A review has found that there were a number of “missed opportunities” to help a pensioner who was a victim of domestic abuse and murdered by her husband.

The 88-year-old woman, identified as Margaret (not her real name), was found dead in her home in February 2017.

Now a combined Domestic Homicide Review (DHR) and Safeguarding Adults Review (SAR) has been published into her death.

This review found that there were a number of “missed opportunities” by various agencies involved in Margaret’s care. Cornwall Council has apologised to Margaret’s family.

The report found that there was a need for increased awareness of domestic abuse among older people.

Margaret, who had been diagnosed with dementia, was discovered in her home by a GP and social worker and found to have multiple injuries which indicated she had been strangled.

Her husband, identified as Donald in the review, was charged with murder but was diagnosed with Alzheimer’s Disease and deemed unfit to stand trial. He was found guilty of murder and committed to a secure hospital. He has since died.

The review found that Margaret and Donald had always been a private couple but had become increasingly isolated and withdrawn.

It found that the couple’s relationship was dominated by Donald but said that this had almost become accepted as “traditional roles within a marriage”.

However the panel felt that some of Donald’s behaviour could be classed as “controlling”. This was indicated by him speaking on behalf of his wife when she was questioned by professionals; his reluctance to allow professionals into the house and his manner when talking to his wife.

The panel found that “professionals were too willing to rationalise Donald’s controlling behaviours and to accept his assurances”.

It also found that there was an element of controlling behaviour which could fall into the description of domestic abuse.

Donald was reluctant to allow professionals to visit him and his wife at home or to allow carers to provide support.

When home visits did take place Donald was reluctant to allow them to speak with Margaret alone which meant there was no opportunity to conduct an individual assessment of her needs or ask questions that she may have responded differently to in private.

The panel felt that the overwhelming focus of professionals had been the health needs of the couple and this meant that social circumstances did not have sufficient prominence.

In the conclusions of the report it states: “The panel has concluded that there were clear signs of neglect in relation to Margaret. There are a number of examples when she was found to be wearing soiled nightwear. On only one occasion did a professional help her to change her garments. There were

also examples of the bed being soiled and of Margaret having bruising and cuts on various parts of her body.

“Although these were noted and formed part of the rationale for raising a safeguarding alert, the panel has concluded that this did not result in any

immediate escalation of concerns or immediate action to mitigate the neglect that was clearly evident. The panel regards this as a significant missed opportunity.”

The panel felt that professionals seemed “to be too willing to adopt an optimistic view about how the couple were coping and to accept the assurances of Donald that he could manage and that he and his wife did not require assistance”.

The report states: “The panel concludes that there were opportunities to act earlier. There was insufficient consideration of removal of Margaret from the home environment, either to hospital or to residential or nursing home care, even if for a short time. Such an action would have reduced risk and allowed for a more thorough assessment of need and risk. The panel concludes that there were missed opportunities to take such pro-active action.”

The panel also highlighted the lack of a domestic abuse policy at the GP surgery.

In its conclusion the panel states: “It is the DHR panel’s overarching conclusion that opportunities to intervene were missed. There was clear evidence of neglect. Although the bruises and cuts that were present on Margaret’s body could have resulted from falls, they may also have been the result of domestic abuse. The panel has concluded that this possibility was not given sufficient prominence in professionals’ thinking.

“The impact of deteriorating mental and physical health on older people can be significant. The desire of older people to maintain their independence, the notion of pride and not wishing to accept help are particularly relevant.

"They are factors that are increasing in prominence as the population ages, people live longer and have to cope and adapt to changes in their physical and mental health. This can undoubtedly lead to them experiencing pressures and stresses that if not addressed can contribute to the occurrence of domestic abuse and violence.

"This is an issue that goes much further than just this case and is a matter that all public services will need to consider and address in relation to the way in which they attempt to support vulnerable people.”

Cornwall Council said that it had accepted the findings of the combined DHR and SAR and apologised to Margaret’s family.

Cornwall Council portfolio holder for adults Rob Rotchell said: “We apologise to Margaret and her family and friends and give them our heartfelt condolences. We recognise the distress that the incident and this subsequent review brings, particularly so long after Margaret’s death.

“This report looks in close detail at the circumstances leading up to Margaret’s death and highlights how organisations which supported her needed to improve to identify and act on serious concerns around domestic abuse, isolation and welfare earlier so that incidents like this could be prevented.

“In the four years since this review started, we have carefully reviewed and learnt fully from its findings and implemented all its recommendations, improving how our health and care professionals share and escalate safeguarding concerns and better equipping them with the skills and expertise to spot the signs of domestic abuse at an early, preventative stage.”

Helen Charlesworth May, joint accountable officer for public health and care for Cornwall Council and NHS Kernow, said: “My deepest apologies go out to Margaret’s family. We would also like to thank them for taking part in the review to help us identify what needed to change locally to prevent domestic abuse.

“This case underlines how older people can become isolated very quickly if their health or social circumstances begin to deteriorate and they are at even greater risk if they are unable to seek help because of their isolation. All our services need to vigilant in identifying the signs of domestic abuse in older people which can be hidden, particularly when additional vulnerabilities such as dementia are present.

“We have worked to significantly increase our health and care practitioners’ understanding of early signs of isolation, domestic abuse, deteriorating physical health or mental health such as dementia, and welfare concerns, so they can take action on any concerns at an early and preventative stage.”

The review had originally been completed in 2019 and Cllr Rotchell said that since then all recommendations from the panel had been implemented.

He said that actions had been taken across the board including the council and NHS.

Cllr Rotchell said that there was now a much better understanding of domestic abuse in the elderly compared to when the incident happened in 2017.

He said that a huge amount of training had been completed at all levels in all agencies to try and improve the situation and reduce risks.

  • If you, or anyone you know, needs help, services are available and continue to run during this time. If you are in immediate danger call 999. The police are still responding to domestic abuse as a priority.

Alternatively, you can contact Safer Futures which offers advice and support to women, men, young people and children impacted by domestic abuse, sexual violence and sexual abuse.

Contact them at saferfutures.org.uk or email saferfutures@firstlight.org.uk or call 0300 777 4777.