“The inquest was told that at the time of the allegation of assault in July 2018 suspects…”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

— 1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed ‘on bail with conditions, to protect alleged victims, where further investigation was required. Instead they were placed under investigation. 2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator. | 3. It was unclear where the information that an individual met the | criteria for a serial and serious DA Perpetrator should or did sit in | GMPs systems. Officers giving evidence did not understand how | such information could be accessed or recorded. 4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA | perpetrators and the actions that were required under GMPs. j policy. 5. Evidence at the inquest suggested that the majority of officers | had received very limited training in relation to DA and in | particular coercive and controlling behaviour. Understanding of how coercive and controlling behaviour in a relationship could be identified was limited. 6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited. 7. Recognition of when and how Claire’s Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence. 8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. | 9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases. 10.The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information, 11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP. 412. Information sharing between all of the statutory agencies in | particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. 13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. 14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies. 15. The inquest was told that at the time the MARAT — front line service — was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result ‘Staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie’s death had been shared nationally.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2020-0242

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0