Report into woman's killing highlights 'significant gaps' in domestic abuse response

'Think Family' approach recommended after manslaughter case

A report into the death of a woman, killed by her own son in January 2021, has highlighted 'significant gaps' in the domestic abuse response on the Isle of Man but found her death wasn't preventable.

A Serious Case Management Review has been published, looking into the events leading up to the incident, and recommending a 'Think Family' approach to consider the impact of Adverse Childhood Experiences.

For the purpose of the report the individuals involved are referred to as 'Family K'.

Mark

The man, known in this study as 'Mark', killed his mother 'Mrs K' by strangling her with a towel.

He also seriously assaulted his father 'Mr K'.

Mark committed the attack during a psychotic episode and was later diagnosed schizophrenic.

Following criminal proceedings he is currently being held in a secure mental health hospital after being convicted of manslaughter and serious assault.

Prior to the fatal event, however, he had no known history of mental illness, nor history of aggression or violence.

In the weeks before he killed his mother Mark's friend called Manx Care's mental health team, concerned after Mark had suffered what he described as 'a schizophrenic episode'. He also recalled other incidences of paranoia and cited his friend's 'high level of cannabis use'.

Mark's mother, and his friend, contacted mental health services five times with concerns, but he was unwilling to engage with the relevant support agencies.

The Serious Case Management Review looks at Mark's life, what may have driven him to commit the offences and what, if any, signs there were in the weeks and months prior to his mother's death.

It considers the impact on him of growing up in a house 'witnessing domestic abuse towards his mother, parental alcoholism, family instability and caring responsibilities'.

Domestic abuse

Mrs K herself is identified as a victim of domestic abuse perpetrated by her husband Mr K. 

Whilst she told police, nurses, her husband's social worker, and mental health services about the abuse she'd suffered, the report finds the support options any of those professionals could offer her were 'extremely limited'.

Amongst a number of recommendations, the review says the Island's safeguarding agencies should adopt a 'Think Family' approach - to consider the impact of domestic abuse on all members of the family and not just the direct victim.

The report highlights the effectiveness of Independent Domestic Abuse Advisors - professionals on-hand to provide advice and support, typically in settings such as emergency departments.

Whilst IDVA's are common in England and Wales, the Isle of Man is yet to introduce such schemes - something the review's author says is 'very concerning'.

It's recommended that the evidence from the review is shared with the Department of Justice and Home Affairs as it develops its domestic abuse strategy - the Island's Domestic Abuse Act 2020 is due to come into force on 4 January, 2023. 

Despite all this the report says, ultimately, it's 'difficult to see how Mrs K's homicide could have been predicted or prevented'.

Young carers and school

Mark, throughout his teenage years, acted as a carer for his disabled father. Meanwhile, his mother had a long term depressive illness. A family relative, dependent on care, had also moved into the house - with much of the caring responsibilities falling to Mark. 

His parents were described as having 'chaotic lifestyles secondary to alcohol use'.

He was registered as being a young carer at school where his attendance had been good up until his last three years of schooling.

Mark's father told the school his poor attendance was due to his caring needs - being relied upon to drive both his parents to appointments during a 'difficult period' for the family.

Despite the school knowing of Mark's responsibilities as a carer the report says it was 'unaware of [his] home circumstances'.

Manx Care is to lead an awareness campaign on the Isle of Man about what it means to be a young carer.

Sally Shaw, Executive Director for Mental Health, Social Care and Safeguarding for Manx Care, spoke to Lewis Foster about the initiative:

Learning opportunities

The Serious Case Management Review has shown government agencies on the Isle of Man 'areas of learning' some of which - such as the 'Think Family' approach - have been detailed above.

Despite finding Mrs K's death could not have been predicted or prevented the report shows how more joined-up thinking, 'professional curiosity' and collaboration is needed between parties such as police, schools, social care services and hospitals.

One recommendation is for Multi-Agency Risk Assessment Conferences to be introduced on the Isle of Man - where information on the highest risk domestic abuse cases can be shared between agencies preventing 'silo mentality'.

MARAC's are quoted in the report as 'the most effective use of public resources; focusing on the highest risk victims while addressing the needs of children early'.

A cost analysis by the Coordinated Action Against Domestic Abuse group in 2010 found, due to the 'substantial economic cost' of domestic abuse, MARAC's save around £6100 per victim, at least.

While such meetings are not currently in place on the Isle of Man, the report states work is ongoing to introduce 'appropriate public protection arrangements', adding that the known information regarding the domestic abuse present within 'Family K' would not have been deemed high enough a priority to warrant a MARAC.

Action plan

The Isle of Man Safeguarding Board, which commissions the Serious Case Management Review, says it has developed an action plan based on the recommendations.

Chair Lesley Walker said: "This review highlights the need for everyone to understand the impact that adverse childhood experiences can have on children’s lives and the importance of professionals and services intervening early to prevent trauma.

"It is critical that practitioners responding to complex family issues, especially domestic abuse should consider the risks and vulnerabilities of all people within the household, with a particular emphasis on children and the impact on their daily lived experiences".

She spoke to Manx Radio's Lewis Foster: