Jury criticises police over deaths
A pregnant woman and her toddler son were killed in their own home by her mentally ill ex- partner after police failed to reveal she was at high risk of homicide, an inquest jury has found.
Rachael Slack, 38, and her 23-month-old son Auden were found with multiple stab wounds in their home in the picturesque village of Holbrook, Derbyshire, on June 2, 2010.
They were killed by Ms Slack's former partner and Auden's father, 44-year-old Andrew Cairns, who had a history of mental illness.
He was also found dead at Ms Slack's home after turning the knife on himself.
Following a six-week inquest into the deaths at Derby and South Derbyshire Coroner's Court, the family of Ms Slack said they hoped "lessons are learned" that protect the lives of other women and children threatened by domestic violence after jurors found Derbyshire Police failings had contributed to the deaths.
They recorded verdicts of unlawful killing in respect of Ms Slack and Auden, and found that Cairns took his own life.
They were asked as part of their deliberations by coroner Dr Robert Hunter to consider if it was more likely than not that a failure on the part of Derbyshire Constabulary made a more than minimal contribution to the deaths.
In respect of Ms Slack, who was an HR manager, jurors found that: "In part her death was more than minimally contributed to by a failure to impress upon her that she was at high risk of serious injury or homicide from her ex-partner."
Regarding Auden, the jury found that in part his death was more than minimally contributed to by a failure to "impress upon his mother that he was assessed at high risk of serious injury or homicide by his father and by a failure to discuss with his mother adequate steps that could be taken to address the risks to him".
Jurors heard that Cairns, a former golf tutor, had been struggling with declining mental health since the break-up of his relationship with Ms Slack in 2009.
He was first detained by police under the Mental Health Act on May 26, 2010, after Ms Slack drove him to the police station because he refused to get out of her car and she was worried about his behaviour.
He was assessed by mental health workers and released after he was found to have no major mental illness.
The next day he was arrested after threatening to kill Ms Slack but was released on police bail on May 28 after denying the accusations.
During the inquest jurors heard that Cairns, who had been prescribed antidepressants, had been known to psychiatric services for a "considerable number of years'' and had been assisted by a variety of mental health services.
Jurors were told that following his contact with Derbyshire Constabulary, Ms Slack and Auden were deemed as being at high risk of homicide but police officers failed to properly impart that to Ms Slack.
As part of his bail conditions Cairns was told not to contact Ms Slack, and a file was also forwarded to Children's Social Care by Derbyshire Constabulary's domestic abuse unit.
Police visited Ms Slack at her home to discuss the incident and security.
Dr Hunter said he would be using his powers as coroner to write to the Home Secretary, police, and mental health services.
He said he would write to the Home Secretary regarding the powers police have in detaining suspects concerning incidents of a violent or sexual nature and also relating to the training police have in responding to domestic violence.
He said the inquest had heard that if a person is bailed pending police inquires, the police have no real powers to deal with a breach; they can arrest someone but that can result in them being bailed within an hour if not charged.
Dr Hunter said he would "urge" the Home Secretary to look at the law in relation to incidents of a violent or sexual nature and, if necessary, amend legislation.
He also said he would contact the Home Secretary because the inquest had raised issues concerning the "epidemic" of domestic violence within England in which two women on average are killed each week, and that there are no national standards of police training for officers in dealing with such incidents.
He said he would also contact police and mental health services concerning policies and improvements that should be implemented regarding electronic document sharing and mutual disclosure of information between agencies.
Ms Slack's family backed the coroner's recommendations and called for a public inquiry following the deaths.
Speaking outside the coroner's court, they said in statement released through their solicitor Sarah Ricca: "We are very grateful to the coroner and the jury for their work in ensuring that these failings have been brought to light.
"The space that has been left in our lives by the tragic loss of Rachael and Auden will never be filled, and never should be.
"Rachael was a devoted mother, a beautiful and truly caring person with a positive outlook on life.
"We hope that the jury's finding that police failings contributed to the deaths of both Rachael and Auden, and also the various reports to be made by the coroner, will ensure that lessons are learned that could protect the lives of other women and children threatened by domestic violence, a problem that the coroner described today as an epidemic.
"We would also add our voice to the calls Refuge and other families, such as the family of Maria Stubbings, for a public inquiry into state failings in response to domestic violence."
Assistant Chief Constable Karl Smethem, Derbyshire Constabulary, said two reviews had been conducted since the deaths.
"We asked the Independent Police Complaints Commission to consider the contact we had with Rachael prior to her death," he said.
"Additionally, we have contributed to a Serious Case Review which has looked at the actions of all the agencies which were involved in this case, including the Derbyshire mental health services and social services.
"This was carried out by an independent author and the review will be released within the next few weeks.
"I am confident that Derbyshire Constabulary's policies and procedures for the investigation of domestic violence incidents, and for the protection of victims, met national guidelines in 2010.
"From the evidence it is clear that Rachael's report of Andrew Cairns' verbal threat to kill was taken very seriously by the police. We were actively investigating the threat, with a view to charging him, and we did take steps to ensure that Rachael and Auden's home was secure.
"As a result of the two reviews which have taken place and subsequent advancements in national guidelines, we have already developed and improved our domestic violence policies and procedures.
"However we will now review the evidence heard at the inquest, and the jury's findings, to see if any further changes are necessary to ensure that the service we provide to the public of Derbyshire is as good as it can be."
Speaking following the inquest Robert Barlow, who was Ms Slack's partner at the time of her death, said he felt very let down and added: "Policies and structures need to be tightened up and our future children and mothers need more safeguarding from this potential situation arising again."
He and Ms Slack were looking forward to the arrival of their now son, whom he revealed they had intended to call George.
Asked how he had since her death, he said: "I can quite easily sum that up and this is based on how Rachael lived her life.
"It is that I dare to laugh, I dare to love again, and I will proudly carry love in my heart and a smile on my face, and live my life to the fullest as Rachael and Auden and our unborn child would have done."
Professor Steve Trenchard, chief executive of Derbyshire Healthcare NHS Foundation Trust, said: "We would like to extend our sympathies to the family and friends of Rachael, Auden and Andrew for their loss of a loved one in this tragedy.
"We welcome the Coroner's findings that there was no evidence presented over the past six weeks regarding Andrew's care that a jury could properly consider was in breach of Article Two of the European Convention of Human Rights.
"We will assess the jury's conclusions and Coroner's comments in more detail as part of our determination to be always changing, always improving, to meet the needs of the people of Derbyshire we serve.
"Immediately after this incident in 2010, we launched our own investigation into the full circumstances behind it.
"We developed and delivered a far-reaching action plan to improve the quality of our care and take it to new levels of best practice wherever possible."
The family of Cairns said they felt "extreme disappointment" that more was not done by the mental health trust to provide the proper level of care for Cairns and they had been "totally let down."
In a statement they said: "Andrew had mental health issues and was arrested under the Mental Health act only days before.
"Specifically, the family is disappointed that the mental health trust failed to verify background information with family members which it was, as the coroner pointed out , common practice in psychiatric medicine to do so.
"They also failed to make an adequate record of a health act assessment on Andrew against common protocol and failed to adequately co-ordinate the care of Andrew, which included a failure to maintain a co-ordinated set of healthcare records.
"They feel strongly that more could have been done and ultimately Rachael, Andrew, and Auden would all still be here today if all of the concerns raised had been listened to and acted appropriately upon at the time."