Domestic abuse victim took her own life after police 'missed opportunities' for protection

A domestic abuse victim took her own life after police missed opportunities to implement protective measures, a Cambridgeshire coroner has found. Kellie Sutton died in August 2017 after taking actions to end her own life.

The 30-year-old was found unconscious at the home she shared with partner Steven Gane in Welwyn Garden City, Hertfordshire, on August 23, 2017, and was treated at the scene by ambulance staff and HEMS. She died at the Lister Hospital after suffering from an irrecoverable brain injury on August 26, 2017.

A jury recorded a short form conclusion of unlawful killing after an inquest in July 2023. They found Ms Sutton took action to end her life after being subjected to months of controlling and coercive behaviour and domestic abuse.

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She met Gane in March 2017 and he moved into her home, where he began to abuse her. On the day of her death, Gane responded to a text from Ms Sutton threatening to kill herself by saying "do everyone a favour".

The PFD report said: "There was extensive and detailed witness evidence gathered by the police for criminal proceedings which demonstrated that Kellie's partner was abusive towards her: both physically violent on at least several occasions and by his controlling and coercive behaviour towards her, which included shouting, threatening, phoning constantly if she was out, isolating her from her family and friends and holding her bank card. She lived in fear of her phone battery dying because if he couldn't get hold of her he would 'go mad' and would become violent."

A neighbour called the police on July 9, 2017, and reported that Ms Sutton was being "beaten up by her partner". Police spoke to Ms Sutton and Gane separately but they both said it was a verbal argument and the matter was closed as a non-crime incident after completing a Domestic Abuse, Stalking, Harassment and Honour Based Violence Assessment (DASH) risk assessment.

The PFD report said: "In a witness statement for the inquest the police accepted, at a senior level, that the response fell below the expected standard in a number of respects, including body worn video capability, the failure to check up on the children and that they showed a lack of professional curiosity and judgment relating to the DASH process and house to house inquiries not being completed." Officers did not speak to the neighbour who called 999.

'Missed opportunities'

The jury found that further investigation or action after that incident could have altered the final outcome in August. They found officers missed opportunities to recognise responses in the risk assessment which led to "a failure to consider implementation of appropriate protective measures".

Gane was convicted of controlling and coercive behaviour in an intimate relationship, one count of assault occasioning actual bodily harm, and one count of common assault. He was jailed for four years and three months.

A prevention of future deaths (PFD) report by Samantha Broadfoot KC, Assistant Coroner for Cambridgeshire and Peterborough, said police had a 'lack of understanding' about coercive and controlling behaviour. It added that there was a lack of awareness of the link between domestic abuse and suicide.

Hertfordshire Police responds to PFD report

T/Assistant Chief Constable Amanda Bell said: "Kellie's death was an absolute tragedy and as a force we have made huge progress to better understand the complexities of coercive behaviour which includes improved officer training and more robust reporting systems. The link between domestic abuse and suicide now features prominently in all our training around sudden deaths. There is now revised guidance for officers attending any report of a sudden death, and this includes looking at the domestic abuse history of the parties because we recognise that this link can exist.

"As a constabulary, our use of digital technology has developed since 2017, enabling our officers to have access to far greater information. At a national level, we have worked with DA Matters who provide training to police forces, and with her family's consent and support we used Kellie's tragic death as a case study to ensure her story continues to educate officers on how they respond to domestic abuse incidents in the future."

She added: "We now also have a civil order team within the Domestic Abuse Investigation and Safeguarding Unit (DAISU), which reviews all domestic abuse reporting and looks for opportunities to proactively use Domestic Violence Protection Orders (DVPOs). There has been new guidance and training for officers and an increased focus in our constabulary's performance meetings. We also encourage use of Clare's Law, which allows the police to release information about any previous history of violence or abuse a person might have. We have a team specifically set-up to focus on providing potential future victims of domestic abuse information to help safeguard them and others, preventing further harm from perpetrators of abuse.

"Following Kellie's inquest, we created a Vulnerability Information Portal. This is an app on officers' phones where they can easily access information about subjects including coercive control, domestic abuse and suicide, plus many other safeguarding matters. It gives them practical advice on how to provide the best service to a victim at the first point of contact.

"We accept the findings of both the jury inquest and the prevention of future deaths report and are due to report back to the coroner in June. We will continue to strive to improve the way we support vulnerable victims, working with partner agencies and other sectors. Throughout the difficult years since Kellie died her family have supported our work and ambition to improve the way we investigate these types of often hidden crimes and they remain in our thoughts."