All new student officers receive Domestic Abuse training which consists of:
• Public Protection research
• Online ‘NCALT’ training packages; recognising abuse, protective orders.
• Scenario activity.
• DARA risk assessment.
All officers in initial training, including those within the accelerated detective route receive DA Matters First Responder training. At the conclusion of this training the learner is expected to be able to define the term ‘domestic abuse’, define their role and explain what is meant by the term ‘coercive control’.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
DAISU have designed and regularly update a guidance manual which they provide to all officers and staff who newly join the unit. This is a comprehensive guide providing information on all areas of domestic abuse including definitions, civil orders, ‘Evidence Led’ Prosecution guidance and safeguarding advice. This manual includes the definition of coercive control and evidential ‘points to prove’ for the offence to be made out, as well as links to the Domestic Abuse Bill and the Hertfordshire Constabulary Vulnerability Handbook.
Input has been provided to ‘Police Now’ detectives, PCSO’s and sergeants/first line supervisors from across the constabulary including the following:
• Domestic Abuse Evidence Gathering
• DVPO and SPO
• DARA
• Stalking and Protection Order process
• The link between domestic abuse and firearms (including guidance for seizure)
• DAISU and Dementia
• Clare’s Law (Right to know and Right to Ask)
• Honour Based Abuse
• MARAC and Safeguarding advice
• High Risk ‘Manhunts’
• Strangulation or suffocation
Most of these training inputs provide real-life case studies to highlight previous failings and areas for improvement both locally and nationally. These were used to help demonstrate cases of coercive control, evidence led prosecutions and incidents of domestic homicide.
Force training days are mandated every five weeks for frontline officers and DAISU have been presenting inputs on Clare’s Law, Protective Orders and SPOs and they deliver an overarching DAISU presentation to the Supervisors on the Frontline Leaders Course.
Hertfordshire and Bedfordshire OPCC have funded a perpetrator programme which brings together a range of professionals from healthcare, criminal justice, and behavioural change experts to introduce clinical, behavioural and support interventions to achieve positive and potentially life affirming futures for perpetrators and their families.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
Further future plans include:
• Lived Experience with survivors of domestic abuse to be rolled out to frontline officers under consideration.
• All frontline to receive training input/refreshers on the subject of protective orders and Clare’s Law.
• Two detective sergeants have recently been trained to deliver an interactive ‘Hydra’ DA exercise which will be delivered to all Detective Constables.
• In August 2024, frontline training days have been booked to deliver an input on stalking and coercive & controlling behaviours.
• DAISU will look to deliver updated training to their own staff, including updated guidance within the DAISU Handbook to cover civil orders, Clare Law, Evidence Led Prosecutions and Coercive behaviour.
• A new DA Influencers initiative has started in which officers from a variety of areas within the force and of all ranks are trained in coercive and controlling behaviour and the expectation is that they will share and champion their knowledge and provide advice and training across the force. This is in the early stages of delivery and guest speakers with lived experience will feature within this process.
• In September 2024 DAISU will attend the Force Control Room (FCR) training days to deliver DA training specific to Kellie’s case and other case studies. This is important as they will be the first point of contact to speak to a victim when they initially call Hertfordshire Constabulary for help and assistance.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
We write further to the Regulation 28 dated 30th April 2024, and are now in a position to respond to your three areas of concern which shows that many changes have taken place since the very sad death of Kellie Sutton.
1. There was a lack of understanding of controlling and coercive behaviour, what it is, and the impact on victims.
Detective Superintendent (Senior Investigating Officer (SIO) of the Kellie Sutton investigation) completed an officer’s report for the Coroner dated 15th June 2022 which summarised the training provided from 2016 – 2022 covering Force Training Days, NCALT, DA Matters and Partnership Training.
In 2016, Daisu was launched as a new department and this was supported by additional inputs to all officers and the Operation Oak web page provided a one stop shop for information.
report also documents DA training delivered within Hertfordshire Constabulary relative to the inquest of Kellie Sutton. Coercive Control was a relatively new offence in 2017, only introduced as legislation on the 29th December 2015. The report documents coercive control training packages that were delivered to front line officers in 2016. In April 2017, further training was provided to front line responders on coercive control, including how to recognise and investigate it.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
A Domestic Abuse training course was also completed in 2017 which focused specifically on coercive control, stalking offences and investigations. In addition to the above Detective Supt Phillips notes that the Force Control Room received training in coercive control in the summer of 2019.
In 2022 further Domestic Abuse training was delivered by a specialist (Domestic Abuse Investigation and Safeguarding Unit (DAISU) Detective Sergeant including the introduction of the new risk assessment tool, ‘DARA’ which replaced DASH, providing a more detailed and accurate assessment of risk. Within this training package coercive and controlling behaviour is defined and officers are encouraged to establish facts using ‘TED/5WH’ questions. They are also advised to speak to children who are present to obtain further valuable information.
A Vulnerability Information Portal was created in response to the investigation into Kellie’s death in August 2023. This is an ‘App’ installed on officers’ work mobile phones and laptops, where they can easily access information about subjects including coercive control, Domestic Abuse and suicide, including many other safeguarding matters. It gives all officers and staff practical advice on how to provide the best service to a victim at the first point of contact and is accessible 24 hours a day 7 days a week. It is easy to navigate and locate important guidance documents.
A DAISU Detective Sergeant moved to a dedicated training role in September 2022 and was tasked with providing training to increase knowledge to frontline officers on a wide variety of domestic abuse subjects. This included an update on processes, how to identify and investigate coercive and controlling behaviour, how to seek civil orders (including DVPN/DVPO’s) as well as other safeguarding measures including reinforcing the Clare’s Law process.
2. There was a lack of awareness of the link between domestic abuse and suicide.
All SOPs are updated annually. The January 2024 Standard Operating Procedure for Sudden Death Incidents details suicide attendance and investigation and the following information is provided within: ‘In cases of Suicide, investigation by Local Crime Units will be required to understand what could have caused the individual to take their own life. This is particularly evident in Domestic Abuse and therefore investigation by suitably trained PIP Level 2 Investigators will be required and supervised by a Detective Sergeant’. (PIP 2 investigators are officers who have been trained in serious and complex investigations).
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
‘Intervention Officers are mandated to attend every incident (refer to section 7). This will be raised through first line Supervisory to the Duty Inspector or Detective Inspector who is mandated to attend. It is discretionary and a decision for the Duty Inspector for the Detective Inspector to attend, based on the circumstances. The Local Crime Detective Sergeant will take ownership of the investigation and be required to attend the scene. This will ensure an appropriate Investigator is allocated to conduct an appropriate and professional investigation, which will include all reasonable lines of enquiry, including ‘Victimology’ - the background and relationships of the deceased, utilising corporate systems; particularly any relationship between the deceased and potential third party. This will seek to establish the reasons as to why the deceased took their own life and assist in evidencing any potential criminal liability of a third party. This is required in all cases, and particularly prevalent in cases of Domestic Abuse where there may have been undetected or unreported criminal liability, and whether Domestic Abuse was a contributory factor, for example cases of coercive and controlling behaviour/harassment.’
‘A thorough investigation as to why the deceased took their own life should be conducted, identifying whether there was any third-party involvement that could provide for any criminal liability. All circumstances of the suicide should be investigated to ascertain any detail that gives rise to concern – including domestic abuse, see Statutory Guidance for DHR below. Attendance is detailed in 6.8 and the suicide will require PIP Level 2 investigation. Victimology and a review of intelligence on corporate systems will support the investigation assisting the investigators to understand the reasons as to why the deceased committed suicide.’
Further to the above, a section regarding Domestic Abuse is included in the Sudden Death SOP:
‘In certain circumstances a Domestic Homicide Review (DHR) will need to be conducted alongside the investigation into the death itself to identity any lessons learned. Domestic Abuse homicide and suicide prevention and reduction are national policing priorities. The Home Office National Statutory Guidance states that the circumstances in which to consider holding a DHR are:
‘The death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by – a) person to whom he was related or with whom he was or had been in an intimate personal relationship, b) a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
Or: Where a victim took their own life (suicide) and the circumstances give rise to concern, for example it emerges that there was coercive controlling behaviour in the relationship or history of Domestic Abuse’.
Where these criteria appear to be met it is the responsibility of the Inspector / SIO with oversight of the initial investigation to ensure that a DHR notification is submitted to Hertfordshire County Council (HCC)/Head of Safeguarding (Hertfordshire Constabulary) so that an assessment of suitability for a DHR process can begin.’ These are also submitted to the Force Statutory review team who represent the force as statutory partners at DHR reviews.
The area Detective Inspector has to review every suicide and sign off the report to be sent to the Coroner. This policy has been agreed by the Heads of Departments and the Hertfordshire Senior Coroner, Mr Geoffrey Sullivan. Every suicide is also reviewed by the statutory review team to who check for DHR criteria and will go back to the SIO / reporting officer if it appears DHR criteria have been missed. DHR information and reference material has been place don’t the force internet section and is accessible to all officers.
Training regarding this policy has been delivered to all front-line officers and Neighbourhood Policing Teams (NPT) within the last 6-8 weeks. Student officers, Detectives (including sergeants and Inspectors) are captured by the Bedfordshire Police, Cambridgeshire and Hertfordshire Constabularies collaborated Learning and Development team. Further plans are being drafted to deliver wider training to capture the remaining relevant staff. The sudden death training also focuses on the failings identified from the Stephen Port investigation and critically emphasises the need for professional curiosity at unexpected deaths, the risk of categorising a sudden death without a global understanding of the circumstances and the risks of prejudice and bias.
As a Constabulary our use of digital technology has significantly advanced since 2017 and officers have access to personal issue laptops and mobile phones enabling them to access far greater information from the scene. Extensive training was delivered in force, using Kellie’s tragedy, to further highlight the link between DA and suicide. This was fully supported by her mother. This training was delivered by the OIC of the Kellie Sutton investigation who hosted a number of Continual Professional Development (CPD) sessions using the case to highlight the learning, describing how the investigation was progressed, encouraging an investigative mindset at any report of suicide with a focus on how Coercive Control can be evidenced without an account from the victim.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
These sessions were tailored and delivered across the Hertfordshire Domestic Abuse Partnership at a number of events and forums for Professionals from across the county, involving Police, Social services, Health, County and District
Councils and charities. This input has also been delivered to other Police Forces. Hertfordshire Constabulary have worked alongside a specialist organisation ‘DA Matters’, who deliver training to police forces nationally. Kellie’s story is used as a case study to educate all officers on how they should respond to Domestic Abuse incidents in the future. Kellie’s family have supported the Constabulary using Kellie’s story in this way.
Domestic Abuse has a dedicated section within the Vulnerability Portal which refers to the link between DA and suicide.
All Hertfordshire Officers are expected to be briefed daily for top priorities, information, and intelligence on DA. A section has been added to highlight the link between DA and suicides, this is to encourage professional curiosity, evidence led prosecutions and coercive behaviours. This is now a regular item within briefings where we have a rolling DA focus which is driven by the key trends / intel at the time. The Statutory review team now attend all Force and Safeguarding weekday DMM. The DMM structure has changed ensuring a key focus on vulnerability including any sudden deaths that require SIO oversight.
As part of initial training, all officers receive a DA Matters First Response training package. This is supported by the College of Policing and contains an input on being able to identify domestic abuse in suspected suicides. The following advice and guidance is provided:
• ‘The College of Policing has made clear that a police investigation into a suspected suicide may reveal evidence suggestive of controlling or coercive behaviour or other forms of domestic abuse as background to the suicide’.
• The report makes the following recommendations for frontline officers: o ‘The first responding officer must use an investigative mindset and professional curiosity when attending the scene of a suspected suicide or unexpected death’.
o The attending officer must conduct checks on local force, PNC and PND systems for a recorded history of abuse including crimes, non-crime incidents, intelligence reports and DA flags.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
o These checks should be carried out either prior to, or at, the scene (not after leaving the scene), to ensure that any DA history is identified at the point where it can inform initial scene handling and effective assessment of risk.
3. There was a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU.
Hertfordshire Constabulary has improved both processes and guidance in relation to DVPN’s and other civil orders. There is a specialist team dedicated to processing Civil Orders established within DAISU to review all DA reports and look for opportunities to proactively use DVPO’s. We recognised that as a force we were not using these sufficiently and a collective push within the safeguarding departments and the LPC has led to a vastly improved picture.
A dedicated DVPN/DVPO officer has been placed in Daisu for intimate DA, and one in CIT for non-intimate DA. These officers will prepare the cases identified and present the DVPN to the Magistrates Court to obtain DVPOs. DAISU review all DVPOs across the county, these are listed on a SharePoint page and Chief Inspectors are held accountable for ensuring that regular checks are conducted during the 28-day period of the DVPO. This is reported on daily at the Force Daily Management Meeting.
New guidance and training of DVPN, Clare’s Law and Stalking Protection Orders has been delivered to all Frontline and Neighbourhood Policing Teams including Supervisors, and there are dedicated sections within the Vulnerability Information Portal. This can provide detailed information and advice on the process, including a simple visual flowchart. Further to this, officers are guided to information provided by the College of Policing, to re-enforce that these can be obtained without the need for arrest:
‘Officers have a duty to take or initiate steps to make a victim as safe as possible. Officers should consider domestic violence protection notices (DVPN) and domestic violence protection orders (DVPO) at an early stage following a domestic abuse incident as part of this duty. These notices and orders may be used following a domestic incident to provide short-term protection to the victim when arrest has not been made but positive action is required, or where an arrest has taken place but the investigation is in progress. This could be where a decision is made to caution the perpetrator or take no further action (NFA), or when the suspect is bailed without conditions’.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
To highlight the improvement in this area, the following are figures relating to DVPO’s obtained by Hertfordshire Constabulary:
2022- 4 orders 2023- 29 orders 2024- 156 orders (as of 4th June) and rising This highlights that between 2022 and 2023 there has been a 624% increase and between 2023 and 2024 a 259% increase.
Hertfordshire DA Training
Athena was introduced in Hertfordshire Constabulary on the 23rd May 2018. This system allows a coordinated approach to repeat offenders and victims and links crime reports and non-crime reports with intelligence.
The DARA risk assessment tool replaced DASH in 2023. DARA is a risk tool for frontline police practitioners responding to domestic abuse. The DARA was designed as an alternative to the Domestic Abuse, Stalking, Harassment and Honour-Based Violence Assessment (DASH) risk checklist, for first responders specifically. A review (undertaken in partnership between Cardiff University, the College of Policing and University College London) provided evidence that the DASH model was implemented inconsistently.
All new student officers receive Domestic Abuse training which consists of:
• Public Protection research
• Online ‘NCALT’ training packages; recognising abuse, protective orders.
• Scenario activity.
• DARA risk assessment.
All officers in initial training, including those within the accelerated detective route receive DA Matters First Responder training. At the conclusion of this training the learner is expected to be able to define the term ‘domestic abuse’, define their role and explain what is meant by the term ‘coercive control’.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
DAISU have designed and regularly update a guidance manual which they provide to all officers and staff who newly join the unit. This is a comprehensive guide providing information on all areas of domestic abuse including definitions, civil orders, ‘Evidence Led’ Prosecution guidance and safeguarding advice. This manual includes the definition of coercive control and evidential ‘points to prove’ for the offence to be made out, as well as links to the Domestic Abuse Bill and the Hertfordshire Constabulary Vulnerability Handbook.
Input has been provided to ‘Police Now’ detectives, PCSO’s and sergeants/first line supervisors from across the constabulary including the following:
• Domestic Abuse Evidence Gathering
• DVPO and SPO
• DARA
• Stalking and Protection Order process
• The link between domestic abuse and firearms (including guidance for seizure)
• DAISU and Dementia
• Clare’s Law (Right to know and Right to Ask)
• Honour Based Abuse
• MARAC and Safeguarding advice
• High Risk ‘Manhunts’
• Strangulation or suffocation
Most of these training inputs provide real-life case studies to highlight previous failings and areas for improvement both locally and nationally. These were used to help demonstrate cases of coercive control, evidence led prosecutions and incidents of domestic homicide.
Force training days are mandated every five weeks for frontline officers and DAISU have been presenting inputs on Clare’s Law, Protective Orders and SPOs and they deliver an overarching DAISU presentation to the Supervisors on the Frontline Leaders Course.
Hertfordshire and Bedfordshire OPCC have funded a perpetrator programme which brings together a range of professionals from healthcare, criminal justice, and behavioural change experts to introduce clinical, behavioural and support interventions to achieve positive and potentially life affirming futures for perpetrators and their families.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
Further future plans include:
• Lived Experience with survivors of domestic abuse to be rolled out to frontline officers under consideration.
• All frontline to receive training input/refreshers on the subject of protective orders and Clare’s Law.
• Two detective sergeants have recently been trained to deliver an interactive ‘Hydra’ DA exercise which will be delivered to all Detective Constables.
• In August 2024, frontline training days have been booked to deliver an input on stalking and coercive & controlling behaviours.
• DAISU will look to deliver updated training to their own staff, including updated guidance within the DAISU Handbook to cover civil orders, Clare Law, Evidence Led Prosecutions and Coercive behaviour.
• A new DA Influencers initiative has started in which officers from a variety of areas within the force and of all ranks are trained in coercive and controlling behaviour and the expectation is that they will share and champion their knowledge and provide advice and training across the force. This is in the early stages of delivery and guest speakers with lived experience will feature within this process.
• In September 2024 DAISU will attend the Force Control Room (FCR) training days to deliver DA training specific to Kellie’s case and other case studies. This is important as they will be the first point of contact to speak to a victim when they initially call Hertfordshire Constabulary for help and assistance.
T/Assistant Chief Constable Hertfordshire Constabulary Headquarters Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF
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- Hertfordshire Constabulary
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 02 September 2021 I commenced an investigation into the death of Kellie Marie SUTTON. Kellie died on 26 August 2017 in Lister Hospital. She was 30 years old. The investigation concluded at the end of the inquest on 06 July 2023. The medical cause of death was 1a) features consistent with hanging. The jury recorded a short form conclusion of unlawful killing and a narrative conclusion as follows: After being subjected to months of controlling and coercive behaviour and domestic abuse by her then partner, on the morning of 23rd August 2017 Kellie Sutton hung herself
. She was treated at the scene by ambulance staff and HEMS before being conveyed to the Lister Hospital. Her injuries were not survivable and she died at 2.30pm on 26th August 2017 in the hospital. The jury found that there were certain failures or inadequacies by Herfordshire Constabulary which may have contributed to Kellie Sutton’s death, but not that they did: see Annex A - Determination sheet.
. She was treated at the scene by ambulance staff and HEMS before being conveyed to the Lister Hospital. Her injuries were not survivable and she died at 2.30pm on 26th August 2017 in the hospital. The jury found that there were certain failures or inadequacies by Herfordshire Constabulary which may have contributed to Kellie Sutton’s death, but not that they did: see Annex A - Determination sheet.
Circumstances of the Death
Kellie Sutton had experienced a series of relationships from a young age with abusive men in the past. She had 3 children. Kellie met her final partner in March 2017 and he moved in to her home where she lived with two of her children in a shared custody arrangement. There was extensive and detailed witness evidence gathered by the police for criminal proceedings which demonstrated that Kellie’s partner was abusive towards her: both physically violent on at least several occasions and by his controlling and coercive behaviour towards her, which included shouting, threatening, phoning constantly if she was out, isolating her from her family and friends and holding her bank card. She lived in fear of her phone battery dying because if he couldn’t get hold of her he would “go mad” and would become violent. In March 2018, i.e. after her death, Kellie’s partner was convicted of controlling and coercive behaviour in an intimate relationship, contrary to s76 of the Serious Crime Act 2015, the offence taking place between 1 March 2017 and 24 August 2017. He was also convicted of one count of assault occasioning actual bodily harm, the offence taking place on 3rd June 2017 and one count of common assault which occurred on 9 July 2017. I am satisfied from the evidence, which included text messages from Kellie to friends and from Kellie to her partner that Kellie was very unhappy in this relationship but did not feel able to extricate herself from it, even though her friends were telling her he was abusive. On 9 July 2017 a neighbour called the police on the basis that Kellie was being “beaten up by her partner”. The police came very quickly and spoke to Kellie and her partner separately but the couple told them that they had just had a verbal argument. A risk assessment in the form of the DASH book was completed which resulted in 6 ticks and the police took the view that this was a ‘standard risk’ case and the matter was closed as a non-crime incident. The police did not speak to the neighbour who called 999 and who was in possession of significant further information about the incident, including that one of the children had witnessed it. In a witness statement for the inquest the police accepted, at a senior level, that the response fell below the expected standard in a number of respects, including body worn video capability, the failure to check up on the children and that they showed a lack of professional curiosity and judgment relating to the DASH process and house to house inquiries not being completed. The controlling and coercive behaviour continued. Over the night of 22/23 August 2017, there were a series of exchanges both verbally and by text message which continued after Kellie’s partner left for work at 650 a.m. This showed a series of increasingly distressed messages from Kellie culminating in her threatening to hang herself to which he had responded with words to the effect of ‘do everyone a favour’. Very shortly thereafter she stopped answering the phone, he rushed home and found her hanging
, at about 810 a.m. Despite him administering CPR to her and the ambulance arriving shortly thereafter, tests showed that she had suffered irrecoverable brain injury from lack of oxygen and brain stem death was confirmed on 26 August 2017 when she was pronounced dead. The inquest jury found that although they were not satisfied that the lack of further investigation or action on 9 July 2017 did contribute to Kellie Sutton’s death, they found that it may have led to further interventions that could have altered the final outcome on 23 August 2017. The jury also found that numerous opportunities were missed at several levels to recognise the significance of the responses in the DASH and that this in turn led to a failure to consider implementation of appropriate protective measures, which could have included issuing a DVPN and/or applying Clare’s law. However, they concluded that they could not be satisfied that these failings did contribute to Kellie Sutton’s death, although they may have contributed to her death. During the course of the inquest the court heard evidence from an expert in the field of violence against women and girls about the harms of controlling and coercive behaviour and abuse, the feelings of entrapment by victims meaning it was very common for a victim to be unable to extricate themselves and the higher incidence of suicide in victims of abuse: one third of all suicides in England and Wales are preceded by domestic abuse. The court heard that an understanding of controlling and coercive behaviour was key to any risk assessment and that it was important to understand that no physical assault was required. The evidence at the inquest indicated a lack of awareness of the link between domestic abuse and suicide. Whilst officers did have an awareness of the ‘harm’ from others through domestic abuse, a heightened awareness of the risk of ‘harm’ by taking one’s own life was relevant to a risk assessment and the consequential steps which may be required. The evidence at the inquest also appeared to reveal a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU. I am of the view that this lack of understanding, notwithstanding training which had been provided, was evident and created a risk of future deaths. The court heard about the lack of systems available at the time to easily identify serial perpetrators of abuse. However, I accept the evidence from the Constabulary about the changes that have already been made and further developments that are on-going. Accordingly this element does not form one of my elements of concern.
, at about 810 a.m. Despite him administering CPR to her and the ambulance arriving shortly thereafter, tests showed that she had suffered irrecoverable brain injury from lack of oxygen and brain stem death was confirmed on 26 August 2017 when she was pronounced dead. The inquest jury found that although they were not satisfied that the lack of further investigation or action on 9 July 2017 did contribute to Kellie Sutton’s death, they found that it may have led to further interventions that could have altered the final outcome on 23 August 2017. The jury also found that numerous opportunities were missed at several levels to recognise the significance of the responses in the DASH and that this in turn led to a failure to consider implementation of appropriate protective measures, which could have included issuing a DVPN and/or applying Clare’s law. However, they concluded that they could not be satisfied that these failings did contribute to Kellie Sutton’s death, although they may have contributed to her death. During the course of the inquest the court heard evidence from an expert in the field of violence against women and girls about the harms of controlling and coercive behaviour and abuse, the feelings of entrapment by victims meaning it was very common for a victim to be unable to extricate themselves and the higher incidence of suicide in victims of abuse: one third of all suicides in England and Wales are preceded by domestic abuse. The court heard that an understanding of controlling and coercive behaviour was key to any risk assessment and that it was important to understand that no physical assault was required. The evidence at the inquest indicated a lack of awareness of the link between domestic abuse and suicide. Whilst officers did have an awareness of the ‘harm’ from others through domestic abuse, a heightened awareness of the risk of ‘harm’ by taking one’s own life was relevant to a risk assessment and the consequential steps which may be required. The evidence at the inquest also appeared to reveal a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU. I am of the view that this lack of understanding, notwithstanding training which had been provided, was evident and created a risk of future deaths. The court heard about the lack of systems available at the time to easily identify serial perpetrators of abuse. However, I accept the evidence from the Constabulary about the changes that have already been made and further developments that are on-going. Accordingly this element does not form one of my elements of concern.
Inquest Conclusion
After being subjected to months of controlling and coercive behaviour and domestic abuse by her then partner, on the morning of 23rd August 2017 Kellie Sutton hung herself
. She was treated at the scene by ambulance staff and HEMS before being conveyed to the Lister Hospital. Her injuries were not survivable and she died at 2.30pm on 26th August 2017 in the hospital. The jury found that there were certain failures or inadequacies by Herfordshire Constabulary which may have contributed to Kellie Sutton’s death, but not that they did: see Annex A - Determination sheet.
. She was treated at the scene by ambulance staff and HEMS before being conveyed to the Lister Hospital. Her injuries were not survivable and she died at 2.30pm on 26th August 2017 in the hospital. The jury found that there were certain failures or inadequacies by Herfordshire Constabulary which may have contributed to Kellie Sutton’s death, but not that they did: see Annex A - Determination sheet.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.