Sylvia Crowther

PFD Report All Responded Ref: 2024-0114
Date of Report 28 February 2024
Coroner Emma Whitting
Response Deadline est. 24 April 2024
All 1 response received · Deadline: 24 Apr 2024
Coroner's Concerns (AI summary)
Police failed to seek the victim's views on bail conditions for her husband, as required by law, and she was not informed of these conditions, missing an opportunity to consider alternative support.
View full coroner's concerns
Although the Domestic Homicide Review (DHR) carried out in this case has already recommended a number of issues for agencies to consider, additional matters have been observed by the Court in relation to Police action: (i) Whilst some officers carried out their tasks effectively and appropriately, overall important steps in the Deceased's husband's arrest and subsequent conditional pre-charge bail did not appear to have been followed. (ii) In particular, S47ZZA PACE 1984 requires the investigating officer to seek the views of the alleged victim on whether relevant conditions should be imposed on the person's bail and then to inform the custody officer of these views but this was not done in this case: the first time that the Deceased was made aware of the nature of her husband's bail conditions was when the Police brought him home after his release on bail to collect his belongings. (iii) An earlier discussion between Police and the Deceased might have highlighted the Deceased’s deep emotional and physical dependence on her husband and the need to consider alternative options to criminal investigation with potentially more supportive care attached to them, such as the use of a DVPN/DVPO as highlighted by the DHR.
Responses
Bedfordshire Police Police / Law Enforcement
15 Apr 2024
Noted
Bedfordshire Police acknowledges the report and outlines its approach to domestic abuse cases, including training, DA champions, and proactive engagement. They explain the use of DVPN/DVPOs and defend the decision to use police bail instead of a DVPO in this specific case due to the victim's complex needs. (AI summary)
View full response
Dear Ms Whitting, RE: Regulation 29 response to Coroners’ regulation 28 report to prevent future deaths in relation to the inquest into the death of Sylvia Crowther I write in my capacity as the Assistant Chief Constable of Bedfordshire Police and in response to the regulation 28 notice dated 28 February 2024. I understand this matter involves a vulnerable female who built up the courage to contact Bedfordshire Police on 3 January 2023, to report being the victim of domestic abuse (“DA”) by her husband. Statistics taken from the National Centre for Domestic Violence inform us that a domestic related call is made to the police every 30 seconds. Less than 24% of all domestic victims ever report their abuse to the Police. It is estimated that around 3 women per week die by suicide as a result of Domestic Violence (“DV”). There is a national strategic policing requirement for forces to tackle Violence Against Women and Girls (“VAWG”), supported by a delivery framework. Tackling VAWG, in particular domestic abuse, is a Bedfordshire Police priority. Officers and staff within Bedfordshire Police have undertaken ‘DA matters’ training and the force now have a total of 38 DA champions across a variety of Policing functions. When a victim contacts Bedfordshire Police, it is crucial that my Officers are seen to be trustworthy, compassionate, and sympathetic to ensure they gain the victim’s trust. At a time of heightened national concern about VAWG, Officers and Staff within Bedfordshire Police are encouraged to deal proactively with alleged perpetrators of DV. We understand from the

charity Refuge that leaving an abusive partner is a process rather than a single act, which takes on average seven attempts. On 3 January 2023, Mrs Crowther made serious DA allegations, naming her husband as the perpetrator. I would expect my Officers to act on such allegations and arrest where appropriate. I understand that happened in this case and, subsequently, safeguarding needs were identified and actioned to prevent further harm. Safeguarding was especially important in this case as Mrs Crowther was classed as vulnerable due to her disabilities. Safeguarding concerns were heightened because the identified perpetrator was listed as her main carer. Policing involves the identification, balance and mitigation or management of competing risks., a process that involves gathering information from multiple sources, including from victims. Having considered the concerns you raise, I am satisfied our force has necessary procedures in place to ensure victims of DA are involved in conversations regarding important decisions, such as police bail. I appreciate that on this occasion the investigating Officer overlooked the requirement for interaction with the victim regarding imposing bail conditions on her husband. This meant that engagement did not take place until after the bail conditions had been imposed. However, I believe the Officer and his supervisor felt bail was necessary due to serious safeguarding concerns and I cannot see that the consultation would have made a material impact on the decision in the circumstances as they presented on this occasion. Nevertheless, reflective feedback has been provided to the individual Officer as well as to the wider Emerald Team in respect of the requirement for victim consultation regarding bail. To reassure you, a process is embedded across the force where upon the conclusion of the criminal interview, contact is made with the victims to discuss the status of the case, the proposed outcomes - including discussions regarding what bail conditions are appropriate (if bail is decided) - and next steps in the investigation. During these discussions, victims are encouraged to discuss any additional bail conditions they feel would be appropriate. Unfortunately, victims of DA investigations are not always supportive of Police action and over the years it has been found that over a third of DA cases are discontinued for this reason. In such circumstances, and when significant concern is still held regarding the welfare of the victim, Police can proceed without the victim’s support in what is called an evidence led prosecution. In Mrs Crowther’s case, after considering all records held on file, this was the decision made. The overarching concern throughout this investigation, was the risk posed to Mrs Crowther by her husband, who was also her main carer. The process during an evidence led prosecution

is still for the investigating officer to engage with the victim regarding the investigation, including any potential bail conditions. Proceeding in these circumstances often means we impose bail conditions which are not agreed to by the victim but are deemed necessary to protect their personal safety and mental wellbeing. This approach prevents repeat offending and escalation of violence. The use of DVPN/DVPO’s are specifically for domestic violence perpetrators, over the age of 18, when violence has been used or threatened. As with evidence led prosecutions, the victim’s consent and engagement is not required for an order to be applied for and granted. Approved orders are in effect for a minimum of 14 days to a maximum of 28 days. Once a DVPO is ordered the responding party can request the order be modified or terminated, but the Court is unlikely to terminate the order unless the respondent can demonstrate there has been a substantial change in circumstances which shows they are not likely to resume acts of domestic violence. Within Bedfordshire we promote the consideration of a DVPO in investigations. Once a DVPO is ordered, it is the responsibility of the individual to comply with the prohibitions. In the event of a breach of a DVPO, the individual is open to arrest, leading to a possible fine of £50 for every day whilst in breach, up to a maximum of £5,000 or two-months imprisonment. In the case of Mrs Crowther, although the investigating officers considered a DVPO, with her additional complex needs, a decision was made that police bail would be more appropriate in terms of safeguarding. This is because with police bail, we have more flexibility in terms of decision making. At any stage during a police bail period, a determination can be made to cancel current conditions once any outstanding enquires have been completed. In conclusion, we consider ourselves to be a learning organisation and are always looking to improve our processes both within our Emerald Department and across the wider force, to ensure we are providing the very best safeguarding for Bedfordshire’s most vulnerable people.
Sent To
  • Bedfordshire Police
Response Status
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56-Day Deadline 24 Apr 2024
All responses received
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 20 January 2023 I commenced an investigation into the death of Sylvia Dawn CROWTHER aged 58. The investigation concluded at the end of the inquest on 25 January 2024. The Conclusion of the Inquest was that the Deceased died as result of Suicide.
Circumstances of the Death
The Deceased suffered with physical disabilities, mental health issues, and alcoholism. Her husband of 39 years was her main carer. At around 19.15 hours on 3 January 2023, the Deceased reported to Police that her husband was being violent towards her. On attending, the Police could see no visible marks or cuts but arrested her husband; the Deceased made it clear that she did not support any criminal action against him. On 4 January 2023, her husband was bailed until 28 February 2023 with conditions that he was not to return to the marital home. Police also made a Safeguarding Referral to Social Services who organised an urgent welfare visit to the Deceased that same evening. The Deceased refused all care services offered during the visit and stated that she would kill herself if her husband did not return home (but not that evening). The Deceased continued to refuse care when contacted by Social Services the following morning but was provided with the telephone number for the Safeguarding Team. Sometime between 14.45 and 15.45 on 6 January 2023 and, in a distressed state, Sylvia left a message on the Safeguarding Team’s phone requesting help. At 15.06 hours, she also sent a text to her Victim Engagement Officer stating that she could not cope on her own and requesting a call. Although a member of the Safeguarding Team spoke briefly to her on the phone at 16.30 hours, they requested Police to make an urgent welfare visit; a ‘prompt response’ was organised by Police Control Room at 16.56 hours but, owing to service demand, they arrived at 19.24 hours and found the Deceased unresponsive on the living room floor. Despite all resuscitation efforts, paramedics confirmed her death at 20.25 hours.

and notes to her husband and to Police were found at the scene. The notes confirmed an intention to end her life and the note to Police indicated that she felt that they had not listened to her.
Copies Sent To
Head of Social Care, Central Bedfordshire Council DHR Report Author
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.