Luisa Mendes inquest: family says police should have done more

The family of Luisa Mendes who died in Lillington after police failed to respond in time to a call from her saying she had been beaten say they hope lessons will be learned.

Friday, 3rd June 2016, 10:22 am
Updated Friday, 3rd June 2016, 11:27 am
Luisa Mendes.

The inquest into her death, which was concluded yesterday (Thursday) and had been taking place at Warwickshire Justice Centre in Leamington over the past three weeks, heard evidence criticising Warwickshire Police’s response to the incident.

Miss Mendes, 44, who was a vulnerable and homeless alcoholic, was found dead at the home of Christopher Taylor in Briar Close, on October 25 2012.

The night before she died there was a ‘silent 999’ call from the house where Miss Mendes had reported that one of two men in the house had beaten her.

A police call handler subsequently called back and spoke to Mr Taylor and his friend Nicholas White who denied there were any difficulties.

During those conversations Miss Mendes could be heard shouting that she was being beaten. The call handler reassured the men that they would be there within the hour and that they should call back if there were further problems, but no reassurance was given to Miss Mendes.

A domestic homicide review into her death identified significant missed opportunities by the police to intervene and potentially prevent the assault which caused her injuries.

Miss Mendes’ brother, Vitor Mendes, instructed specialist lawyers at Irwin Mitchell to investigate her death to help the family gain answers as to what happened and to find out if more could have been done to prevent the incident.

At the inquest a jury found that Miss Mendes died from a ruptured spleen as a result of deliberate application of force from a third party after the calls from the police.

During the inquest the jury heard how Mr Taylor, an alcoholic himself who was deemed unfit to give evidence at the hearing, had admitted to attacking Miss Mendes on the night before she died.

The Jury also found that the failure to upgrade the emergency call to ‘violent’, an inadequate handover procedure and the errors or omissions of supervision of the police control room also contributed.

An investigation by the Independent Police Complaints Commission (IPCC) and the domestic homicide review have been critical of Warwickshire Police’s response to Miss Mendes’ emergency call.

Witnesses from the police control room during the inquest accepted that the call should have been categorised as ‘violent’ rather than ‘rowdy/nuisance’ and that in any event, because it was graded a ‘priority’, police resources should have been deployed to the property within one hour of the call.

The inquest heard that the inspector and control room supervisor failed to notice that the priority call had not been responded to within the hour.

The Warwickshire Police force call handling guidelines state that where there is a risk or is likely to be a risk of the use of violence or the immediate threat of violence, calls should graded as ‘emergency’ - requiring attendance within 10 minutes if urban or within 20 minutes if rural - rather than ‘priority’ - requiring attendance as soon as possible within one hour.

The IPCC investigation identified that three police staff had cases to answer for gross misconduct following both collective and individual failures.

The evidence showed that there were police resources on 24 October 2012 to deploy to the incident and the IPCC report notes the lack of rationale as to why police resources were not dispatched.

The report notes that Miss Mendes’ previous involvement in incidents of nuisance or rowdy behaviour may have led to them prioritising other calls over this incident.

Nancy Collins, a specialist lawyer at Irwin Mitchell representing Vitor Mendes said: “The family feel strongly that more could and should have been done to help Luisa when she was at her most vulnerable.

“They hope that lessons will be learnt from the inquest and the various investigations to prevent other vulnerable individuals suffering in similar circumstances in future.

“The domestic homicide review in particular flags some important issues in relation to domestic abuse. and the family hopes the Review’s recommendations for domestic violence and abuse policies will be developed and updated on a national level by all agencies involved.”

Vitor Mendes said: “We were all devastated and heart-broken by my sister’s death. We just wanted to find out exactly what happened and why the police didn’t help her when she needed them most.”

***** The domestic homicide review into Miss Mendes’ death was published yesterday (Thursday) by the South Warwickshire Community Safety Partnership (SWCP).

The review is an independent report, in line with Home Office Guidance and looks at the way agencies interacted with Miss Mendes and each other and what lessons can be learned to assist those facing similar situations in the future.

Cllr Michael Coker, spokesperson for the South Warwickshire Community Safety Partnership, said: “The Mendes family have suffered a great loss and we thank those who knew Luisa and contributed to the review at such a difficult time.”

“We believe, at times, agencies dealt with situations at face value and could have done more to understand Luisa’s circumstances.

“Agencies involved in the review fully accept the report’s findings and recommendations, and improvements have already been made.”

Dee Edwards, the independent chairwoman and author of the review, added: “There were many complex factors that contributed to the vulnerable situation Luisa found herself in before her death, including domestic abuse and alcohol misuse, mental health problems and homelessness.

“There is no doubt that Luisa’s vulnerability restricted the life choices available to her and placed her at risk of harm.

“Above all we want this review to help us better support individuals with complex needs and understand the cause of their problems. We would urge anyone who may be experiencing domestic violence and abuse to tell someone and access the support available.”

Actions taken to address the key recommendations include:

•Improved domestic violence policies, procedures and training of professionals. This means front line workers are better able to identify domestic violence and abuse and refer people to specialist support, especially when abuse may be masked by a presenting problem such as substance misuse or antisocial behaviour.

•Warwickshire has signed up to Alcohol Concern’s innovative Blue Light Programme which is designed to reduce alcohol related harm and domestic abuse and violence associated with treatment resistant drinkers.

The programme has been developed in response to learning from Domestic Homicide Reviews nationally.

•Warwickshire County Council has commissioned a domestic abuse training, support and referral programme aimed at GPs. Called IRIS -Identification and Referral to Improve Safety, the programme also provides specialist support workers linked to GP surgeries.

•Agencies in Warwickshire have implemented a MASH - a Multi Agency Safeguarding Hub - to co-locate agencies together and focus on providing a coordinated, consistent approach to safeguarding children and adults. The MASH went live from Tuesday 3 May 2016 to safeguard children and victims of domestic abuse and will be incorporating adults in need with effect from 1 September 2016.

•The multi-agency processes within the Warwickshire MASH ensure multi agency triage of all domestic abuse incidents. The Warwickshire MASH is designed to be for all ages and all vulnerabilities in order to properly identify those individuals and families with complex needs.

•Risk assessment processes have been put in place to identify repeated domestic abuse incidents that on their own are not judged as being high risk, but collectively could be considered high risk and escalate them into a multi agency risk assessment conference, known as a MARAC for a coordinated multi agency response.

•Police contact handlers have received comprehensive national decision model and vulnerability assessment training and exercises aimed at giving them a much heightened awareness, and consistency of response in identifying and supporting vulnerable callers / victims from harm.

•New contact management technology currently being introduced will help police call handlers quickly retrieve relevant details on people, objects, locations and events. This will assist them in considering the broader picture when assessing vulnerability and support decisions around police and partner agency interventions.

•Warwickshire Police has adopted a culture of continuous improvement and of sharing learning at the earliest opportunity to ensure officers and staff provide the best protection possible for those that are most vulnerable. Officers and staff are actively encouraged to use their professional curiosity to look beyond what they see initially to protect people from harm especially that posed to vulnerable children and adults and those with complex needs. Warwickshire Police and West Mercia Police aim to lead the way nationally on recognising and responding to vulnerability.

•Warwick District Council’s homeless strategy which took effect in April 2015 included a number of actions that identify a range of future housing options and alternatives for people with complex needs who become homeless.

In consultation with voluntary and statutory agencies, some of the key actions included the development of a protocol for dealing with council and housing association tenants who are victims of domestic violence and are facing homelessness, developing a mental health protocol and Housing Advice Staff offering housing advice drop in surgeries in other agencies buildings, for example the Salvation Army.

The report makes recommendations for action by Coventry and Warwickshire Partnership NHS Trust, NHS England (West Midlands), The Recovery Partnership, South Warwickshire NHS Foundation Trust, Swanswell, Warwick District Council - Housing, Warwickshire County Council - Social Care and Support, Warwickshire Police, Warwickshire Probation Trust and University Hospital Coventry and Warwickshire.

The full Overview Report, Executive Summary, Action Plan and response letter from the Home Office for this review can be viewed via

Warwickshire’s specialist domestic abuse helpline can be called for free on 0800 408 1552. Lines are open from Monday to Friday 9am to 9pm and on Saturday from 8am to 4pm.

The helpline is closed on Sunday.

In an emergency dial 999.

**** We have been asked to point out that the Christopher Taylor referred to in this story and previous reports on this inquest is not Chris Taylor of St Mary’s Road, Leamington. We apologise for any confusion caused *****