Angela Mittal

Coroner's concerns

AI summary

Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.

View full coroner's concerns

Given the likelihood that the areas of concern relate not just to the police force in my jurisdiction, I have addressed this report to the National Police Chiefs’ Council. I note that the website of the NPCC currently lists violence against women and girls as the first area of work that they are focusing on. Thames Valley Police’s own training confirms that coercive and controlling behaviour is a major risk factor in domestic homicide. 1. Whether sufficient steps have been taken to ensure that frontline staff have a clear understanding of domestic abuse and coercive and controlling behaviour – to think not just about physical abuse, but also about controlling behaviour and how that may escalate.
2. I am concerned that Thames Valley Police’s DASH risk assessment form (called a DOM5) does not make it sufficiently clear that the definition of “serious harm” can include psychological harm from coercive and controlling behaviour. It may be that other formulations of this document nationally do make this clear – I have looked only at the form used by Thames Valley Police.
3. I heard evidence about a new tool for risk assessing domestic abuse, created by the College of Policing. Both the senior Thames Valley Police officer and the College of Policing witness gave evidence that this system is likely to result in better risk assessment for domestic abuse. As I understand it, this new tool has not been adopted by Thames Valley Police at this time, because of competing financial priorities, and an issue with compatibility with the Niche system.

Responses

2 respondents

National Police Chiefs' Council Police / Law Enforcement

3 Oct 2024 PDF

Action Taken

The NPCC highlights the national launch of the Domestic Abuse Risk Assessment (DARA) tool in November 2022 and ongoing work with forces and IT providers to drive implementation, in addition to various supporting products available to deliver against the curriculum. (AI summary)

View full response

Dear Ms Connor,

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 13th August 2024.

The notice sets out concerns that arose from the information received during the inquest into the death of Angela Mittal. I am very sorry to read of the circumstances of Angela’s death. My sympathies are with her family and friends.

Domestic Abuse (DA) is a priority for the NPCC and key partners and much work has taken place in this area to drive improvements and consistency in the policing response. The College of Policing sets national standards for learning and development for UK Policing and provides guidance and advice in various forms including Authorised Professional Practice (APP).

A programme of work was developed to improve the policing response to DA, including a project to examine existing risk assessment processes for victims of DA, a review of the existing training curriculum and the development of APP for this area of work. In 2015 with the inception of new legislation for the offence of coercive and controlling behaviour, several products were made available on the College learning network (College Learn) aimed at embedding knowledge of the legislation. Using a video briefing, two victims provide an insight of their lived experience of controlling and coercive behaviour, while advice and guidance is also given on the legislation. In addition, forces were provided with a new training guide and content for a half-day classroom session so that there was an option for face-to-face inputs. Although this was not centrally delivered forces were encouraged to deliver against the national curriculum using the specific products available. Simultaneously, the College of Policing used the DA curriculum to underpin a course for first responders. The DA Matters course is focussed predominantly on understanding, identifying and

responding to coercive and controlling behaviour, the impact of such behaviours on victims, including the clear links to victim suicide and the heightened risk posed by suspects who use coercion and control in their abuse of victims. This consists of a one-day course for responders and a two-day course for ‘champions,’ those with a more involved, mentoring role. DA Matters was developed with the support of ‘Safelives,’ (a national service for victims of DA), and other key stakeholders including Women’s Aid, Suzy Lamplugh Trust, and other specialist support services. The course was piloted and evaluated in 2016 and a model of delivery, (which included co-delivery with a DA specialist) is promoted through the licensing of the product (essentially outlining the conditions by which forces must use the training course). Safelives, Welsh Women’s Aid and Women’s Aid are now the licensed providers for the course, delivering to 75% of frontline workforce and training force/partner trainers to continue delivery thereafter. Our providers are part of our Editorial Board whereby we ensure maintenance of the product. This course is highly regarded and included as required learning for the policing of domestic abuse within the Government Domestic Abuse Strategy. Many forces have received Government funding to deliver the programme, with all but one Home Office force having delivered or under contract to deliver the course. In 2022 further funding from the Home Office to build on the DA Matters first responder course to deliver learning for investigators of ‘course of conduct’ offences including coercive and controlling behaviour, stalking and harassment. This learning will be delivered through Hydra, an immersive learning platform which takes officers through cases in a simulated environment. Train the trainer events were tested and delivered and concluded in April 2024 before the course was rolled out nationally. More broadly DA is embedded in the curriculum for all entry routes into policing with various supporting products available to deliver against the curriculum (for example, areas such as Domestic Violence Disclosure Scheme (DVDS), Domestic Violence Protection Orders (DVPOs), response to DA /Stalking (Abusive Relationship digital learning, Domestic Abuse Risk Assessment (DARA/DASH) are catered for). Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse , stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focussed on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk. This training also provides the information on the harmful impacts of CCB.

The DARA was launched nationally in November 2022. Unfortunately, implementation has not been as smooth as anticipated due to competing demands for amending the various IT systems used for recording the risk assessment process, however, the NPCC and the College have been working closely with forces and relevant IT providers to drive implementation. I hope the information provided will go some way to address your concerns. Please do not hesitate to contact me if you require further action or information in relation to my response.

Thames Valley Police Police / Law Enforcement

3 Oct 2024 PDF

Action Planned

Thames Valley Police will replace current questions in the DOM 5 with questions from the DARA, include reference to the College of Policing definition of serious harm, and train every front line officer in its use. (AI summary)

View full response

Dear Mrs Connor Inquest into the Death of Angela Mittal

Preventing Future Deaths response of the Chief Constable of Thames Valley Police

Thank you for your report sent by letter dated 13 August 2024 under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in respect of circumstances surrounding the tragic death of Angela.

Your report contains three matters of concern which I shall address below:

Response to the Regulation 28 concerns

Whether sufficient steps have been taken to ensure that frontline staff have a clear understanding of domestic abuse and coercive and controlling behaviour

Detective Superintendent is the Thames Valley Police lead for Domestic Abuse and Stalking. In his written and oral evidence (particularly his statements dated 29 January 2024 and 22 May 2024), Detective Superintendent gave an explanation of the training police officers received in 2018 regarding coercive control and how that training has evolved to the present day. I do not wish simply to repeat information of which you are already aware, but will set out in summary our current relevant training programme and future plans to raise awareness of the impact of coercive and controlling behaviour and the potential for it to lead to tragic consequences.

We are always seeking to improve our training. Changes to training practice and content can be brought about in a number of ways. The training of new recruits is mandated through the College of Policing and delivered through a number of courses, collectively known as Foundation Training. All our training inputs have been reviewed and in some cases improved by an independent domestic abuse training consultancy. I am satisfied Chief Constable

Thames Valley Police HQ Oxford Road Kidlington OX5 2NX

Tel:

By Email Mrs Heidi J Connor Senior Coroner HM Coroner's Office Reading Town Hall Reading

that our Police Constable Entry Programme, Police Constable Degree Apprenticeship and our Degree Holder Entry Programme all contain inputs covering domestic abuse and coercive and controlling behaviour.

Beyond Foundation Training, front line officers are subject to further training inputs delivered in a variety of ways.

Thames Valley Police have commissioned the Safe Lives charity to deliver its ‘DA Matters’ training to all front-line officers since January 2020. This includes sessions on coercive and controlling behaviour. This training also includes an input known as ‘Crime Data Integrity’. This is essentially training officers to identify and accurately record crime and to that end specific videos have been produced covering behavioural crimes such as harassment, stalking and coercive and controlling behaviour.

Front line staff are also expected to attend 2-3 ‘Teams In Action’ training days per annum. The current training underway on these days includes communication with victims, domestic abuse risk assessments, Domestic Violence Protection Notices (DVPN) and Domestic Violence Disclosure Schemes (DVDS).

Contact Management staff (call takers and their supervisors) have received a number of training inputs on handling domestic abuse calls. Their input on crime data integrity focused on domestic abuse and missed crimes. The tragic death of Angela was used as a case study to reinforce the importance of identifying coercive and controlling behaviour.

It is of note that in 2019 Contact Management added the following question to the Call Handlers’ question set (the list of questions asked for every domestic abuse call) to identify Coercive and Controlling Behaviour, recognising that a victim/survivor may not use that particular term but may describe behaviour amounting to Coercive and Controlling Behaviour.

“Has the victim disclosed anything that could indicate an element of control over them by the perpetrator? (If yes, record the detail as this is likely to be an indicator for Coercive Control)”

In 2024 Contact Management leaders commissioned an external training provider to develop a new training package (including Coercive Control) and asked for the circumstances of Angela’s death to be included as a case study.

The training course designed for specialist domestic abuse officers has also recently been reviewed and refreshed. Inputs on coercive and controlling behaviour run throughout the programme.

All training for front line staff is in addition to the Operational Guidance products that are available to guide officers on how to identify and deal with coercive and controlling behaviour. These products can be accessed any time through an officers laptop or via mobile phone app.

I am satisfied frontline staff are equipped with sufficient training to understand domestic abuse and coercive and controlling behaviour. Thames Valley Police is committed to providing ongoing and updated training in these important areas.

I am concerned that Thames Valley Police’s DASH risk assessment form (called a DOM5) does not make it sufficiently clear that the definition of “serious harm” can include psychological harm from coercive and controlling behaviour. It may be that other formulations of this document nationally do make this clear – I have looked only at the form used by Thames Valley Police.

You are right to point out that the current TVP Domestic Abuse risk assessment form (Dom5) does not define the term ‘serious harm’. The College of Policing defines the risk of serious harm as follows - ‘A risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible.’ This definition is included in the risk assessment model known as the DARA. I have asked Detective Superintendent to include this definition on our current risk assessment form.

I heard evidence about a new tool for risk assessing domestic abuse, created by the College of Policing. Both the senior Thames Valley Police officer and the College of Policing witness gave evidence that this system is likely to result in better risk assessment for domestic abuse. As I understand it, this new tool has not been adopted by Thames Valley Police at this time, because of competing financial priorities, and an issue with compatibility with the Niche system.

It is important to note that competing financial priorities are not the issue here. The principal challenges are compatibility with our NICHE crime recording system and the delivery of training to front line police and staff. Thames Valley Police require a contractor to initiate the changes on the NICHE system. The development of Electronic Case Files was prioritised over the implementation of DARA and that project has overrun. Any solution to this must also be compatible with other processes such as our ability to refer the information captured in our domestic abuse risk assessments in a timely fashion to other agencies with responsibilities for the protection of victims/survivors and their children, such as Children’s Social Care and colleagues in the health service. A change from DASH to DARA is a significant departure from the current process which has been in place for many years. It is crucial that all officers and staff who make use of DARA are fully trained in its development and use. In order to do this we will need to train thousands of officers’ and staff, which will take some considerable time. It is also important to note that our partner agencies also use DASH and any change to the risk assessment model must bear this in mind as the police will be using a tool that is unfamiliar to those agencies.

There are challenges to implementing the DARA risk assessment model within our current version of the NICHE crime recording system. In the future TVP will be looking to adopt an updated NICHE safeguarding and vulnerability module when available. In the mean time I have asked Detective Superintendent to explore an interim solution. This will include the replacement of the current questions in the DOM 5 with the questions contained within the DARA and include clear reference to the College of Policing definition of serious harm which can include psychological harm from coercive and controlling behaviour. This will be attached to the crime recording system in the form of a template. The DARA includes a number of questions designed to assess the level of coercive and controlling behaviour and the level of risk posed. Included in this implementation will be the training of every front line officer in its use.

The death of Angela is yet another example of the tragic consequences of domestic abuse. Thames Valley Police is determined to do all it can to learn from this devastating event and prevent future deaths in similar circumstances.

Report sections

Investigation and inquest

The family requested me to refer to the deceased as Angela. I will reflect that in this report. I conducted an inquest into the death of Angela Mittal which concluded on 26th of July 2024. The conclusion of the jury was as follows: Angela was unlawfully killed. The following Thames Valley Police findings have been admitted:
a. The officers who spoke to Angela on 29th of November 2018 did not recognise that she was reporting the crime of coercive control.
b. The officers who spoke to Angela on 29th of November 2018 did not record the crimes she reported, either of assault or coercive control.
c. The officers who spoke to Angela on 29th of November 2018 accepted that the risk grading on the DOM-5 risk assessment form should have been medium rather than standard.
d. The senior officer who saw Angela on 29th November 2018 accepted that he did not fully review the DOM-5 risk assessment form before signing it.
e. The officers who spoke to Angela on 29th November 2018 did not take information available to them (on the command and control system used then, from a call Angela had made to the police earlier that morning) into account in their assessment of risk. This was despite the call handler identifying domestic violence and coercive control in the course of that 16 minute telephone call.
f. The officers who spoke to Angela on 29th November 2018 did not investigate the crimes Angela reported to them that day. Based on all the evidence heard in court, we the jury conclude that the admitted failings of Thames Valley Police, on the balance of probabilities, did not contribute to Angela’s death.

Circumstances of the death

Angela was murdered at her home address by her husband on 26th of December 2018. She was 41 years old at the time of her death. We heard in evidence that Angela had spoken to Thames Valley Police by telephone and in person on the 29th of November 2018. She reported an allegation of assault around a month prior to that, and also many of the elements of coercive control. She also reported an assault on her young child to the call handler, but this was not recorded as a crime, nor handed over to the police officers who saw her that day. Because of the involvement of a child in the family home, a referral was made to the Multi-Agency Safeguarding Hub within Wokingham Borough Council Children’s Services. A decision was made to carry out a Child and Family Assessment under Section 17 of the Children Act of 1989. Angela had moved out of the marital home whilst she was in contact with the social worker at Wokingham Borough Council. Although she had discussed the possibility of returning to the marital home, she did not tell the social worker of a definite plan to do so. Tragically, and against her family’s advice, Angela returned home on the evening of 25th of December 2018. Her husband rang Thames Valley Police the following morning to tell them that he had murdered his wife. Before this inquest took place, a criminal trial and a domestic homicide review had been undertaken. It is important to acknowledge, in relation to the concerns listed below, that the death occurred some five and a half years ago.

Copies sent to

recipients, who have an interest in this matter3. College of Policing

Inquest conclusion

Angela was unlawfully killed. The following Thames Valley Police findings have been admitted:
a. The officers who spoke to Angela on 29th of November 2018 did not recognise that she was reporting the crime of coercive control.
b. The officers who spoke to Angela on 29th of November 2018 did not record the crimes she reported, either of assault or coercive control.
c. The officers who spoke to Angela on 29th of November 2018 accepted that the risk grading on the DOM-5 risk assessment form should have been medium rather than standard.
d. The senior officer who saw Angela on 29th November 2018 accepted that he did not fully review the DOM-5 risk assessment form before signing it.
e. The officers who spoke to Angela on 29th November 2018 did not take information available to them (on the command and control system used then, from a call Angela had made to the police earlier that morning) into account in their assessment of risk. This was despite the call handler identifying domestic violence and coercive control in the course of that 16 minute telephone call.
f. The officers who spoke to Angela on 29th November 2018 did not investigate the crimes Angela reported to them that day. Based on all the evidence heard in court, we the jury conclude that the admitted failings of Thames Valley Police, on the balance of probabilities, did not contribute to Angela’s death.

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links