It is noted in the DHR31 report that had a secondary risk assessment been conducted (in line with police policy) on the medium risk score, then a review of the facts alongside the professional judgement of a specialist might have suggested that a grade of ‘high’ was more appropriate, resulting in referral to MARAC. The report also states that had such a referral been made, then information held by other agencies could have been shared and a clearer understanding of the risks posed appreciated. Moreover had information regarding risk ‘been shared and collectively addressed’ then the victim’s death ‘may have been prevented’.
Failure to identify and assess risk
DHR31 observes another occasion on which the police failed to identify risk. The police received an emergency call from the perpetrator’s brother at his mother’s address reporting that the perpetrator had smashed the door down with a hammer, was inside the house smashing it up and was threatening to kill them all.
No record was made of the initial remarks of [the perpetrator’s] brother, who reported that [the perpetrator] was threatening to kill them all. The threat was not explored, risk assessed, risk managed, investigated or brought to the attention of an Inspector, in accordance with the police Threats to Life Policy (DHR31).
The absence of risk identification and assessment is also noted in DHR30 in which the perpetrator had been assessed by social services with respect to the risk he posed to his siblings and not his mother. This is despite the fact that a month before the murder, the victim had told her son’s social worker that he had assaulted her. When the social worker questioned the perpetrator he ‘described how he became intimidating to his mother’ and was quoted to have said ‘he could have murdered her’.
The perpetrator in DHR8 also posed a risk to his siblings as well as his mother. Thus even though the police were called to an incident by the perpetrator’s sister at which his mother was present, only the risk to his sister was assessed. Similarly both of the brothers in DHR25 perpetrated violence towards their own intimate partners, leading the DHR report to observe that the nature of the relationship between the brothers did not in and of itself ‘feature highly in the work of any agency’.
The Individual Management Review of another perpetrator in DHR22 notes that it ‘was never seemingly grasped that his mother [was] at risk of serious harm from [her son]’. These findings suggest that risks to mothers from violent sons needs to receive more attention, both in risk identification, assessment and management and in access to support.
Multi Agency Risk Assessment Conferences (MARAC)
In DHR30, the social worker sent a DASH risk assessment to the MARAC coordinator. Although this reflected an incident in which the perpetrator was victim to his older brother, it did state that the perpetrator’s brother had also previously hurt his mother and sister. However due to the perpetrator moving out of the family home and area, the family was never discussed through a ‘domestic violence’ lens. DHR reports 25 and 31 also note at least one occasion where referral to a MARAC could have been made but was not.
Factor analysis
The following section presents a risk factor analysis across the eight AFH cases drawing on data contained within the DHR reports. The same important caveats highlighted in relation to this exercise in the context of IPH should also be noted here.
The frequency of risk factors
Table 10 sets out the risk factors identified in the DHR reports. The most frequent were: violence towards others, including other family members, neighbours and agency workers (n=5) followed by violence towards an intimate partner (n=3). In fact in DHR25 the report notes that ‘some practitioners have commented that they had always viewed the most likely victim of [the perpetrator] to have been [his wife]’. Physical violence towards the victim of the homicide was known in a quarter of cases. There was no reference to coercively controlling behaviours in the adult family violence cases, suggesting that this might be specific to IPV.
In terms of perpetrator characteristics the presence of mental health issues was extremely high in this sample (3 confirmed and 3 suspected; n=6, 75%). Depression featured alone in two cases and alongside other mental conditions in another two. Psychosis featured in three cases, bipolar in one, and paranoid schizophrenia in another. A diagnosis could not be decided on for one perpetrator who was assessed only after the murder (DHR2). It is of note that, unlike the IPH cases, three quarters (n=6) of the AFH sample were found guilty of manslaughter by diminished responsibility (n=5) and by virtue of insanity (n=1). Two perpetrators faced a murder charge (outcome unknown).
Problematic substance use was also very high in this sample with five of the perpetrators having problems with drugs and/or alcohol. One of the diminished responsibility defences was that the perpetrator had killed his mother in a ‘drunken rage’. Previous criminality was also very high (n=5). This cluster needs to be explored in further AFH samples to see if these should be emphasised in risk assessment of AFV cases. Table 10: Recorded risk factors
Perpetrator’s use of violence Formal agency
Violence towards child, others 5
Violence in an intimate relationship 3
Physical violence to victim 2
Threats to kill 1
Perpetrator characteristics
Depression 6
Alcohol, drug misuse 5
Previous criminality 5
Suicidal thought, attempts, threats 1
Money/debt issues 1
Clustering
Alongside the fact that many of the factors found in the IPH cases were not present here (coercive control), or not relevant (separation and conflict over child contact), in two cases (DHR2 & 28) there was no clustering of risk factors. In DHR2 only mental ill health is present (although raised only after homicide, diagnosis not agreed). Similarly analysis of DHR28 identifies only mental health concerns and gambling (money/debt issues). It is observed in one of these reports that anybody could have been at risk.
Whilst the victim of this case is the father of the perpetrator, consideration needs to be given to the fact that he was attacked by his son during a psychotic episode. There were no signs or indicators of domestic violence before this incident and consideration needs to be given to the fact that any other person could have been victim of attack by [the perpetrator] whilst he was in a psychotic state (DHR28).
In contrast, at the other end of the spectrum, two reports (DHR25 & 30) note six risk factors including: violence in an intimate relationship, physical violence, mental health, alcohol/drug misuse and previous criminality.22 One case notes five risk factors and the remaining three note four factors.
Commonalities across all of these cases include: violence towards child/others, mental health or problematic substance use and previous criminality. But when ‘other criminality’ is explored, some other form of violence against women is evident i.e. attack of sister, niece; use of women involved in prostitution; and ‘a serious incident against a female’. Indeed several review reports specifically note that the perpetrator displayed patterns of threatening behaviour towards women (DHR24, & 30). This suggests that the sons who killed their mothers demonstrated a high level of hostility towards women.