A domestic homicide review into the death of Luisa Mendes has been published today 2 June 2016 by the South Warwickshire Community Safety Partnership (SWCP).

Luisa Mendes, aged 44, died in October 2012 at a house in Leamington Spa. Her  death has been subject to a Coroner’s Inquest which concluded this afternoon.

The domestic homicide review is an independent report, in line with Home Office Guidance. The review looks at the way agencies interacted with Luisa and each other and what lessons can be learned to assist those facing similar situations in the future.

Cllr Michael Coker, spokesperson for the South Warwickshire Community Safety Partnership, said: “The Mendes family have suffered a great loss and we thank those who knew Luisa and contributed to the review at such a difficult time.”

“We believe, at times, agencies dealt with situations at face value and could have done more to understand Luisa’s circumstances.   Agencies involved in the review fully accept the report’s findings and recommendations, and improvements have already been made.”

Dee Edwards, the Independent Chair and Author of the review, added: “There were many complex factors that contributed to the vulnerable situation Luisa found herself in before her death, including domestic abuse and alcohol misuse, mental health problems and homelessness.

“There is no doubt that Luisa’s vulnerability restricted the life choices available to her and placed her at risk of harm.

“Above all we want this review to help us better support individuals with complex needs and understand the cause of their problems. We would urge anyone who may be experiencing domestic violence and abuse to tell someone and access the support available.”

Actions taken to address the key recommendations include:

• Improved domestic violence policies, procedures and training of professionals. This means front line workers are better able to identify domestic violence and abuse and refer people to specialist support, especially when abuse may be masked by a presenting problem such as substance misuse or antisocial behaviour.

• Warwickshire has signed up to Alcohol Concern’s innovative Blue Light Programme which is designed to reduce alcohol related harm and domestic abuse and violence associated with treatment resistant drinkers. The programme has been developed in response to learning from Domestic Homicide Reviews nationally.

• Warwickshire County Council has commissioned a domestic abuse training, support and referral programme aimed at GPs. Called IRIS -Identification and Referral to Improve Safety, the programme also provides specialist support workers linked to GP surgeries.

• Agencies in Warwickshire have implemented a MASH – a Multi Agency Safeguarding Hub – to co-locate agencies together and focus on providing a coordinated, consistent approach to safeguarding children and adults. The MASH went live from Tuesday 3 May 2016 to safeguard children and victims of domestic abuse and will be incorporating adults in need with effect from 1 September 2016.

• The multi agency processes within the Warwickshire MASH ensure multi agency triage of all domestic abuse incidents. The Warwickshire MASH is designed to be for all ages and all vulnerabilities in order to properly identify those individuals and families with complex needs.

• Risk assessment processes have been put in place to identify repeated domestic abuse incidents that on their own are not judged as being high risk, but collectively could be considered high risk and escalate them into a Multi Agency Risk Assessment Conference, known as a MARAC for a coordinated multi agency response.

• Police contact handlers have received comprehensive National Decision Model and vulnerability assessment training and exercises aimed at giving them a much heightened awareness, and consistency of response in identifying and supporting vulnerable callers / victims from harm.

• New contact management technology currently being introduced will help police call handlers quickly retrieve relevant details on people, objects, locations and events. This will assist them in considering the broader picture when assessing vulnerability and support decisions around police and partner agency interventions.

• Warwickshire Police has adopted a culture of continuous improvement and of sharing learning at the earliest opportunity to ensure officers and staff provide the best protection possible for those that are most vulnerable. Officers and staff are actively encouraged to use their professional curiosity to look beyond what they see initially to protect people from harm especially that posed to vulnerable children and adults and those with complex needs. Warwickshire Police and West Mercia Police aim to lead the way nationally on recognising and responding to vulnerability.

• Warwick District Council’s Homeless Strategy which took effect in April 2015 included a number of actions that identify a range of future housing options and alternatives for people with complex needs who become homeless. In consultation with voluntary and statutory agencies, some of the key actions included the development of a protocol for dealing with council and housing association tenants who are victims of domestic violence and are facing homelessness, developing a mental health protocol and Housing Advice Staff offering housing advice drop in surgeries in other agencies buildings, for example the Salvation Army.

If you or someone you know has experienced or is experiencing domestic abuse and would like support, call Warwickshire’s specialist domestic abuse helpline on free phone 0800 408 1552. Lines are open from Monday to Friday 9am until 9pm and on Saturday 8am until 4pm. The helpline is closed on Sunday. In an emergency dial 999.

The report makes recommendations for action by Coventry and Warwickshire Partnership NHS Trust, NHS England (West Midlands), The Recovery Partnership, South Warwickshire NHS Foundation Trust, Swanswell, Warwick District Council – Housing, Warwickshire County Council – Social Care and Support, Warwickshire Police, Warwickshire Probation Trust and University Hospital Coventry and Warwickshire.

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