What must change so children are put first in child contact

What must change so children are put

rst in child contact arrangements and

the family courts

Nineteen Child

Homicides

safe child contact saves lives

Women’s Aid is the national charity working to end domestic abuse against women and children.

Over the past 40 years, Women’s Aid has been at the forefront of shaping and coordinating

responses to domestic violence and abuse through practice. We empower survivors by keeping their

voices at the heart of our work, working with and for women and children by listening to them and

responding to their needs. We are a federation of over 220 organisations who provide more than

300 local lifesaving services to women and children across the country.

Please cite this report as:

“Women’s Aid, Nineteen Child Homicides (Bristol: Women’s Aid, 2016)”

For more information about the work of Women’s Aid, please go to www.womensaid.org.uk

Foreword

This report should not need to be written, that much is disturbingly obvious. First,

while it is impossible to prevent every killing of a child, when the risks are known no

other consideration should be more important – yet there is evidence here that other

considerations were rated more highly. Second, starkly similar ndings more than 10

years ago led to the publication of guidance which, if followed, would have made these

killings less likely. Yet here we are.

Nothing in this report should be used to blame individual professionals for the deaths

of these children. Only those who killed them deserve blame. But we have a duty

to the children and their families to identify what more should have been done to

protect them – particularly when guidance on how to do so has been available since

2008, following the publication of Women’s Aid’s previous report on child homicides

and child contact arrangements, a decade ago.

This report shows, that whatever the stated requirements on the family courts, there

is a deeply embedded culture that pushes for contact with fathers at all costs. This is

supported by the testimony to Women’s Aid of mothers who have survived domestic

abuse and the specialist services that support them. The knowledge that severe

abuse has taken place does not stop this relentless push to maintain as close a bond

between father and child as possible. A father who has abused his child(ren)’s mother

is routinely seen as a “good enough” dad. The impact of abuse on the whole family,

particularly persistent, coercive and controlling behaviour which continues after the

relationship has ofcially ended, is routinely misunderstood.

The evidence here is a stark reminder of the dangers of power without accountability:

perpetrators of abuse who have accumulated all power over their partners’ and

children’s lives, and courts which persist in dangerous misunderstandings and

assumptions, effectively colluding in the terrorising – and in some cases serious harm –

of women and children.

We call on Government and the senior judiciary to ensure that no more children die

as a result of a simple failure to follow the guidance that exists. We call on judges to

take responsibility for their own understanding of coercive control, how it works, and

how it affects both women and children. And then, nally, to act on that understanding.

In another ten years, we must not yet again be repeating the same investigation, with

the same ndings. In fact, of course, ten years is far too long.

We must have change now.

Polly Neate, Women’s Aid Chief Executive

Contents

Executive summary 7

Introduction 9

Summary of the 12 cases 15

Key ndings 17

Discussion of key themes 21

Recommendations 35

Conclusion 37

Endnotes 39

Executive summary

Nineteen Child Homicides tells the stories of 19 children who were killed by a parent

who was also a perpetrator of domestic abuse, in circumstances relating to child

contact (formally or informally arranged). Our focus is on children but, in some of

these cases, women were also killed.

The blame for these killings lies with the perpetrators. However, we have concluded

that these cases demonstrate failings that need to be addressed to ensure that the

family courts, Child and Family Courts Advisory and Support Service (Cafcass),

children’s social work and other bodies actively minimise the possibility of further

harm to women and children.

This study reviewed relevant serious case reviews for England and Wales, published

between January 2005 and August 2015 (inclusive). It uncovered details of 19

children in 12 families who were killed by perpetrators of domestic abuse. All of

the perpetrators were men and fathers to the children that they killed. All of the

perpetrators had access to their children through formal or informal child contact

arrangements.

Key themes

Despite some clear progress on the policy framework around child contact and

domestic abuse since the 2004 publication of Women’s Aid report Twenty-nine

Child Homicides, we believe that there are still improvements to be made. Some key

themes emerged from our analysis of the serious case review reports identied for

this study.

These key themes are:

1. The importance of recognising domestic abuse as harm to children.

2. Professional understanding of the power and control dynamics of domestic

abuse.

3. Understanding parental separation as a risk factor.

Twelve families:

• Nineteen children killed.

• Two women killed.

• Two children seriously harmed through attempted murder.

• Seven men dead by suicide after committing child homicide.

Nineteen Child Homicides

4. The way in which statutory agencies interact with families where there is

domestic abuse.

5. Supporting non-abusive parents and challenging abusive parents.

Recommendations

This report makes some clear recommendations for each of these key themes, but

there are two overarching recommendations that the Government, family court

judiciary and Cafcass must urgently act upon:

• Further avoidable child deaths must be prevented by putting children rst

in the family courts - as the legal framework and guidance states.

• There is an urgent need for independent, national oversight into the

implementation of Practice Direction 12J - Child Arrangement and Contact

Orders: Domestic Violence and Harm.

Women’s Aid believes that to prevent further avoidable child deaths, lessons must

be learned from the deaths of these 19 children. This report highlights key failings

that need to be addressed in child contact cases involving domestic abuse.

Family courts, Cafcass, children’s social work and other agencies must work together

to ensure that children and mothers are not at risk of further harm after the

parents have separated.

Introduction

In 2004, Women’s Aid published the Twenty-nine Child Homicides report.

This report detailed the ndings from a review of public documents relating to 13

families where 29 children had been killed by abusive fathers. The killings happened

between 1994 and 2004, and were committed by perpetrators of domestic abuse

in circumstances relating to child contact (informally or formally arranged). Its

ndings prompted a review of judicial practice and the issuing of a new Practice

Direction

12J on prioritising the safety of children and non-abusive parents in child

contact decisions in the family courts.

Despite some positive advancements, in terms of the policy framework in relation

to domestic abuse and contact applications, Women’s Aid frequently hears from

survivors and domestic abuse services about unsafe child contact arrangements.

Both groups urged us to launch a campaign to ensure that children are put at

the heart of the family courts. This report therefore forms part of a wider public

campaign Women’s Aid is conducting to improve the safety of child contact in cases

where there is, or has been, domestic abuse.

As part of our Child First: safe child contact saves lives campaign, Women’s

Aid has conducted an investigation into cases where children had been killed by a

perpetrator of domestic abuse during, or as a result of, unsafe child contact since

the publication of our 2004 report. Our review covers the period January 2005

to August 2015 (inclusive) in England and Wales. We found serious case review

reports about 19 children, in 12 families, who had been killed in circumstances

relating to child contact by a father who was a perpetrator of domestic abuse.

Our report examines the circumstances in which these abusive fathers were given

access to their children (either through informal arrangements or by arrangements

made in court). We investigate what lessons can be learned for government policy

and for agencies working with families where one parent is abusive, including the

family court judiciary and Cafcass.

We want to make it clear from the start that, although this report examines the

role of statutory and voluntary agencies and lessons that can be learned in child

The key recommendations from this report:

• Further avoidable child deaths must be prevented by putting

children rst in the family courts - as the legal framework and

guidance states.

• There is an urgent need for independent, national oversight into

the implementation of Practice Direction 12J - Child Arrangements and

Contact Order: Domestic Violence and Harm.

Nineteen Child Homicides

safeguarding, the culpability for these child homicides lies squarely with the abusive

fathers who killed their children.

Women’s Aid recognises the importance of safe child contact, when it is proved to

be in the best interests of the child(ren) and where the arrangements for contact

prioritise the child(ren)’s safety and wellbeing. In all cases of alleged domestic abuse

there must be robust and effective assessment by experts of the implications for the

child’s and the non-abusive parent’s safety and wellbeing.

Women’s Aid is concerned that the publication of this report should avoid causing

further distress to the families involved in these cases. Therefore, we have removed

any identifying data, such as serious case review report titles, publication and crime

dates, the gender and ages of individual children, place names or people’s names

(although the latter are usually already redacted in public serious case review

reports). However, we are happy to make these data available to the Government

for their condential use. We have attached a ‘Case Number’ to each serious

case review to help structure our research and report-writing. These numbers are

randomly assigned and do not relate to the chronology of the reports.

Progress since publication of Twenty-nine Child Homicides

(2004)

2004 Women’s Aid’s 2004 report gave details of 29 children in 13 families who

were killed between 1994 and 2004 in England and Wales.

2005

Her Majesty’s Inspectorate of Courts Administration report on Cafcass

and the court service handling of domestic violence cases highlighted the

problems caused by the emphasis on the presumption of contact rather

than the protection of the child.

2006 Lord Justice Wall

presented a report to the President of the Family

Division in response to Twenty-nine Child Homicides. His report focused

on the ve cases described in the report where the family courts were

involved

2007 The Family Justice Council published a report to the President of

the Family Division which discussed both the Twenty-Nine Child

Homicides report and the response from Lord Justice Wall. This report

recommended a ‘cultural change’ in judicial practice in terms of moving

away from a presumption of ‘contact is best’ to a culture of “contact that is

safe and positive for the child is always the appropriate way forward.”

The Family Justice Council called for a Practice Direction to be issued

reecting recent case law on best practice and clarifying the court’s

approach to contact where there are allegations of domestic abuse.

Nineteen Child Homicides

2008 The President of the Family Division issued Practice Direction 12J Child

Arrangements and Contact Order: Domestic Violence and Harm (rst issued

in May 2008, later amended) which states that:

“The family court presumes that the involvement of a parent in a child’s life

will further the child’s welfare, so long as the parent can be involved in a way

that does not put the child or other parent at risk of suffering harm.”

2014 Practice Direction 12J is substantially revised. It now contains a wider

denition of domestic abuse that emphasises coercive control; it directs

courts to consider a range of ways in which domestic abuse may be

evidenced. It requires courts to ensure that, where domestic abuse has

occurred, any child arrangements order protect the safety and wellbeing of

the child and the parent with care and is in the best interests of the child.

Despite the progress that has been made, there are still very clear barriers to women

and children survivors of domestic abuse accessing safe contact through the family

courts.

The ‘pro-contact’ approach taken by the family justice system has seemingly

overtaken the need for any contact orders to put the child’s best interests rst.

The paradox highlighted by survivors of domestic abuse that a parent can be seen

as a violent perpetrator of domestic abuse and a good enough father plays out

often in the family courts and “neglects the safety needs of children and women, and

the impact on them of previous or continuing domestic violence”

. As the results

of this study show, the presumption that contact is always benecial for children,

unless explicitly proven otherwise, is harmful and has contributed to the tragic cases

discussed here.

The cultural assumption in the family justice system that contact with both parents

is the most benecial outcome for a child is perpetuated by a public conception

of the family courts as being biased against fathers applying for contact. There is

no evidence to suggest this is the case. Research shows that the majority of non-

resident parents achieve the type of contact and the amount of contact they

seek. One study of 203 child contact orders found that there was only one order

prohibiting any contact, and only 3% of contact orders were for supervised visiting.

Two recent major changes to the family justice system compound the barriers often

faced by survivors of domestic abuse and the increasingly complex and arduous

routes to safe child contact.

The rst is the Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO)

which has severely curtailed eligibility for legal aid in private family law cases.

Although legal aid is available for court proceedings where a party can produce

specied evidence of domestic abuse (referred to as the Domestic Violence

Gateway), there are many cases in which the necessary evidence under the

Domestic Violence Gateway is either unavailable or unobtainable

, so that victims of

Nineteen Child Homicides

domestic abuse disputing contact are forced to become Litigants in Persons (LIPs).

As a consequence, survivors nd themselves being cross-examined by the

perpetrator of domestic abuse, or by the perpetrator’s barrister, and they may also

have to cross-examine the perpetrator themselves. This leaves women in a very

vulnerable position where they may not be able to have access to a fair hearing.

Research by Rights of Women, Women’s Aid and Welsh Women’s Aid found that:

• 38% of women responding to a survey who had experienced or were

experiencing domestic violence did not have the prescribed forms of

evidence to access family law legal aid.

• 26% of these went on to represent themselves at court.

The second change is the Children and Families Act 2014 which also introduced

three key changes in family law:

1. Presumption of parental involvement

There is now a presumption enshrined in law that children should have

ongoing involvement with both parents following separation so long as this

does not put the child at risk of suffering harm. This may have the effect

of strengthening the courts’ emphasis on enabling contact and minimising

perceptions of risk.

2. Child arrangement orders

Contact and residence orders have now been replaced with child arrangement

orders.

3. Mediation Information and Assessment Meetings (MIAMs)

The requirement to attend a MIAM before entering the family justice system

is now statutory except where domestic violence has been alleged in the

last 12 months. The introduction of MIAMs has meant that many women feel

obliged to take part in mediation before a family court case, or instead of

going to court for a hearing. Although mediation could be dangerous where

a relationship has been abusive, research has demonstrated that family courts

may nonetheless direct parties to attend mediation assessment prior to

commencing proceedings, with the result that cases involving domestic abuse

may be mediated inappropriately.

Exclusion from compulsory MIAMs due to

domestic abuse has the same evidence criteria as legal aid, which means many

women will be forced into mediation with their perpetrator unless they can

produce specic forms of evidence.

There has been much progress in the policy, practice and framework of child

contact in domestic abuse cases since the publication of Twenty-nine Child Homicides

in 2004. However, Women’s Aid has signicant concerns about the experiences of

survivors of domestic abuse and their children in the family courts and through

child contact with a perpetrator of domestic abuse. Survivors and their children

Nineteen Child Homicides

frequently report to Women’s Aid, and to organisations in our federation of services,

that they feel re-victimised and traumatised through the family court and child

contact process. Increasingly, since the enshrinement of the presumption of parental

involvement in legislation, there are growing concerns amongst some practitioners

and academics that the courts are prioritising contact with an abusive parent over

the safety of the child and non-abusive parent.

Methodology

In this study Women’s Aid aimed to identify those cases where a child had been

killed by a perpetrator of domestic abuse in circumstances relating to child contact

(formally or informally arranged). In reviewing the relevant serious case reviews, we

aimed to identify the key issues around enabling safe child contact. This included

exploring the courts’ and other statutory agencies’ roles in minimising the risk of

further harm to adult and child survivors of domestic abuse.

Our study is an exploratory one involving the review of published serious case review

reports. Serious case reviews are undertaken by Local Safeguarding Children Boards

when abuse or neglect of a child is known or suspected, and either the child has died

or has been seriously harmed. We know that a signicant proportion of serious case

reviews involve domestic abuse: a study of 139 overview reports from serious case

reviews found that about two-thirds (63%) of cases featured domestic abuse.

Data collection and analysis

We used the online search engine in the NSPCC National Case Review

Repository

to identify reports relevant to our research. Our review period was

January 2005 until August 2015 (inclusive). This period relates to the dates when

the reports were published, rather than the dates of the homicides. We used the

following search terms to nd relevant reports:

• “Domestic Abuse”

• “Partner Violence”

• “Domestic Violence”

• “Family Violence”

• “CAFCASS”.

We then read the synopses of the Case Reviews identied by this search, and

identied 29 cases that were possibly relevant to our study. We obtained the serious

case review reports for these 29 results either from the NSPCC Library or by

requesting them from the relevant Children’s Safeguarding Boards. We also included

in our study one recent review that had not been identied in the initial online

search, but we had been alerted to its publication by a news story. We then read all

30 reports to identify which were relevant to our study. Our criteria for relevance

were that the serious case review related to a case from England or Wales in which:

• a child had been killed

Nineteen Child Homicides

• the perpetrator was the child’s parent and had perpetrated domestic abuse against the

other parent

• the parents were separated and child contact had been arranged informally or formally.

After applying these criteria, 12 out of the 30 reports were found to be relevant.

We did not apply any exclusion criteria regarding the gender of the perpetrator of domestic

abuse. However, in all of the relevant cases (12 families) it was the father who was the

perpetrator.

Limitations of the methodology

Our study is limited in that we only have access to public, redacted documents. In eight cases we

only had access to executive summaries and some of these contained little detail.

It should also be noted that serious case review panels do not have access to family court

records and it is not their role to review court proceedings, although they do work with and

receive information from Cafcass where the family courts are involved.

It is possible that there may have been some relevant cases that were not revealed by the search

terms used or that there were some very recent serious case review reports not yet in the

NSPCC repository.

In recognising the limitations of our research, we call for further detailed investigation of the

issues highlighted in our ndings which will require better data collection and monitoring of cases

of domestic abuse in the family courts.

Summary of the 12 cases

Case One Executive Summary

Two children killed.

Children killed by father during weekend

contact visit.

Father found guilty of their murder.

Court-ordered shared residence with the

consent of both parents.

Case Two Overview Report

Two children killed.

Children were killed by the father they lived

with (arranged through the family court).

Father then committed suicide.

Contact with the mother was at the

discretion of the father.

Suggestion that the killer may have wanted

to kill the mother too.

Case Three Overview Report

Two children killed.

Children killed by their father during a

contact visit.

Father committed suicide.

Contact with father agreed as part of a

Non-Molestation Order and Occupation

Order.

Case Four Executive Summary

One child killed.

Child was killed by father.

Father committed suicide.

Interim arrangements had been made in

family court for child to live with father.

Case Five Executive Summary

Two children killed.

Killed by their father during overnight

contact. Father committed suicide.

Contact with father arranged in the family

court.

Father also attempted (unsuccessfully) to

harm or kill step-son and mother.

Case Six Executive Summary

One child killed.

Killed by their father during a weekend stay.

One further child seriously harmed

(attempted murder) by their father.

Father was on bail at time of the killing for

charges of sexual assault against the mother.

Father convicted of murder and attempted

murder.

Contact was informally arranged.

Twelve families:

• Nineteen children killed.

• Two women killed.

• Two children seriously harmed through attempted murder.

• Seven men dead by suicide after committing child homicide.

Nineteen Child Homicides

Case Seven Executive Summary

Two children killed.

Mother of children killed.

All killed by father of children.

Father committed suicide.

Children thought to have had informal

contact with father (not clear whether the

killing happened during a contact visit).

Case Eight Executive Summary

One child killed and one child seriously

harmed (attempted murder).

Father attempted suicide.

Father convicted of murder and attempted

murder.

The children were resident with their

mother and had contact with the father –

arranged through the family court.

Case Nine Executive Summary

One child killed.

Child killed by father.

Child lived with mother, contact with father

possibly arranged though court (not clear in

SCR report).

Father possibly committed suicide (not clear

in SCR report).

The Coroner’s Court recorded an open

verdict.

Case Ten Overview Report

Two children killed.

Killed by father during a contact visit.

Father committed suicide.

Children were living with mother and

grandparent, father had interim arrangement

(made in family court) for contact twice a

week.

Case Eleven Executive Summary

Two children killed.

Children killed by father during a contact

visit.

Father committed suicide.

Contact informally arranged.

Case Twelve Overview Report

One child killed.

Mother of child killed.

Both killed by the father of the child.

Child resident with mother and had contact

with father.

Father found guilty of their murders.

Father seriously injured – not clear if this

was self-inicted.

One child (from the mother’s previous

relationship) managed to escape from scene

of crime.

Mother had applied to family court for a

residence order, it is not clear what contact

arrangement were currently in place and

whether these were arranged in court.

Key ndings

Our review uncovered details of 19 children in 12 families killed by perpetrators

of domestic abuse in circumstances relating to child contact (informally or formally

arranged). In addition, two other children were seriously physically harmed at the

time of these homicides, and two women were killed. These homicides took place

in England and Wales and were described in serious case review reports published

between January 2005 and August 2015 (inclusive). All of the perpetrators were

men and fathers to the children they killed.

• There were 28 deaths in 12 families: 19 children and two mothers were

killed; seven fathers committed suicide.

• 19 children in 12 families were killed by perpetrators of domestic abuse

who had access to their children through formal or informal child contact

arrangements.

• All 12 fathers were known to statutory agencies as perpetrators of domestic

abuse. Eleven of the 12 fathers were known to the police as perpetrators of

domestic abuse – in the one remaining case, the report is not clear about

whether the police had been involved.

• Two more children were seriously physically harmed (attempted murder) -

plus one attempt at serious harm of a child was averted, and another child

escaped the scene of the killing, avoiding physical harm.

• Two mothers were also killed by the father of their children. One of these

mothers had been assessed by the police at “standard” (upgraded to

“medium”) and “high” risk at different times; the other mother was assessed

at “standard” or “moderate” risk at various points.

• The children’s ages ranged from just over one year to 14 years (the age of

children is not given for three of the 19 children).

• In two cases, it is suggested that the father may have tried (unsuccessfully) to

lure the mother to a location to kill or seriously harm her.

• Seven perpetrators committed suicide. In addition, there was one attempted

suicide and another case where the perpetrator appears to have committed

suicide, but this is not made clear in the serious case review report.

• For 12 children (in seven families) of the 19 children killed, contact with the

perpetrator (their father) was arranged in court. This might also be true

for two more of the children killed; however, this is unclear in the published

serious case review reports. For six families, this contact was arranged in

family court hearings (two of these were interim orders) and for one family,

contact was decided as part of the arrangements for a Non-molestation

Order and Occupation Order.

Nineteen Child Homicides

• A welfare report is known to have been undertaken relating to four children

(in two families) of the 12 children where the contact had been arranged in

court. In one additional family (two children involved), a welfare report was in

the process of being prepared.

• In two families the father was granted overnight contact, and in an additional

two families the father was granted a residence order (one of these was an

interim order). All of these fathers were known perpetrators of domestic

abuse.

• Nine of the 12 perpetrators are known to have committed domestic abuse

after separating from the child(ren)’s mother. In addition, for one of the

perpetrators, information about post-separation abuse is unclear in the

report. For two of the perpetrators, no information is given about whether

there was any abuse after separation.

• The types of abuse committed after separation included harassment and

threats via letter, telephone and text message; attempted strangulation; sexual

assault; threats to abduct children and actual abduction, which are indicators

of high risk perpetrator behaviour. In one case, the father had made threats

by telephone while in prison for offences that included violence against the

mother; he was subsequently granted a residence order concerning his

children by the court.

• Seven of the 12 perpetrators were known to have mental health problems.

• Four of the 12 perpetrators were known or suspected to have problematic

alcohol or drug use.

• Three of the mothers are described as having mental health problems; in the

remaining reports the mental health of the mother is not mentioned or is not

clear.

• Two of the mothers were known to have problematic alcohol use.

Excluded reports

Amongst the excluded reports there are three reports that seemed signicant to

the central themes in our study but did not meet our review criteria:

1. One report details the case of a mother, who had reported experiencing

domestic abuse, and is presumed to have killed her child. The child was due

to live with the father who had been granted a residence order by the court.

This case was excluded from our study as the presumed killer had reported

experiencing domestic abuse and we were looking for cases where the killer

was a perpetrator of domestic abuse.

2. One report was excluded as it did not relate to contact arrangements.

However, it was strongly related to domestic abuse as the father concerned

(a perpetrator of domestic abuse) had killed his two children after the

mother had left the family home to escape the domestic abuse.

Nineteen Child Homicides

3. One report gave details of a case where a child was removed from the care

of a disabled mother from birth by the local authority, and after a time in

foster care was subsequently placed in the care of the father. This report

was excluded from our study because the child had not been killed and

the case did not involve child contact arrangements between the parents;

the child had never been in its mother’s care. The father had a history of

committing domestic abuse and there had been allegations that he had

committed sexual abuse against a minor. Injuries to the child were discovered

and the child was subsequently removed from the father’s care. The father

received a community sentence for neglect.

Discussion of key themes

Our discussion of the ndings centres around ve themes:

1. the importance of recognising domestic abuse as harm to children;

2. professional understanding of the power and control dynamics of domestic

abuse;

3. understanding parental separation as a risk factor;

4. the way in which statutory agencies interact with families where there is

domestic abuse; and,

5. supporting non-abusive parents and challenging abusive parents.

We are particularly interested in the lessons learned in these serious case reviews

and what insight they provide about how to improve the safety of children and

domestic abuse survivors after separation from abusive partners, including in cases

where the family courts are involved.

Since May 2008, the family courts and Cafcass have been guided by Practice

Direction 12J to “ensure that where violence or abuse is admitted or proven, that

any child arrangements order in place protects the safety and wellbeing of the child

and the parent with whom the child is living, and does not expose them to the

risk of further harm.”

In reviewing those cases where child contact was arranged

through the courts

iii

, we especially considered how risk from domestic abuse was

assessed, what efforts had been made to minimise the “risk of further harm” and

what opportunities and barriers there had been to achieving this goal.

1. The importance of recognising domestic abuse as harm

to children

The impact of domestic abuse on children

The perpetration of domestic abuse in families where there are children constitutes

harm to children, even when the children are not directly physically harmed by the

perpetrator. An Expert Court Report about child contact and domestic abuse

released in 2000 clearly states that:

“…important opportunities were missed to assess the specic level of risk

to the children, particularly during the court proceedings…” (Case One)

“Domestic violence involves a very serious and signicant failure in

parenting – failure to protect the child’s carer and failure to protect

the child emotionally (and in some cases physically – which meets any

denition of child abuse).

The Adoption and Children Act 2002 (section 120) extended the legal denition of

“harm” as stated in the Children Act 1989, to include “impairment suffered from

seeing or hearing the ill treatment of another.” This came into force in January 2005.

There is also evidence of the frequent co-existence of domestic abuse and abuse

directly against a child. One study found that 34.4% of under-18s who had lived with

domestic violence had also been abused or neglected by a parent or guardian.

A study of 139 overview reports from serious case reviews found that about two-

thirds (63%) of cases featured domestic abuse.

Statutory agencies, domestic abuse and child safeguarding

A common theme in the serious case review reports we reviewed was the lack

of consideration of how domestic abuse could pose a specic risk to children.

Children’s specic experiences of domestic abuse and the impact on their safety,

health and mental wellbeing were not often directly assessed or addressed.

One report states that:

Often, assessing and managing the risk to the children was dealt with in an

inadequate way. For instance, in one case, a statutory service posted a letter to the

non-abusive parent to explain the risk of domestic abuse to children. Three of the

reports we reviewed particularly highlighted the lack of direct social work with

the children, despite statutory agencies knowing about the domestic abuse being

perpetrated by their fathers.

One serious case review report notes that:

Family courts, domestic abuse and child safeguarding

Lord Justice Wall’s comments in 2006, in response to the publication of Twenty-nine

Child Homicides, continue to be pertinent today:

“There was some very good recording about the two subject children by

some professionals but no direct work was undertaken with the children

to understand, for example, the impact of domestic violence incidents or

their parent’s separation.” (Case Seven)

“…children were not seen and spoken to on their own by anyone from

the statutory agencies until they were seen by Cafcass in [date given]. At

that point the conict surrounding the parents’ relationship breakdown

and the contact between the children and father had been going on for a

year.” (Case Eight)

“It is, in my view, high time that the Family Justice System abandoned any

reliance on the proposition that a man can have a history of violence to

the mother of his children but, nonetheless, be a good father.”

In the cases we reviewed where contact was arranged through the courts, abuse of

the mother was often seen as a separate issue from the child’s safety and wellbeing,

rather than the two being intrinsically linked. Indeed, the mothers themselves were

often quoted as also believing that the abusive father would never harm his children.

A study published in 2014 (which comprised an analysis of case law and in-depth

interviews with barristers, solicitors and family court advisers employed by Cafcass)

found that most professionals and judicial ofcers continue to endorse a message

of ‘contact at all costs’ after Practice Direction 12J was issued. It also found that

domestic abuse that was not very recent and did not involve severe physical

violence was often being discounted as irrelevant to the contact arrangements. The

study concluded that:

In our review, we found that an abusive parent was often able to successfully

present himself to the court or to children’s social work professionals as a good

father, and be granted unsupervised access to his children or even be granted a

residence order.

This happened even when the father had perpetrated abuse after

separation; even when there had been criminal sanctions for his violence or ongoing

criminal proceedings for violence; even when he had made threats to kill the

children in the past and even when, in one case, the mother said in her application

to the court that the father had previously told her that “he had nothing to live for

and intended to commit suicide” and that “he can understand fathers killing their

children”. (Case Ten)

In one case, the review authors pointed out that no agency had regarded

unsupervised contact with the father as posing a risk to the children, despite the fact

that the father was on bail for charges of sexual assault against the mother at the

time of the killing. (Case Six)

Another report stated that the:

This shows a common and concerning perception: that a father who has

perpetrated domestic abuse need not be seen as a bad parent, or as having the

potential to commit ongoing violence and harassment - including using the family

courts and child contact as a vehicle to continue this abuse.

Concerns about this perception were also expressed by Lord Justice Wall in

“If we are to achieve the ‘cultural shift’ called for by the Family Justice

Council, we need to acknowledge properly that ‘the family’ is not always

a safe haven but a place where abuse can occur.”

“…father was seen either, as a ‘bad person’ abusing his partner and

involved in drug-use, or, a ‘good man’ who was working hard to care for

his children. In reality, he was both, and the risks associated with his

former actions needed to be fully assessed.” (Case Two)

Nineteen Child Homicides

his 2006 report to the President of the Family Division (cited previously) and

subsequently in remarks he made to the Hertfordshire Family Forum in 2007:

A recent study of family court proceedings also warns against the faulty thinking that

abusive behaviour can be separated from parenting ability in any assessment of risk:

One of the serious case review reports in our research notes that one of the social

workers involved refused to meet the father at his home because of “…concerns

expressed about his behaviour…”(Case Ten). Yet subsequently, the father was

granted an interim order by the court which meant that his children met with him

alone twice a week.

Conversely, women are often seen as being ‘implacably hostile’ by family court

professionals when they are raising concerns about contact. Research suggests that

mothers generally want their child(ren) to have contact with their fathers as long as

this contact is safe and in the best interests of their child(ren), and when they raise

concerns about contact it is because they have well-founded fears around abduction

or violence.

Children’s voices

The extent to which the children’s views were ascertained for the court is not

always made clear in the reporting in the serious case reviews.

In one case, the Cafcass Ofcer had only interviewed one of two child siblings

before they were killed (while an interim order was in place). In the same case,

someone from Children’s Social Care met with the children only once, and

the children disclosed that their father emotionally abused them and that they

were afraid of him. This information was given to the family court and the court

subsequently made an interim order for the father to have unsupervised contact

with his children twice a week.

In two cases, the serious case reviews suggested that there may have been too

much weight given to the children’s wishes to see their fathers without sufcient

assessment of the risk to their welfare and safety. A careful balance needs to be

made between listening to children’s wishes and their accounts of their experiences,

while not expecting them to weigh up the risks themselves or to manage their own

safety and wellbeing.

“…we should continue to promote the message that it is not possible at

one and the same time to be guilty of serious violence to your partner

and to hold yourself out as a good parent.”

“We have seen that the parameters of what constitutes the ‘safe family

man’ are expanding to include increasingly abusive, ‘dangerous’ fathers,

a process that may be exacerbated by the presumption of parental

involvement.”

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One report noted:

Recommendations:

• The Government and senior leaders in the family courts and Cafcass need to

take action to bring about cultural change within the family court system to

ensure that the safety and wellbeing of child(ren) and non-abusive parents are

understood and consistently prioritised.

• Children should always be listened to and their safety must always be at the

heart of any child contact decision made by the family court judges.

• Children’s experiences of domestic abuse and its impact on them should always

be fully considered by the family court judiciary with an acknowledgment that

post-separation abuse is commonly experienced by non-abusive parents.

• The Ministry of Justice must ensure that all family courts including judges

and involved statutory agencies are aware of and fully implement Practice

Direction 12J.

• The Government needs to urgently review whether the current workings of

the family courts are upholding the human rights of children and non-abusive

parents and whether the family courts are fullling the State’s obligations under

Article 2 (The right to life) and Article 3 (No torture, inhuman or degrading

treatment) of the Human Rights Act 1998 and Article 31 (Custody, visitation

rights and safety) of the Council of Europe Convention on Preventing and

Combating Violence Against Women and Domestic Violence.

2. Professional understanding of the power and control

dynamics of domestic abuse

Recognising a pattern of coercive control

Key to understanding domestic abuse is understanding power and control and its

manifestations in an abusive intimate relationship. Coercive controlling behaviour

in an intimate relationship has been described as “the entrapment of women in

personal life”

and deliberately restricting a woman’s “space for action”

A new offence of “controlling or coercive behaviour in an intimate or family

relationship” was introduced in the Serious Crime Act 2015 and came into force

“Both of the children wanted to see their father and stay for

weekends… Neither had fears or concerns about this. Their wishes and

feelings in relation to contact were in fact given too much weight in

comparison to other factors that they could not understand, given their

age and level of development.” (Case One)

“The father showed a pattern of jealous, controlling behaviour which

persisted after the separation…” (Case One)

Nineteen Child Homicides

in December 2015. The Act describes the offence as happening between two

people who are personally connected when one person knowingly “repeatedly or

continuously engages in behaviour towards another person (B) that is controlling

or coercive” and “the behaviour has a serious effect on B”

. Women may also

experience violent and controlling behaviour from multiple family members.

A survey of women using specialist BMER (Black, Minority Ethnic and Refugee)

domestic abuse services found that in 27% of 75 cases (of women not living in

refuge) there had been post-separation harassment and violence from the extended

family.

It is signicant that in many of the serious case review reports we examined the

perpetrator is described in terms that indicate coercive control; for example as

“controlling”, “a bully”, “jealous” or “intimidating”. In one of the serious case reviews

we examined, the Cafcass Ofcer said she felt intimidated by the father who she

described as “agitated, unreasonable, intimidating, controlling and aggressive” and

refused to meet on her own with him again (Case Ten).

Ongoing coercive control appears to be a signicant feature of the domestic

abuse in many of the cases. There were many examples in the serious case reviews

of efforts by perpetrators to control and coerce the mother (before and after

separation) including:

• isolating them from support (in one case the perpetrator stopped visits by a

Home-Start volunteer to the mother)

• patterns of jealous behaviour

• monitoring of/obsession with the mother’s private life

• coercing the mother into agreeing to child contact

• threats to harm the mother or “make her life hell”

• threats to harm children

• threats to abduct children or actual abduction

• very frequent communications after separation, for example “constantly texting”

• threats to commit suicide

• not letting the mother see professionals on her own (e.g. being with her when

she saw health professionals about injuries he had caused)

Conversely, there often seemed to be a dominant focus by statutory agencies on

individual incidents rather than a recognition of patterns of abusive and controlling

behaviour:

“The assessment of risk to the children [date given] by the police was

not robust enough as it dealt with the risk in an episodic way rather

than take a longer view of the elements of risk.” (Case Eight)

Nineteen Child Homicides

Sometimes the absence (or absence of disclosure) of obvious physical injuries

meant that agencies were not alerted to the nature of the relationship, for instance

one report noted that there was:

A recent study of how domestic abuse is dealt with in the family courts also noted a

failure to identify seemingly minor incidents as part of ongoing patterns of signicant

and highly dangerous controlling behaviour, and a failure to understand domestic

abuse as gendered power imbalance:

There are increasing concerns around survivors of domestic abuse having to

represent themselves in the family courts as Litigants In Person (LIPs).

Allowing

a perpetrator of domestic abuse who is controlling, bullying and intimidating to

question their victim when in the family court regarding child arrangement orders is

a clear disregard for the impact of domestic abuse, and offers perpetrators of abuse

another opportunity to wield power and control.

Inadequate assessment of risk of domestic abuse was raised as an issue in the

serious case reviews. In one case, there was no risk assessment carried out by

Cafcass before an interim order for residence with the father was made. The father

killed the child before a risk assessment and permanent contact arrangements were

completed. Understanding of the nature and impact of domestic abuse, and the

importance of an adequate and expert risk assessment are vital in order to establish

what is in the best interests of the child.

Identifying who holds the power

The gender of the perpetrator was male in all of the cases examined and this is

signicant. Domestic abuse is deeply rooted in gender inequality and oppressive

social constructions of the family, and of femininity and masculinity. The domestic

abuse is often described in the reports we read in terms of being a characteristic

of the relationship between the parents, rather than the abuse of one person

against another in an intimate relationship setting. By labelling these relationships

“…his attempts to contact Mother were seen as a one-off incident rather

than a course of events which would have led to an arrest.” (Case Seven)

“…aggressive behaviour and violence between the parents, although

there is never any referral to any agency of physical violence to the

children by the adults or any reported physical injuries to mother.”

(Case Eight)

“Domestic violence that is considered to be ‘minor’ or ‘petty’ and/or is

designated as ‘old’ or ‘historical’ is not thought to be relevant to contact

because courts and professionals fail to contextualise it within the

gendered power and control dynamics of domestic violence.”

Nineteen Child Homicides

in vague, euphemistic terms the agency of the abuse is fudged. For example, in the

reports we read domestic abuse is variously described as “conictual” (Case Two),

“violence between the parents” (Case Eight), “parental disharmony” (Case Nine),

“tempestuous relationship” (Case Twelve), “Relationships between the parents were

acrimonious” (Case Nine) and “parental discord”(Case Nine).

This failure to identify who holds the power and control is a major barrier in

assessing and addressing the safety of the child(ren) and non-abusive parent. It is

also a barrier to understanding why the non-abusive parent may sometimes seem

‘uncooperative’ or ‘not engaging’ or may agree to contact arrangements despite

safety concerns. In one report the mother had told a social worker that unless she

allowed the father to have custody he would “hound” her (Case Two). Another

mother had told a social worker that she felt “bullied by [father] around contact and

agreed to it when she did not want to.”(Case Ten) She also agreed to court ordered

contact with the father as her legal representative had advised her that “…the court

was unlikely to agree to father having no contact…” (Case Ten). In another case, it

was reported in the serious case review that a relative of the mother (after she was

killed) said that there had been ongoing contact between the mother, children and

the father, “... although he believes the mother was coerced into this.” (Case Seven)

The mother in this case had told some agencies that there was no contact between

her and the father.

Post-separation violence and control

There was also a lack of understanding by agencies of how violence and control

might continue or escalate after separation (see the following section for further

discussion about this) and that pursuing child contact might be a means of enacting

this continuing control. In this light, a father killing his children can be seen as the

ultimate enactment of power-wielding, rather than ‘losing it’ in a temporary loss of

control. One report commented that by giving the father residence and discretion

over how the mother saw her children, the court was perhaps reinforcing his

continuing control over the mother:

Recommendations:

• All members of the family court judiciary and Cafcass should have specialist

training to understand the dynamics of domestic abuse and be able to recognise

coercive control.

• The Ministry of Justice and family court judiciary should ensure that survivors

of domestic abuse representing themselves in court as LIPs will not be

questioned by their abuser, or in turn have to question their abuser.

“…the recommendation to the court that father should manage the

contact with the children was problematic. At best this arrangement

meant there was on-going direct contact between two individuals who

repeatedly showed that they had difculty maintaining appropriate

boundaries. At worst it was enabling father who had previously abused

his partner for [number given] years to have signicant power over her.”

(Case Two)

Nineteen Child Homicides

3. Understanding parental separation as a risk factor

The point at which a survivor leaves an abusive partner is a signicantly dangerous

time for her and her children. 76% (16 out of 21) of homicides by a partner or

ex-partner reviewed in a 2003 report involved separation.

A recent study with

domestic abuse service-users in London found that 88% of women (out of 72

women) had experienced some form of post-separation abuse.

Analysis of serious case reviews in a report published by the Government in 2012

highlighted parental separation as a signicant risk factor in terms of harm to

children:

Perceptions of separation and ongoing risk

In the cases we reviewed, agencies often mistook parental separation as equating

to an end of the abuse and a reduction in risk for the mother and child(ren). In fact,

the risk continued or increased after separation. The faulty thinking in interpreting

separation as a protective factor was pointed out in several of the serious case

reviews:

“…those involved thought the separation had reduced the risks to the

child.” (Case Nine)

“This [parental separation] may be a context within which children are

at risk of suffering signicant harm, particularly where the separation is

coupled with ongoing domestic violence or controlling behaviour; where

there are conicts around contact arrangements; or where children are

caught in the midst of acrimonious separations. Domestic violence featured

prominently in these cases, and it was clear in several cases that the

impact on children did not stop when the parents separated, often with

ongoing threats or controlling behaviour affecting both the mother and her

children. Some of these cases highlighted that acrimonious separations

can present direct risks to children’s safety and welfare, including risks of

homicide.”

“There was consideration that the child might be at risk of physical abuse,

but this was discounted as the parents had separated. Wide ranging multi-

agency understanding of the continued impact of the parental discord

following separation was not fully recognised.” (Case Nine)

“…the system [storage of risk assessment information] is predicated

upon “incident” and not “information” – a fact that is relevant to this case

because the impending separation of [father] from his child (caused by

[mother’s] application to court) was a piece of “information” that should

have heightened the awareness of practitioners to her vulnerability, and

should have been seen as the “change in circumstances” that increased her

risk from “medium” to “high”. (Case Twelve)

Nineteen Child Homicides

In our review, we found plenty of evidence of continuing abuse after separation and

sometimes escalating abuse. One report described:

Nine of the 12 perpetrators are known to have committed domestic abuse

after separation from the child(ren)’s mother. For the other three perpetrators,

information about post-separation abuse is unclear or not given. In one case the

father had made threats by telephone while in prison for offences that included

violence against the mother and was charged with malicious communication; he was

subsequently granted a residence order for his children’s care by the family court

(Case Two).

Child contact with the perpetrator often means that women can never completely

and safely separate from their abusive ex-partner. In two of the reports the mother

was also killed by the father. In two additional reports, there are suggestions that

the father may have tried (unsuccessfully) to lure the mother to a location in order

to seriously harm or kill her. In one report the mother had successfully managed to

break free from an abusive partner by going to live in a domestic abuse refuge and

she had established a new life with her children, but her ex-partner found a route

back into her life and her children’s lives by applying for child contact through the

family court. Child contact arrangements gave the perpetrator further opportunities

to perpetrate violence and ultimately kill his two children. (Case One)

Recommendation:

• All members of the family court judiciary and Cafcass should have specialist

training to understand the dynamics of domestic abuse and be able to recognise

coercive control, and the tactics used by abusive fathers to use child contact as

a means to further abuse their ex-partner.

“In addition, all agencies were reassured by the understanding that the

parents had separated, not taking account of known research which

suggests separation may indicate increased risk.” (Case Seven)

“The signicance of parental separation as a risk factor, particularly where

there is known controlling behaviour and/or domestic violence is not well

understood or integrated into assessment frameworks.” (Case Eleven)

“A comprehensive assessment of the risks posed to the child by

the parental discord after separation of the parents was never fully

completed because those involved thought the separation had reduced

the risks to the child.” (Case Nine)

“…a history of sporadic domestic abuse call outs over a long period of

time, which intensify when the relationship ends...” (Case Eight)

Nineteen Child Homicides

4. The way in which statutory agencies interact with families

where there is domestic abuse

Who knew about the abuse?

In all of the 12 families some statutory agencies were aware of the abuse being

perpetrated. In 11 of the 12 families the police knew about the domestic abuse,

sometimes responding to multiple incidents. In the one remaining family it is unclear

whether the police had been involved.

Health services also had signicant knowledge of the abuse – either because of

presentation by the mother with physical injuries indicative of abuse, or because of

disclosure by the mother or father of mental health difculties. In six families it is

clear that health services (including GP practices, Accident and Emergency services,

midwives and health visitors) knew about or had seen evidence of the abuse.

However, healthcare professionals did not always share this with other agencies

(such as the police or social care) or enquire about suspicious injuries. Nor did

they always ask about the impact on the children in the family or instigate child

protection procedures.

As previously noted, the connection between domestic abuse against a parent and

harm to children is a signicant one, but this was not always recognised by agencies

who knew about the abuse. Several reports conclude that parenting ability was not

sufciently assessed by key agencies, or indeed was not considered at all.

One report sums up this lack of attention on the impact on the children in the

following way:

Information sharing

Several reports comment on problems with information sharing that led to Cafcass

and the family courts not having the full picture of the domestic abuse. One report

particularly notes that information was not sought from health professionals, which

would have revealed the mental health problems of both parents, and the father’s

problematic alcohol use.

“The interaction of the different issues was not recognised by the agencies

as the inter agency collaboration was limited ...” (Case Eight)

“The learning identied for health organisations includes the need for

greater enquiry about domestic abuse and to consider its impact upon

children within the family.” (Case Three)

“In their decision making and actions the agencies involved focused

on their immediate remit and provided services to the adults without

considering them in their roles as parents and their abilities to meet their

children’s needs.” (Case Eight)

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Comments on information sharing from other reports include:

Another report highlighted that Cafcass had not recognised the case as one where

domestic abuse was relevant and Practice Direction 12J should have been followed.

This is despite the mother having been in a domestic abuse refuge with her children

and previous police and healthcare agencies’ knowledge of the abuse. (Case One)

There are also problems noted about information sharing between statutory

agencies such as the police, social care, schools, health professionals and some ‘silo

working’ where agencies involved did not link up to create a full picture of the

family life of the children. Two reports particularly note the problems involved in

information sharing across local authority boundaries.

Recommendations:

• There must be improved communication and information sharing between

the family courts and statutory agencies, including the police, health services,

social care and schools.

• There must be better information sharing between statutory agencies about

domestic abuse that includes a focus on the risks to children.

• Statutory agencies must enquire about any children affected by domestic abuse

when they receive a disclosure or evidence of abuse and pass information on

to relevant child and adult support and protection agencies.

• Statutory agency professionals, such as social workers, police ofcers, GPs,

nurses and teachers, should receive specialist training and ongoing professional

development on domestic abuse.

“The concerns of the case conference [child protection conference] were

never directly communicated to CAFCASS, the Court Welfare Service.”

(Case Nine)

“Cafcass system for checking information with other agencies, unless

otherwise stated in a court order, is with the police, Children’s Social Care

Services and schools. If the children are not yet of school age checks are

undertaken with Health. The experience of this Review is that consideration

should be given to checking older children and their parents with their GP

practice in relation to ongoing mental health treatment and substance

misuse in cases of disputed contact.” (Case Eight)

“There should have been more communication and information sharing

between Cafcass and Children’s Social Care.” (Case Ten)

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5. Supporting non-abusive parents and challenging abusive

parents

Support for mothers

In some of the reports the mother had received support from specialist domestic

abuse services. However, in many of the serious case reviews it is unclear whether

the survivor had been offered or referred to any specialist support, even when

the abuse she was experiencing was known to the police or social care. We know

that three of the mothers are described as having mental health problems; in the

remaining reports the subject of maternal mental health is not covered, or is unclear.

These mental health issues are likely to be have been as a result of or exacerbated

by the domestic abuse.

In two cases the mother was contacted in an unsafe way by social care who posted

a letter that could easily have been intercepted by the perpetrator and provoked a

violent backlash. In one case, a letter was sent by social care about domestic abuse

to the same woman on ve different occasions. Not only is this an unsafe way to

offer support, it is unlikely that a woman experiencing domestic abuse will engage

with support being offered in this impersonal way. In one of these two cases, the

letter sent to the mother included an explanation about how domestic abuse

posed a risk for children, yet there is no mention of any such communication to the

perpetrator of the domestic abuse.

In the one case where the mother and children had been resident in a domestic

abuse refuge, their time in this specialist service is described as a time of “respite

and consolidation”. The report author remarks that:

Victim-blaming

Victim-blaming is sadly a common theme in the serious case reviews, with statutory

agencies sometimes putting the onus on the non-abusive parent to protect their

children and/or end the abuse (by ending the relationship), rather than focusing on

the actions of the abusive parent and holding them to account.

One report notes that social workers had concerns about the mother’s “…abuse of

alcohol and her choice of partners” (Case Two). There doesn’t seem to have been

sufcient consideration that her alcohol abuse might have been a coping mechanism

she employed because of her experiences of domestic abuse. Nor does there

seem to have been sufcient consideration that concerns should have focused on

challenging the violence of her abusive partner and providing support for her, rather

than on the implied criticism of her choices.

“…at no point did any agency challenge his behaviour or make him

aware of the impact of his behaviour on the children.” (Case Six)

“During this time [in a refuge service] the mother was able to rebuild her

condence as a person and as a parent and the children lived calmer,

safer lives.” (Case One)

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Two reports particularly note the absence of focus on holding the father to account

and on challenging his behaviour:

Another report notes that there is no record of the father being asked about

domestic abuse in his safeguarding interview with Cafcass despite allegations from the

mother about his controlling behaviour.

Black and minority ethnic women may face additional barriers in escaping domestic

abuse and accessing support. In one case, the report authors note that the mother

(who had grown up in another country) risked losing community contacts and

support in reporting the abuse.

Support for mental health, drugs and alcohol issues

We found evidence of the “toxic trio” (identied by Brandon et al, 2012,

their analysis of serious case reviews), namely domestic abuse co-existing with

alcohol/drug abuse and mental health problems and the particular danger this

constitutes for children. Seven of the 12 perpetrators were known to have mental

health problems; two of these were granted a residence order. Four of the 12

perpetrators were known or suspected to have issues with problematic alcohol or

drug use.

Recommendations:

• The Ministry of Justice and family court judiciary should ensure there is

improved communication between the family courts and criminal courts.

• Family courts must ensure there is better access for survivors of domestic

abuse to special measures for their protection during hearings.

• Family court judiciary should ensure there is no unsupervised contact for a

parent who is awaiting trial for domestic abuse related offences or where

there are ongoing criminal proceedings for domestic abuse.

“After father came out of prison [for offences including violence against

the mother] he appears to have quickly established himself in the minds

of professionals as a reformed character and the professional memory of

his previous behaviour as witnessed by his criminal record was not given

sufcient weight…” (Case Two)

“…there was no formal assessment of [Father] and the knowledge of

his self-reported concerns was not shared across agencies. He was not

provided with any opportunity to change and when he nally met with the

social worker to try and get contact with his children, he was advised to

seek legal advice.” (Case Seven)

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Recommendations

The key recommendations from this report:

• Further avoidable child deaths must be prevented by putting

children rst in the family courts - as the legal framework and

guidance states.

• There is an urgent need for independent, national oversight into

the implementation of Practice Direction 12J - Child Arrangements and

Contact Order: Domestic Violence and Harm.

1. The importance of recognising domestic abuse as harm to children

• The Government and senior leaders in the family courts and Cafcass need to

take action to bring about cultural change within the family court system to

ensure that the safety and wellbeing of child(ren) and non-abusive parents are

understood and consistently prioritised.

• Children should always be listened to and their safety must always be at the

heart of any child contact decision made by the family court judges.

• Children’s experiences of domestic abuse and its impact on them should always

be fully considered by the family court judiciary with an acknowledgment that

post-separation abuse is commonly experienced by non-abusive parents.

• The Ministry of Justice must ensure that all family courts including judges

and involved statutory agencies are aware of and fully implement Practice

Direction 12J.

• The Government needs to urgently review whether the current workings of

the family courts are upholding the human rights of children and non-abusive

parents and whether the family courts are fullling the State’s obligations under

Article 2 (The right to life) and Article 3 (No torture, inhuman or degrading

treatment) of the Human Rights Act 1998 and Article 31 (Custody, visitation

rights and safety) of the Council of Europe Convention on Preventing and

Combating Violence Against Women and Domestic Violence

2. Professional understanding of the power and control dynamics of

domestic abuse and 3. Understanding parental separation as a risk

factor

• All members of the family court judiciary and Cafcass should have specialist

training to understand the dynamics of domestic abuse and be able to

recognise coercive control.

• The Ministry of Justice and family court judiciary should ensure that survivors

of domestic abuse representing themselves in court as LIPs will not be

questioned by their abuser, or in turn have to question their abuser.

4. The way in which statutory agencies interact with families where

there is domestic abuse

• There must be improved communication and information sharing between

the family courts and statutory agencies, including the police, health services,

social care and schools.

• There must be better information sharing between statutory agencies about

domestic abuse that includes a focus on the risks to children.

• Statutory agencies must enquire about any children affected by domestic abuse

when they receive a disclosure or evidence of abuse and pass information on

to relevant child and adult support and protection agencies.

• Statutory agency professionals, such as social workers, police ofcers, GPs,

nurses and teachers, should receive specialist training and ongoing professional

development on domestic abuse.

5. Supporting non-abusive parents and challenging abusive parents

• The Ministry of Justice and family court judiciary should ensure there is

improved communication between the family courts and criminal courts.

• Family courts must ensure there is better access for survivors of domestic

abuse to special measures for their protection during hearings.

• Family court judiciary should ensure there is no unsupervised contact for a

parent who is awaiting trial for domestic abuse related offences or where

there are ongoing criminal proceedings for domestic abuse.

Further investigation

• There must be further detailed investigation of the issues highlighted in our

ndings which will require better data collection and monitoring of cases of

domestic abuse in the family courts.

• The Ministry of Justice must set up a process for independent, national

oversight, with a clear reporting mechanism, into the implementation of

Practice Direction 12J and into the handling and outcomes of family court

cases involving domestic abuse.

• The Ministry of Justice and Local Safeguarding Children Boards must ensure

that serious case review reports have a consistent approach and the impact

of the recommendations made must be evaluated to ensure we are learning

lessons from these tragic cases.

Conclusion

In order to prevent further avoidable child deaths, it is essential that the lessons

are learned from the deaths of these 19 children and two women, and that real

progress is made. There are clear ways forward for the family court judiciary,

Ministry of Justice and other relevant agencies to ensure that the same mistakes are

not repeated and we see no further avoidable child deaths in circumstances relating

to unsafe child contact.

Responsibility for the deaths of the 19 children and two women identied in this

report lies squarely with the abusive fathers who killed their children. However, we

have concluded that there are failings that need to be addressed to ensure that

the family court judiciary, the Ministry of Justice, Cafcass, children’s social work and

other bodies are minimising the possibility of further harm to women and children.

In those cases involving the family courts, the child contact arrangements made

contributed to the circumstances in which these children and women were killed.

In the cases we reviewed, the link between the perpetration of domestic abuse and

poor parenting seemed seldom to be made by statutory agencies, including Cafcass

and the judiciary. A man could be seen as a dangerous perpetrator of domestic abuse,

but this was not seen as negating his ability to be an adequate or even good father.

The long-term physical and emotional wellbeing impact that domestic abuse has

on children, as well as possible behavioural and developmental impacts, is well

documented

. However, the serious case reviews considered here suggest that

there was often limited understanding of this by professionals working in statutory

agencies, and this impact was not routinely fully considered in the making of legal

arrangements for child contact. This must addressed through specialist domestic

abuse training for the family court judiciary and statutory agencies. A good

understanding of the power and control dynamics of domestic abuse is critical in

assessing safe child contact.

Our study highlights the family courts’ and other statutory agencies’ limited or lack

of understanding of the gendered nature of domestic abuse, the pervasive nature

of coercive control, and that child contact is often used by perpetrators of domestic

abuse as a vehicle to continue abuse after separation. In these 12 families, there

were signicant missed opportunities to protect and support women and children

in abusive relationships. With a new criminal offence of controlling and coercive

behaviour that came into force in December 2015, there is an even more pressing

need for family courts to understand the nature and impact of coercive control in

domestic abuse.

We conclude that, in cases involving a perpetrator of domestic abuse, the family

courts need to challenge the existing ‘contact at all costs’

culture in order to

always put the child rst. Unless this happens, the family courts will continue to

enable circumstances that can ultimately cost the lives of the children they are set

up to serve, and sometimes their mothers’ lives too.

Endnotes

Notes

(i)

At the time of this response Lord Justice Wall was a Lord Justice Appeal, he

was subsequently the President of the Family Division and Head of Family Justice,

England and Wales.

(ii)

For one of these children (who died whilst in the father’s care) the Coroner’s

Court recorded an open verdict. For this case there is only an executive summary

available, containing little detail; however the document does reference evidence

on ‘licide-suicide’ suggesting that the report’s authors regarded this as a case of

a father killing himself and his child. This is never made completely clear, however.

(Case Nine) For three other cases (where the father had committed suicide) the

inquest into the deaths was ongoing or it was unclear whether it had yet concluded.

However, all three of these serious case reviews reports indicated that the father

was presumed to have killed the child(ren).

(iii)

Not all of the cases reviewed were post-May 2008 (when the Practice Direction

was issued) but we thought it was useful to consider the issue of the courts’ and

Cafcass’ role in the minimisation of further harm for all cases.

(iv)

It should be noted that one of the mothers (who was ultimately killed alongside

her children) had previously been “convicted of the injuries caused to the half-

sibling” (a half-sibling to the children who were killed). This child was removed from

her care, later returned and then went to live with the birth father (a different father

to the father who killed two younger children). (Case Seven)

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Nineteen Child Homicides - What must change so children are put rst in child contact arrangements and the family courts

Women’s Aid Federation of England,

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