A murderer had his mother in a headlock as she was on the phone to police to report he was in her home, a shocking report detailing the years-long abuse she suffered at the hands of her son reveals.
While the mother was identified as a "high-risk" victim of domestic abuse since 2017, her son "fell outside existing risk" structures, largely because he was never convicted of assault of a family member, the Domestic Homicide Review states.
The son, a drug addict in and out of prison and with history of abusive behaviour was returned by police to his mother’s home a month before he killed her in March 2021.
The PSNI said it is "taking forward the learning identified within the review," while a senior officer offered her "sincere apology to the families and the loved ones" of the woman, named as 'Ellen' in the report.
The Domestic Homicide Review team was set up under the Department of Justice to see if any lessons can be learned in domestic murder cases.
In her report, former Detective Superintendent Anne Marks concludes there was "no coordinated joined up approach to targeting and intervening" in the harmful behaviours of the victim's son, named as 'Thomas’ in the report.
"He was known to the police, children and adult services, health and addiction services, prisons, health care in prisons, probation, PPS, courts, and housing, but all worked in silos with no overarching plan in place to disrupt and limit his harmful behaviour," Ms Marks finds.
There was no effective coordinated management of his risk and quality assured interventions. He fell outside existing risk management structures, specifically Public Protection Arrangements Northern Ireland (PPANI), largely because he was never convicted of assault within the domestic setting.
But he was on police systems as "a high-risk domestic abuser" since 2017, though the report notes that from youth the man "displayed repeated violent, abusive, coercive, and controlling behaviours towards 'Ellen' and others". He consistently ignored civil orders and bail conditions imposed on him.
Overall, Ms Marks reports, there was "limited understanding by professionals involved in Ellen’s case as to the gravity and impact of child to parent violence".
The PSNI said it is "taking forward the learning identified within the review and already have additional training in place to strengthen officer’s understanding around identifying vulnerability, specifically relating to domestic abuse".
Detective Superintendent Lindsay Fisher said: "We have worked closely with the Department of Justice and other partners involved to review this case thoroughly so that any missed opportunities and areas for improvement can be identified.
“Today, I offer my sincere apology to the families and loved ones of 'Ellen,' who are having to relive such a tragic and traumatic event in their lives. We know any retrospective actions taken will not bring her back.
“We will be taking time as a Police Service, with our partner agencies, to reflect on the further learning from this case and work to put in place more robust information sharing processes and review our internal practices and procedures.
“Too many lose their lives to domestic violence in Northern Ireland. We will work in partnership to improve our response to these crimes so that potential opportunities to safeguard are not missed.”
The reviews details numerous occasions when the man came to the attention of various agencies.
Files were submitted to the Public Prosecution Services (PPS), the majority of which related to breaches of non-molestation orders (NMOs) granted in favour of an extended family member. There were four cases that related to his mother, one of which he was prosecuted for.
"Thomas was committed to prison custody on eight occasions during the period under review," Ms Marks wrote.
She concludes "attending police did not always recognise domestic abuse, resulting in Ellen not being referred to the trauma informed support services provided by Women’s Aid".
One incident, for example, "exemplified professional failure to link ‘other crimes’ in the context of coercive and/or controlling behaviours".
The "high-risk perpetrator of domestic abuse" was able to contact Ellen on numerous occasions from prison custody, nearly 400 times, "as there was no system in place to risk assess the appropriateness of this".
Overall, there was "limited understanding by professionals involved in Ellen’s case as to the gravity and impact of child to parent violence".
Ms Marks cited one example when Ellen telephoned police to report that Thomas was in her home. While on the call, she complained she could not breathe.
A week later she informed an officer that on the evening the incident occurred Thomas had her in a headlock
In terms of other organisations, there are no records the risk posed to Ellen was assessed by prison services when Thomas was released to her address in 2020.
The seriousness was not fully understood by probation services when Ellen contacted their offices to complain that Thomas had turned up at her home, or by the PPS, when, for example, in 2018 no application was made for a restraining order.
For the timeframe under review there were several incidents when offences were disclosed but no investigation took place.
"There were eleven occasions when Thomas was in breach of an non molestation order (NMO) in relation to an extended family member. On four of those occasions no action was taken.
"There were occasions when Thomas was in breach of his bail conditions where no follow-up action was taken."