Joanna Hillard
PFD Report
All Responded
Ref: 2026-0128
All 1 response received
· Deadline: 30 Apr 2026
Coroner's Concerns (AI summary)
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
View full coroner's concerns
The provisions of the Mental Capacity Act 2005 (which Jo was assessed under) , pre-date the Serious Crime Act 2015, particular Section 76 which relates to the offence of controlling and coercive behaviour.
The Mental Capacity Act 2005 aims to ensure that people with social care needs who have an impairment of their brain or mind are supported to make their own decisions, wherever possible, on a background of least-restrictive options to curtail someone’s liberty and freedom of action. People should be assumed to have mental capacity unless it can be demonstrated otherwise.
The Mental Capacity Act only applies if at the material time he/she is unable to make a decision for himself/herself in relation to the matter because of an impairment of, or disturbance in the functioning of, the mind or brain” (Section 2(1)) MCA 2005).
I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this.
The Mental Capacity Act 2005 aims to ensure that people with social care needs who have an impairment of their brain or mind are supported to make their own decisions, wherever possible, on a background of least-restrictive options to curtail someone’s liberty and freedom of action. People should be assumed to have mental capacity unless it can be demonstrated otherwise.
The Mental Capacity Act only applies if at the material time he/she is unable to make a decision for himself/herself in relation to the matter because of an impairment of, or disturbance in the functioning of, the mind or brain” (Section 2(1)) MCA 2005).
I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests. I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this.
Responses
Noted
(AI summary)
(AI summary)
View full response
Dear Samantha,
Thank you for the Regulation 28 report of 5th March 2026, sent to the Department of Health and Social Care (DHSC), about the death of Mrs Joanna Hillard. I am replying as the Minister with responsibility for adult social care Mental Capacity.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Joanna Hillard’s death; I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
I acknowledge your concern that coercive and controlling behaviour, fear and trauma may affect a person’s ability to make and communicate decisions, even where capacity may be assessed as present under the Mental Capacity Act (MCA) 2005. The Prevention of Future Deaths (PFD) report raises concerns over:
1. Whether the Mental Capacity Act 2005 adequately reflects the impact of coercive and controlling behaviour on decision-making.
2. Gaps and inconsistency in professional understanding of coercive control and fear on victims’ choices and disclosures.
3. Limitations of safeguarding options where a person is assessed as having capacity but remains at high risk.
4. The need for clearer multi-agency guidance and training on capacity, risk, evidence and escalation in domestic abuse contexts. In preparing this response, departmental officials have liaised with NHS England’s (NHSE) South West Safeguarding Team. This was to establish whether NHSE had been made aware of the lessons identified in your report, and to seek information on any relevant work
already under way, including follow-up action. While these teams had not previously been sighted on the report, it has now been brought to their attention.
The Department for Health and Social Care has committed to delivering a range of new policies that form part of the cross-government Violence Against Women and Girls (VAWG) strategy, published in December 2025.
DHSC’s announcement of ‘Steps to Safety’ within the VAWG strategy will allow general practice staff to identify, support and refer victims and survivors of domestic abuse and sexual violence into wider support services. ‘Steps to Safety’ will also focus on identifying early harmful behaviours and recognising early indicators of domestic abuse, enabling earlier signposting and support before abuse begins or escalates.
The model will include:
• training to all staff in the General Practices so they can identify and respond to domestic abuse and sexual violence;
• a specialist support worker linked to a group of general practices to support General Practice staff and support and advocate for victims;
• clear links with local specialist services to refer people into. The Secretary of State also appointed Jess Asato MP as his advisor on VAWG, reflecting his strong commitment to increasing the role the NHS plays in reducing VAWG. The VAWG advisor is considering how the culture within the NHS can be shifted to improve the health system’s response to better support victims and survivors. NHS England is also strengthening national mandatory safeguarding training for all NHS staff for launch in late 2026. It will reinforce to staff their safeguarding responsibilities and support them in identifying and responding to victims of abuse, which includes those experiencing coercive control. The PFD report acknowledges that Joanna had access to Independent Domestic Violence Advisors / Independent Sexual Violence Advisor support and was well known to professionals but, due to the extent of the coercive control, could not take up the support. Professionals were frustrated by their lack of powers to do much else as Joanna was determined to have mental capacity to make decisions. It is hoped that the support we are putting in place with ‘Steps to Safety’ will help identify domestic abuse earlier and interventions put in place before abuse escalates. Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed and updated alongside the modern adult safeguarding framework (including the Care Act 2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant where coercion or undue influence interacts with an impairment or disturbance of the mind or brain so that the person cannot make the specific decision, in such cases, practitioners should complete and record a decision-specific capacity assessment. Where an adult has capacity, the MCA is not a general route to override unsafe or unwise decisions, and other safeguarding, civil and criminal routes may be more appropriate.
The current code doesn’t refer to coercive and controlling behaviour as these did not constitute an offence until 2015, although there is the inference of the individual concerned being influenced by a person. However, the draft Mental Capacity Act Code of Practice consulted on in 2022, expressly recognises that coercion, undue influence and fear may affect a person’s ability to use and weigh information when making decisions. The Court of Protection has repeatedly recognised that controlling and coercive behaviour can undermine genuine autonomy, even where a person appears cognitively able to decide. The PFD report also indicates that a capacity assessment was undertaken. This underlines that the presumption of capacity does not remove the need to assess where there is a proper basis for doing so. We will make clear in the updated MCA Code of Practice (to be consulted on) that practitioners should not equate “assume capacity” with “do not assess”. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 5th March 2026, sent to the Department of Health and Social Care (DHSC), about the death of Mrs Joanna Hillard. I am replying as the Minister with responsibility for adult social care Mental Capacity.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Joanna Hillard’s death; I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
I acknowledge your concern that coercive and controlling behaviour, fear and trauma may affect a person’s ability to make and communicate decisions, even where capacity may be assessed as present under the Mental Capacity Act (MCA) 2005. The Prevention of Future Deaths (PFD) report raises concerns over:
1. Whether the Mental Capacity Act 2005 adequately reflects the impact of coercive and controlling behaviour on decision-making.
2. Gaps and inconsistency in professional understanding of coercive control and fear on victims’ choices and disclosures.
3. Limitations of safeguarding options where a person is assessed as having capacity but remains at high risk.
4. The need for clearer multi-agency guidance and training on capacity, risk, evidence and escalation in domestic abuse contexts. In preparing this response, departmental officials have liaised with NHS England’s (NHSE) South West Safeguarding Team. This was to establish whether NHSE had been made aware of the lessons identified in your report, and to seek information on any relevant work
already under way, including follow-up action. While these teams had not previously been sighted on the report, it has now been brought to their attention.
The Department for Health and Social Care has committed to delivering a range of new policies that form part of the cross-government Violence Against Women and Girls (VAWG) strategy, published in December 2025.
DHSC’s announcement of ‘Steps to Safety’ within the VAWG strategy will allow general practice staff to identify, support and refer victims and survivors of domestic abuse and sexual violence into wider support services. ‘Steps to Safety’ will also focus on identifying early harmful behaviours and recognising early indicators of domestic abuse, enabling earlier signposting and support before abuse begins or escalates.
The model will include:
• training to all staff in the General Practices so they can identify and respond to domestic abuse and sexual violence;
• a specialist support worker linked to a group of general practices to support General Practice staff and support and advocate for victims;
• clear links with local specialist services to refer people into. The Secretary of State also appointed Jess Asato MP as his advisor on VAWG, reflecting his strong commitment to increasing the role the NHS plays in reducing VAWG. The VAWG advisor is considering how the culture within the NHS can be shifted to improve the health system’s response to better support victims and survivors. NHS England is also strengthening national mandatory safeguarding training for all NHS staff for launch in late 2026. It will reinforce to staff their safeguarding responsibilities and support them in identifying and responding to victims of abuse, which includes those experiencing coercive control. The PFD report acknowledges that Joanna had access to Independent Domestic Violence Advisors / Independent Sexual Violence Advisor support and was well known to professionals but, due to the extent of the coercive control, could not take up the support. Professionals were frustrated by their lack of powers to do much else as Joanna was determined to have mental capacity to make decisions. It is hoped that the support we are putting in place with ‘Steps to Safety’ will help identify domestic abuse earlier and interventions put in place before abuse escalates. Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed and updated alongside the modern adult safeguarding framework (including the Care Act 2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant where coercion or undue influence interacts with an impairment or disturbance of the mind or brain so that the person cannot make the specific decision, in such cases, practitioners should complete and record a decision-specific capacity assessment. Where an adult has capacity, the MCA is not a general route to override unsafe or unwise decisions, and other safeguarding, civil and criminal routes may be more appropriate.
The current code doesn’t refer to coercive and controlling behaviour as these did not constitute an offence until 2015, although there is the inference of the individual concerned being influenced by a person. However, the draft Mental Capacity Act Code of Practice consulted on in 2022, expressly recognises that coercion, undue influence and fear may affect a person’s ability to use and weigh information when making decisions. The Court of Protection has repeatedly recognised that controlling and coercive behaviour can undermine genuine autonomy, even where a person appears cognitively able to decide. The PFD report also indicates that a capacity assessment was undertaken. This underlines that the presumption of capacity does not remove the need to assess where there is a proper basis for doing so. We will make clear in the updated MCA Code of Practice (to be consulted on) that practitioners should not equate “assume capacity” with “do not assess”. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Apr 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 26th February 2021, my predecessor, Mr Tony Williams, commenced an investigation into the death of Joanna Hillard. The investigation concluded at the end of the inquest, heard by me, on the 26th February 2026. The conclusion of the inquest was
Box 3: Joanna HILLARD, aged 64, was discovered at her home address at around 09:18hrs on the Twenty-Fifth of February 2021. She was last seen alive at 22:30hrs the evening before and so it is not known exactly when she Despite CPR she could not be revived and was pronounced deceased by the attending paramedic. Joanna's specific motivation to act as she did is not fully clear on the evidence available, but on the balance of probabilities derived from her low mood due to a coercive and controlling domestic relationship and her social and living circumstances, and this has more than minimally contributed to her death.
Box 4: Suicide contributed to by coercive and controlling behaviour
Box 3: Joanna HILLARD, aged 64, was discovered at her home address at around 09:18hrs on the Twenty-Fifth of February 2021. She was last seen alive at 22:30hrs the evening before and so it is not known exactly when she Despite CPR she could not be revived and was pronounced deceased by the attending paramedic. Joanna's specific motivation to act as she did is not fully clear on the evidence available, but on the balance of probabilities derived from her low mood due to a coercive and controlling domestic relationship and her social and living circumstances, and this has more than minimally contributed to her death.
Box 4: Suicide contributed to by coercive and controlling behaviour
Circumstances of the Death
The inquest explored whether behaviour was caused by either his Parkinsons or the Pramipexole medication he was prescribed. His Parkinsons Nurse, after liaising with his Consultant, told friends and professionals that this was unlikely because was on such a low dose and such behavioural changes are more commonly seen with much higher doses than was on. One of the findings at the Inquest was that condition and/or properly prescribed medication did not cause his behaviour but on the balance of probabilities it exacerbated underlying personality traits.
From the September of 2019 embarked on a relentless campaign to embarrass, belittle, intimidate and control Jo, and isolate her from her friend and family. The inquest heard examples of this: (i) Her finances were controlled ( forced her to relinquish her carers allowance by frightening her into thinking she was committing fraud. This meant that she had no access to independent financial means). (ii) He made her recount in mortifying detail , friends, family and neighbours her [his perception of her] sexual inadequacies Witnesses explained that Jo was a private and dignified person and she would have found this experience utterly humiliating and mortifying. (iii) had found a Filippo bride online. He but insisted that they remain living together in the home so that Jo could continue to care for him once his Filipino bride and her relative had obtained a visa; with the four of them living in the house together. (iv) He tried to bully Jo into signing her home over to him, which would have left her homeless and with nothing. (v) Jo engaged a solicitor to help her property matters and once found out about this, he made her end the retainer, meaning that she had no independent and factually correct advice about her position and her rights; it was only what was telling her. (vi) She had to contact her children, friends and family in secret as her conversations were monitored, or could be heard in the background telling Jo what she was to say.
The coercion and control continued even when they were not physically together. In February 2020 Jo was taken by family to Scotland. Whilst there Phillip phoned her relentlessly for hours throughout the day and night until she went home. In March 2020 went to the Philippines to meet his internet-bride and during his absence still controlled Jo’s movements, what she did and who she spoke to etc. remained living together. Whilst administrative processes were in place for his internet-bride to be granted a visa, there were no firm plans or date when she was expected to be in the country and/or living with them.
Evidence from family was that the situation had settled a bit by November 2020.
On the 25th February 2021, Jo was discovered in the workshop/garage attached to the home. left the UK after Jo’s death to live in the Philippines, where it is understood he still resides, and so there has been no investigation, prosecution or conviction under Section 76 of the Serious Crime Act 2015. During her lifetime Jo did not/would not support a prosecution.
I was satisfied that Jo was not happy in her living situation but did not feel able to leave because (i) she had been brainwashed (to quote the family’s phrase) by into believing all of this was her fault and so she felt guilty and that she ‘owed him’ and it was therefore her duty to say and (ii) she wanted to protect from his behaviour which he also exhibited towards them when he was unable to control Jo to the extent and degree that he wanted. He would use his Parkinsons Disease as a weapon and would continually play the consummate victim (even though he was anything but). The Court heard from a variety of professionals who were either directly involved with Jo, or involved ‘behind the scenes’ trying to protect and safeguard her.
The IDVA (Independent Domestic Violence Advocate) told the Court that this was the worst example of coercion and control that she had seen in her 16 years of experience. Multiple professionals from domestic abuse and safeguarding units/organisations and departments were involved with Jo. All agreed that whenever she spoke it was a regurgitation of narrative; what he wanted, what he needed, how he viewed things; she had lost the ability to identify and say “I” want/need/think/feel. She was stuck in a relentless cycle of self-blame; enforced on her by . Her family described her as being “brainwashed”. controlled her thoughts and decision making process even when he wasn’t in the room with her (and professionals, quite appropriately, insisted on seeing Jo on her own. They also had to see her on her own due to covid and the requirement for social distances). The physical separation did not make a difference; the mental and emotional control was still there.
All professionals trying to support Jo agreed that what they wanted for her, and what she needed to be able to recover, was to leave , but she would not do this due to the coercion and control. All professionals were equally ‘professionally frustrated’ by their lack of power to take decisions in her best interests to keep her safe. Jo was assessed, under current legislation (the Mental Capacity Act 2005) as having capacity to make decisions to remain living with , even if those decisions were regarded by others as unwise.
From the September of 2019 embarked on a relentless campaign to embarrass, belittle, intimidate and control Jo, and isolate her from her friend and family. The inquest heard examples of this: (i) Her finances were controlled ( forced her to relinquish her carers allowance by frightening her into thinking she was committing fraud. This meant that she had no access to independent financial means). (ii) He made her recount in mortifying detail , friends, family and neighbours her [his perception of her] sexual inadequacies Witnesses explained that Jo was a private and dignified person and she would have found this experience utterly humiliating and mortifying. (iii) had found a Filippo bride online. He but insisted that they remain living together in the home so that Jo could continue to care for him once his Filipino bride and her relative had obtained a visa; with the four of them living in the house together. (iv) He tried to bully Jo into signing her home over to him, which would have left her homeless and with nothing. (v) Jo engaged a solicitor to help her property matters and once found out about this, he made her end the retainer, meaning that she had no independent and factually correct advice about her position and her rights; it was only what was telling her. (vi) She had to contact her children, friends and family in secret as her conversations were monitored, or could be heard in the background telling Jo what she was to say.
The coercion and control continued even when they were not physically together. In February 2020 Jo was taken by family to Scotland. Whilst there Phillip phoned her relentlessly for hours throughout the day and night until she went home. In March 2020 went to the Philippines to meet his internet-bride and during his absence still controlled Jo’s movements, what she did and who she spoke to etc. remained living together. Whilst administrative processes were in place for his internet-bride to be granted a visa, there were no firm plans or date when she was expected to be in the country and/or living with them.
Evidence from family was that the situation had settled a bit by November 2020.
On the 25th February 2021, Jo was discovered in the workshop/garage attached to the home. left the UK after Jo’s death to live in the Philippines, where it is understood he still resides, and so there has been no investigation, prosecution or conviction under Section 76 of the Serious Crime Act 2015. During her lifetime Jo did not/would not support a prosecution.
I was satisfied that Jo was not happy in her living situation but did not feel able to leave because (i) she had been brainwashed (to quote the family’s phrase) by into believing all of this was her fault and so she felt guilty and that she ‘owed him’ and it was therefore her duty to say and (ii) she wanted to protect from his behaviour which he also exhibited towards them when he was unable to control Jo to the extent and degree that he wanted. He would use his Parkinsons Disease as a weapon and would continually play the consummate victim (even though he was anything but). The Court heard from a variety of professionals who were either directly involved with Jo, or involved ‘behind the scenes’ trying to protect and safeguard her.
The IDVA (Independent Domestic Violence Advocate) told the Court that this was the worst example of coercion and control that she had seen in her 16 years of experience. Multiple professionals from domestic abuse and safeguarding units/organisations and departments were involved with Jo. All agreed that whenever she spoke it was a regurgitation of narrative; what he wanted, what he needed, how he viewed things; she had lost the ability to identify and say “I” want/need/think/feel. She was stuck in a relentless cycle of self-blame; enforced on her by . Her family described her as being “brainwashed”. controlled her thoughts and decision making process even when he wasn’t in the room with her (and professionals, quite appropriately, insisted on seeing Jo on her own. They also had to see her on her own due to covid and the requirement for social distances). The physical separation did not make a difference; the mental and emotional control was still there.
All professionals trying to support Jo agreed that what they wanted for her, and what she needed to be able to recover, was to leave , but she would not do this due to the coercion and control. All professionals were equally ‘professionally frustrated’ by their lack of power to take decisions in her best interests to keep her safe. Jo was assessed, under current legislation (the Mental Capacity Act 2005) as having capacity to make decisions to remain living with , even if those decisions were regarded by others as unwise.
Copies Sent To
following
Similar PFD Reports
Reports sharing organisations, categories, or themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.