Sheffield woman killed herself following domestic violence – report says lessons must be learned

A domestic homicide report into the death of a woman named as Leah in summer 2020 by Sheffield Drug and Alcohol/Domestic Abuse Coordination Team (DACT) was included in the latest review of the Sheffield Children Safeguarding Partnership.

The city’s three safeguarding partners are Sheffield City Council, NHS South Yorkshire Integrated Care Board and South Yorkshire Police.

The overall review into its work will be discussed at a meeting of Sheffield City Council’s education, children and families policy committee next Thursday (November 2).

The report said that Leah died by suicide from an overdose of alcohol and prescription drugs. Her partner, named as AP, had breached a domestic abuse violence protection order and was present leading up to her death.

The report said that AP was her on-off partner for two years and was not the father of her children. Leah had suffered abuse as a young person and from previous partners. She previously attempted suicide and had problematic alcohol use.

AP was a child victim of domestic abuse and “struggled with alcohol, drug use and poor mental health”. He was supervised by the probation service.

The report said: “Leah and AP’s relationship was violent and volatile from the start. AP was coercive and controlling, using physical, psychological, sexual and emotional abuse.

“Incidents often included alcohol. The children were sometimes present. There were 12 police investigations as the abuse escalated.

“He threatened suicide, breached orders and caused damage to Leah’s mum’s property. He attacked Leah at an airport and was found guilty of battery.Incidents were assessed as standard or medium risk.

“He attacked his mother and sister in a high-risk incident, but the MARAC referral did not include Leah, although she was present.”

A MARAC referral is a meeting of different agencies such as police and social services, held to discuss how to help victims at high risk of murder or serious harm.

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The report added: “Six weeks before her death, Leah retaliated in self-defence and was heard at MARAC as a perpetrator. Children’s social care started an assessment and a week before her death she told the police she feared for her life.”

The review found that agencies “failed to identify and address the risk of suicide as a possible outcome of the domestic abuse she was experiencing – it was thought her children were a protective factor”.

It added: “Leah lived in fear of AP. Coercive and controlling behaviour was not recognised. He would “control her” by threatening to kill himself if she left him.

“Agencies focused on AP’s mental health and self-harm and didn’t identify him as a perpetrator.

"A trauma-informed approach was required to better understand Leah and AP in the context of their life histories and experience.

"This may have changed practitioner’s attitudes towards them, built trust and engagement in support.”

The review found that police did not use five previous incidents that took place in a five-month period to properly assess Leah’s risk and take steps that would have held AP to account.

It also said that safeguarding children’s referrals were not completed for occasions when the children were not present.

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The review concluded: “As in previous Sheffield reviews, where there are substance misuse issues and poor mental health it is important to ask about domestic abuse.

“Had Leah’s act of self-defence/violent resistance been identified as such, then a trauma-informed approach could have been used, a safety plan agreed, and her needs considered.”

The review made the following recommendations:

• Using a trauma-informed approach with complex cases of domestic abuse.

• A specialist risk assessment should be made of all victims, consider their children and refer to social care.

• Agencies should consider if it is self-defence or violent resistance when women apparently perpetrate domestic abuse.

• Agencies should report and act on breaches of orders such as domestic violence protection orders.

• The spellings of all names should be checked to ensure records are not overlooked.