Of the many risk factors identified in the parents’ backgrounds, the most prominent in these reviews is the ongoing risk posed by situations of domestic abuse. This was seen as a factor in cases from all categories of serious and fatal maltreatment. It is now abundantly clear from research that living with domestic abuse is always harmful to children, and it is rightly seen as a form of child maltreatment in its own right (Humphreys and Bradbury-Jones, 2015). Many of the SCRs are populated by multiple reports of domestic abuse incidents or allegations; often in the context of vulnerable mothers with multiple, abusive partners:
“The mother described the child’s father as controlling, jealous and unpredictable and reported instances of domestic abuse and harassment by him. Some of the incidents related to the father’s denial of access to the Child… it is known that both of the mother’s later partners had previously been convicted of domestic abuse related offences against their respective previous partners.”
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Domestic abuse was a feature in nearly all the cases of overt filicide. In some cases this was overt violence, with multiple, often severe episodes of physical violence recorded. However, this was not always present, nor always of a degree sufficient to raise the level of concern attributed by professionals. The cases do, however, demonstrate the concept of coercive control (Stark, 2007). A picture emerged of women living with aggressively controlling men, who would isolate these women, impose restrictions on them, and control many aspects of their lives. The women would behave in ways that highlighted the fear within which they lived, but often would not disclose the abuse they were experiencing from their partners:
“In her contribution to this SCR, the Mother confirmed that it was the Father who accompanied her to the Hospital and that she did not disclose any abuse to the hospital staff. She said that she felt she was a long way from home, felt very vulnerable at this time, the children were not with her in the hospital and she was concerned about how she would get home if she told anyone about the truth of how she received her injuries. She said that the Father was being very controlling at the time and would not leave her on her own.”
The context of coercion and control may present significant barriers to women disclosing either their own or their children’s suffering, particularly in situations where the offending partner is present:
“She could not understand why the hospital staff thought that she and the Father were comfortable in each other’s company, as she felt that there was evidence in their behaviours in the hospital of the tension that existed between them. The Mother confirmed that she was not seen alone apart from a very brief time when having x-rays undertaken.”
This highlights the need for sensitivity in providing opportunities for women to disclose, the need for repeated opportunities and a safe, trusted environment within which women can voice their concerns:
“[The Midwife] asked Mother about domestic abuse and she reported that this was not an issue. Mother has said during this Review process that she does not recall being asked. It is important to continue to ask women who may be wary of telling professionals, for fear of the repercussions for themselves and any children. They may be under scrutiny from a controlling and volatile partner which causes such stress that women are not clear they have been asked. In this case there is no evidence that Mother was ever asked again.”
This control typically continued following separation, often extending to issues around contact with the children. Indeed, in some cases it was restrictions placed on the father’s contact, or the fear of that, that appeared to be the trigger for the fatal incident. In some reviews there was evidence of a lack of recognition of the ongoing vulnerability of abused
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women to coercive behaviour by their partners, ex-partners, or other controlling men, even after separation:
“As a result of Father’s arrest, as far as professionals working with the family were concerned, any concerns regarding risk of domestic violence were therefore effectively eliminated.”
“There was significant evidence, despite [the mother’s] assertions that the relationship had ended, that [the father] remained in contact with her and the children. The daily difficulties that [the mother] faced as an abused and coerced woman and the impact that this would have on her decision making, her self- identity and her ability to protect herself and the children was not understood within a framework of research informed knowledge.”
Domestic abuse was not just an issue in the cases where the perpetrator was the father, but also in at least two of the filicide cases perpetrated by mothers, in both of which the mother also committed suicide. In these cases, it is possible that the isolation, control and fear built up through the ongoing domestic abuse may have contributed to a
vulnerable mother taking her own life and those of her children as the only conceivable escape from her situation.
In accepting the reality of coercive control as the dominant issue in domestic abuse, we have to recognise that it is usually women in a relationship who are the victims of men’s controlling behaviour. However, coercive behaviour may also be exhibited by women on their partners, or, to different extents by both partners in a relationship. An uncritical attribution of control to a male partner may lead to gender bias and a failure to appreciate the full complexity of a relationship. In the following example, a psychiatrist recognised the coercive behaviour of the mother in the context of significant ongoing mental health needs:
“It is significant that this psychiatrist who knew mother better than most identified her as being the aggressor as opposed to her partner.”
There has been considerable progress over recent years in recognising the harm caused to children through all domestic abuse, with systems put in place to enable women to disclose domestic abuse, to identify the risks to children, and to refer and assess cases where there are children in the family. This was evidenced in much of the good practice observed in many of these SCRs, for example in the assessment of the detective constable in one casewhoundertook a further risk assessment following a mother’s decision to retract her statement:
“[The officer’s] assessment is robust and shows a good understanding of the risk factors associated with domestic abuse cases… The officer notes [the mother’s] statement that she did not intend to reconcile with [her partner] but is clear that he doubts this represents the reality. It concludes with a strong recommendation to
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proceed to charging, via the CPS, irrespective of [the mother’s] retraction and the officer also identifies that there are safeguarding implications.”
One of the limitations observed in several serious case reviews, however, was the impact of an incident-focused approach to domestic abuse. Police officers would respond to specific domestic incidents, assess any risks to the children as a consequence of that specific incidence, and act in accordance with that assessment. While relevant to that incident, this approach does not recognise the ongoing controlling nature of domestic abuse, nor the daily reality with which women and children are often living and the harm caused even in the absence of any physical violence, as in the following case:
“The Police in their investigations of the domestic abuse incidents did however give attention to the part that the male partners played in each incident,
sometimes resulting in his arrest for related offences. The purpose of Police
involvement was to resolve the particular incidents as they arose and to ensure no immediate recurrence of violence, (which they generally effectively undertook), rather than to develop a longer term view about the role of the father/male partner in the family.”
Working within an incident-focused model carries the risk of harm to children continuing unabated for long periods of time, and ignores the huge damage that will already have been done to the victims by the time any action is taken. As Stark (2007, p.218)
comments, ‘A growing consensus favours intervention in relationships where there is extreme violence, stalking, or an injury to a child. But by the time abuse reaches this point, coercive control is likely to have severely eroded a woman’s personhood from the inside out, the way carpenter ants devour a house.’ This was demonstrated in the
following case, in which a child, who subsequently died of natural causes, had lived, with his siblings for many years in an environment of ongoing harm:
“However, there were five referrals to children’s social care due to domestic abuse and parental alcohol misuse between 2007 and 2012. The referrals do not appear to have been recognised or responded to as a significant pattern of risk and harm. [The mother] and the children continued to live with the impacts of domestic abuse and [the father’s] alcohol dependency for a further 5 years before the children were made subjects of a child protection plan.”
One of the real difficulties experienced when confronted with situations of possible domestic abuse is how to respond when a woman retracts or refuses to pursue an allegation of abuse. In such situations, the police may have little to proceed with in bringing charges, but may still have serious concerns about the welfare of the woman and any children. The recent introduction of a new offence of controlling or coercive behaviour in intimate or familial relationships in the Serious Crime Act, 2015, should help to move things forward, and needs to become embedded in the thinking and action of professionals in response to domestic abuse.
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Similarly, professionals need to recognise the extreme difficulty for any woman living in a situation of domestic abuse to effect any change, including the difficulties of moving out of a controlling relationship:
“Potentially the health visitor could have given stronger advice about how difficult it is for women to extricate themselves from abusive relationships, and perhaps directed her to receive further advice and support from a more specialist service, such as a Women’s Aid service.”
Often in such situations women may seem to act in ways which, to professionals, may appear inconsistent and potentially harmful, but could be understood very differently when appraised in the light of coercive control. When, for example, a pregnant mother discharged herself from hospital against medical advice and appeared to be acting
against the best interests of her unborn baby, she may actually have been doing her best to protect her older children who were at home in the care of her controlling partner. Given these difficulties, professionals should always be cautious in accepting assurances from a mother that a known violent partner does not present any risks to her children, or that circumstances have changed. While individuals may indeed change, such change is probably the exception rather than the rule, takes time, and may be difficult to have complete assurance about. Women may minimise the risks experienced by themselves and their children in response to threats and coercion from their partner, or as a means of minimising the harm their children may suffer. Furthermore, while a mother may be
correct in believing that her partner would not physically harm her child, this does not acknowledge the severe emotional harm suffered by the children from living in a household where controlling behaviour is the norm, or the potential risks where a
controlling partner does not get his own way. This was highlighted in the following SCR in which there was copious evidence of ongoing domestic abuse:
“[The mother] contacted the community midwife and did disclose domestic abuse in her relationship but claimed that [her partner] was never violent to the children. A referral should have been made to [children’s services] and [the mother’s] assurances that the children were safe should not have been taken at face value. This reflected an inappropriate professional view that domestic abuse was not a child protection issue.”
There was evidence in some of the reviews that professionals continue to attribute blame to mothers for the harm their children suffer, and to place the responsibility for protection on the mother herself, rather than recognising the responsibility of the offending partner:
“[The mother] was reluctant to take out an injunction against [the father] and although [the mother] had attended the Domestic Abuse Freedom Project, her understanding of the impact of domestic abuse on the children’s overall
development and emotional wellbeing was felt to be still questionable as she had continued to allow [the father] to have contact with the children.”
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Learning from these serious case reviews, it is our view that a step-change is required in how we as professionals and as a society understand and respond to domestic abuse. We need to move away from incident-based models of intervention to a deeper
understanding of the ongoing nature of coercive control and its impact on women and children. There is now substantial research to back up such a shift (see for example Holt, 2015; Humphreys and Bradbury-Jones, 2015; Katz, 2015).
As part of this shift, we need to acknowledge that change is hard to achieve in these contexts, and it is likely that ongoing monitoring and support will be needed. In light of this, it is important that professionals take seriously any disclosed abuse, and take responsibility for acting on any disclosures, not leaving it to potentially vulnerable victims to act for their own or their children’s protection.
Similarly, when working with cases in which domestic abuse is a feature, it is essential that the abusive partner is included in the assessment and planning, not leaving the responsibility for protection solely in the hands of the mother. This requires a robust level of challenge to abusive partners to take responsibility for their actions, and where they are not doing so, the recognition that the child will remain at risk.
Learning Points
Domestic abuse is always harmful to children
Any evidence of domestic abuse in a relationship in which there are children should prompt a careful consideration of the harms those children are
suffering and how they can be effectively protected
Domestic abuse should not be seen solely in terms of violent incidents, but consideration should be given to the ongoing contexts of coercive control and the impact of these on the parent and children
Professionals should not rely on victims of domestic abuse to act for their own or their children’s protection
Controlling behaviour may continue to pose risks to mothers and children, even following separation