Lessons learned after deaths of domestic abuse victims in South Gloucestershire

The deaths of two men whose neglect was missed by social workers have been reassessed to help prevent future tragedies.

One man was killed by his wife and South Gloucestershire Council’s health and wellbeing board heard that the murder case prompted a child safeguarding practice review after the mother of three children was convicted of their dad’s murder.

Both the man and his wife had claimed to be victims of domestic abuse at the hands of the other and it had been difficult to determine who was the perpetrator, the meeting was told.

The council's children’s partnerships and safeguarding adults board business manager Sarah Taylor said the youngsters were on child protection plans - and that care proceedings had begun when their father died because of concerns about the parents’ poor mental health, substance misuse and emotional neglect.

"It was very difficult to unpick who was actually the perpetrator and who was the victim".

She told the meeting: “A lot of the learning from Family A was about domestic abuse and thinking about the assumptions that are made when there’s domestic abuse about who’s the victim and who’s the perpetrator.

“It was very clear that in this family both of the adults had been referred as victims to Next Link, our domestic abuse provider, but both had made allegations about one another and it was very difficult to unpick who was actually the perpetrator and who was the victim.

“The mother in this instance was a South Gloucestershire care leaver and had considerable childhood trauma.

“There was some learning about being able to work effectively with fathers and making sure their voice is heard and understanding what a day in the life of the child is like.”

She said the policy of “separate and isolate”, where parents are asked to split up so children are protected from witnessing domestic abuse, did not always work.

Ms Taylor said the mum told the review, published in January, that she was never going to leave her husband and that, because of the requirement for them to separate, she could not then ask for help or be honest with professionals because of the threat of losing her children.

"Important lessons were also learned from the death of Mr D"

Ms Taylor also said that important lessons were also learned from the death of Mr D, a man in his late 50s who died by suicide in 2021

He was diagnosed with paranoid schizophrenia and depression, suffered from chronic back pain and was keen to return to Swindon where his family lived, having become increasingly isolated during the pandemic, members heard.

Ms Taylor said: “There was evidence that he was self-neglecting, but those factors weren’t really recognised by people working with him at the time.

“Some of the people working with him never saw inside his accommodation and those who didn’t recognise self-neglect".

“Self-neglect was a significant factor"

She added: "Self-neglect was a significant factor, with individual practitioners struggling to make progress with Mr D because he didn’t want to engage with professionals.”

She said one of the lessons learned from the review was that a multi-agency meeting should have been held to join up the information held by different organisations, which was further compounded by the fact they spanned two local authority areas.

Ms Taylor said: “It was really difficult to see that anyone had a real grip on what was happening for Mr D.

“There were choices in Swindon where there was a housing panel but Mr D was never successfully selected to have his case heard, and being across two local authority areas meant nobody really grasped that.”

Credit: Adam Postans, Local Democracy Reporter