Jan 30 2014
The murders of a pregnant woman and her toddler son by her mentally ill ex-partner could not have been "reasonably predicted", a serious case review has found - despite criticisms from an inquest jury and the woman's boyfriend over authority "failures".
Rachael Slack, 38, and her 23-month-old son Auden were found with multiple stab wounds at 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 the house, slumped over her body, after turning the knife on himself.
A jury at an inquest into their deaths last year was critical of police for failing to impress upon Ms Slack that she was at high risk of homicide after she had contact with officers about Cairns's increasingly worrying behaviour.
And Ms Slack's new partner, Robert Barlow, said she "could have been alive today" had police intervened.
But a serious case review by Derby Safeguarding Children Board (DSCB) found that the tragedy could not have been foreseen with information known at the time.
In the months leading up to the deaths, Cairns - who had a history of mental illness dating back to a 1999 suicide attempt - had become increasingly depressed and his behaviour more concerning for family and Ms Slack, who continued to check on him even after their relationship broke down in late 2008.
The DSCB report considered a number of factors, including threats made by Cairns to kill Ms Slack on May 27, 2010, after she told him she was in a new relationship and expecting a baby.
Cairns, a former golf tutor, made the threats hours after being detained by police under the Mental Health Act when Ms Slack had driven 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.
On May 27 he was again arrested after making the threats to kill Ms Slack but released on police bail the next day after denying the accusations.
The serious case review report said that, "taken at face value", the threats Cairns made are believed to have been carried out on June 2.
It went on: "The question is therefore whether the mother's report, in the context of other information available to professionals, provided a basis on which the eventual outcome could have been reasonably predicted. There are a number of factors which suggest that this would not be the case."
The report said Derbyshire Constabulary receives around 150 to 160 reports of threats to kill each year and their analysis identified this case as the "only one of those reports over at least a three-year period which has been followed by enactment of the threat".
Officers had no contact with Ms Slack or Cairns about his mental health issues which "would have effectively discriminated this case from any of the other 'Threats to Kill' reports".
The police were also not made aware of Cairns's behaviour after his release from custody, or that he had been hanging around outside Ms Slack's house after his release.
In addition, the report found mental health professionals did not know about the events of May 27 or those afterwards.
"Only an extremely small number" of individuals who share the characteristics of depressive mental illness and involvement with mental health professionals go on to commit such acts," the report said.
It concluded: "On this basis the review has concluded that no individual or agency could have reasonably predicted that (Cairns) would kill (Auden) and (Ms Slack), thereafter taking his own life, as is believed to have occurred on the morning of 2 June 2010."
Although the killings were not predictable, the report said, the risk assessment carried out after Ms Slack contacted police indicated that Cairns posed a serious risk to her and although she was advised by officers not to have any contact with him she was not convinced of the risk.
The review chimes with comments made by Mr Barlow after the inquest.
He told ITV's Daybreak in October last year: "I wasn't made aware of the (police) risk assessment (into the potential for homicide) and the outcome.
"It would have just underlined the severity of the threats that Andrew had made on Rachael and Auden.
"Without a shadow of a doubt, there is every possibility she could have been alive today."
The report recommends partner agencies work closer and share information when working with mental health clients, and the potential impact on children.
Derbyshire County Council, Derbyshire Constabulary and NHS Derbyshire County should specifically address the application of thresholds for referral and intervention in their review of the multi-agency domestic violence protocol.
Christine Cassell, the safeguarding children board's chairman, said: "Our deepest sympathies are with the family, loved ones and friends who have been devastated by this terrible tragedy.
She added the report "found the deaths could not have been prevented based on the information and means available".
Ms Cassell said the eventual outcome "could not have been predicted", while concluding that although such incidents were "incredibly rare", any such occurrence was "one too many".
Following the report's commissioning, the board also reviewed arrangements for all agencies responding to domestic violence incidents involving children, resulting in the establishment of new multi-agency systems for referral and intervention.
Ms Cassell said: "We will continue to monitor how recommendations from serious case reviews are put in place to make sure they are really making a difference to professional practice."
Derbyshire Police welcomed the report and said it had actioned all the key recommendations set out, including changing how its officers made referrals to social services - now done via a computer system rather than fax, and also adding in questions specifically about any children which might be affected on its domestic violence risk assessments.
The force said a programme of training for officers on using those new processes had been set up and was continuing.
Assistant chief constable Karl Smethem said he had also personally written to the Derbyshire coroner following the inquest to outline the force's current procedures in how it deals with the victims of domestic violence.
He added victim support had been a key area of investment for the force in recent years, pointing out that one in ten of all incidents its officers dealt with were domestic violence-related.
Mr Smethem said: "Each victim is given an information pack.
"If they are believed to be at a high risk they are given a plan and asked to sign a form to show they understand the dangers they may face.
"We have 30 officers dedicated solely to dealing with domestic violence crimes and all police officers play their part in tackling these offences."
Last year the force handled 18,342 domestic violence incidents, with 1,080 deemed high risk - in all those cases none of the perpetrators carried out their threats.
NHS Derbyshire County said it had "fully embraced the lessons learned" from the case, adding it had taken "the strongest action possible" to protect children.
A spokesman said best practice on safeguarding children was a key element of staff training, while the trust had developed better communication between health visitors and GPs about vulnerable children.
The trust has also developed guidance for health workers on domestic violence, and simplified its electronic record-keeping in adult mental health services.
It has also changed its risk assessments for adults with mental health issues, to now take account of the possible impact on any children or other family members.