1.1 On 18November 2003, at the family home of Old Hallowes in the village of Hermitage in West Berkshire, Alan Pemberton shot and killed William, his seventeen year old son and Julia, his wife from whom he was separated, and then himself. Julia had told Alan in September 2002 that because of his emotional and psychological abuse she wanted their marriage to end.
1.2 This document is the report of a domestic homicide review set up by West Berkshire Council on behalf of the West Berkshire Safer Communities Partnership. The review has been conducted by an independent panel convened for the purpose with terms of reference described in chapter two. The report concerns the events that occurred during the period between September 2002 and November 2003; the actions of agencies and individual professionals; and the response of agencies and professionals to Julia and William‘s family following the deaths. It contains the panel‘s findings and conclusions and the learning we (the panel) have identified together with recommendations to improve services for victims of domestic violence and their children.
1.3 We have considered the actions of the three agencies: Thames Valley Police (TVP), Berkshire West Primary Care Trust (BWPCT) and West Berkshire Council (WBC). We also reviewed the involvement of William‘s school, the Pemberton family‘s GP as an independent contractor within the NHS; the private consultant psychiatrist who saw Alan Pemberton; and we met with the Coroner who conducted the Inquest into the deaths on 28 and 29 September 2004.
1.4 Thames Valley Police1 is the largest non-metropolitan force in England and Wales, covering 2,200 square miles and serving a population of 2.1 million. It covers 16 crime and disorder reduction partnerships (CDRPs), within the areas of two county councils (Oxfordshire and Buckinghamshire) and seven unitary authorities; including the unitary authority of West Berkshire.
1 Thames Valley Police official website September 2008
1.5 Prior to September 2005 West Berkshire was one of ten basic command units (BCUs).
Following a restructuring initiative by Thames Valley Police entitled Challenge and Change the ten were reduced to five BCUs. West Berkshire BCU merged with the BCUs of Reading and Wokingham to form Berkshire West BCU spanning three local authority areas (Local Police Areas) whose boundaries are coterminous with those of the Crime and Disorder Reduction Partnerships. Berkshire West BCU has a population of approximately 437,500 of which the population for West Berkshire Local Police Area is approximately 139,328. The BCU has its own dedicated Public Protection Unit (PPU) which includes Domestic Violence and Child Abuse Investigation Units.
1.6 Thames Valley Police have approximately 4,165 police officers, 3,150 police staff, 250 special constables and 500 police community support officers and some 500 volunteers.
The chief officer team comprises the Chief Constable, the Deputy Chief Constable, Assistant Chief Constable Local Policing, Assistant Chief Constable Operational Support, Assistant Chief Constable Specialist Operations and the Director of Resources. 2
1.7 The PCT in the period covered by this review was the Newbury and Community Primary Care Trust, established in 2001. It served a population of 106,500 residents, covering an area of 200 square miles around west, north and southern Berkshire. Berkshire West Primary Care Trust (BWPCT) was formed on 1 October 2006, from the merger of Newbury and Community Primary Care Trust with Reading and Wokingham Primary Care Trusts.
1.8 West Berkshire Council is a unitary authority. It was created in April 1998 when the former Newbury District Council took on responsibilities from Berkshire County Council, which was abolished. The council provides services for children and young people, community services including housing, environment and public protection.
1.9 The deaths of Julia and William Pemberton have had a significant impact on the lives and well being of the family and friends who remain; they were left with questions about what they or others might have done differently that could have predicted or prevented the deaths of Julia and William and Alan‘s suicide.
1.10 This review owes its existence to the persistence and determination of the family and friends of Julia and William, their local Members of Parliament, the Attorney General, Baroness Scotland and the willingness of the then Chief Constable of Thames Valley Police to voluntarily participate in the first domestic homicide review in line with section 9 (although not enacted) of the Domestic Violence, Crime and Victims Act 2004.3 We believe each of the interested parties took part in the hope that any learning might help prevent the deaths of future victims of domestic violence.
Background to the commissioning of the review
1.11 The West Berkshire Safer Communities Partnership Strategy Group took part in the Review at the request of the Home Office. On 6 June 2005 all parties to the West Berkshire Safer Communities Partnership (WBSCP) agreed a proposal to commission a domestic violence homicide review on the terms set out in papers presented to the WBSCP by the then Deputy Chief Constable (DCC) for Thames Valley Police.
1.12 The review was to be conducted in line with section 9 of the Domestic Violence, Crime and Victims Act 2004, though this was not yet in force, „with a view to identifying the lessons to be learned from the death.‟4
1.13 The review process was to be proportionate and sensitive to the facts of the case, the issues raised and the concerns expressed by family members and others.
1.14 The WBSCP prepared Terms of Reference and appointed Verita, a consultancy specialising in the management and conduct of investigations, reviews and inquiries in public sector organisations, to conduct the review. Brian Parrott a former Director of Social Services and at the time a Director of Verita was appointed to chair the review. Jim Gamble a Deputy Chief Constable and the lead for Domestic Violence for the Association of Chief Police Officers (ACPO) and Christine Mann as the Department of Health‘s National Domestic Violence Coordinator were appointed as expert advisers and members of the review panel.
3 See Chapter 12 – paragraph 12.152
4 Domestic Violence, Crime and Victims Act 2004: Section 9
1.15 Initial meetings were held by the chair of WBSCP, the chair of the review and members of the family. There were a number of issues upon which it was not possible to reach agreement between the parties. These included the process for appointment of the review chair; contact/communication between the prospective review chair and the agencies whose involvement was to be reviewed; the focus of the review and proposed review process and the family involvement in that process.
1.16 An agreement could also not be reached between the Partnership and the family with regard to the Terms of Reference or the independence of the members of the panel.
1.17 In the family‘s view, the state‘s obligations to institute an investigation pursuant to Article 25 of the European Convention on Human Rights would not be fulfilled by the proposed review. This was in the context of the Inquest, which had taken place on 28 and 29 September 2004, which had been the narrower form of Inquest.6 In October 2005 the family made application to the High Court to have the decision to commence the review on 1 October quashed and for an order to be made requiring the Partnership to set up and organise an enquiry after consultation with the family.
1.18 In his judgement on 31July 2006, Lord Justice (LJ) Moses stated that the family had expressly declined to have Article 2 considered at the Inquest. He went on to say that it had been open to the family to challenge the conduct of the Inquest by way of a judicial review.
They had not done this within the required three months and that this ‗crucially undermined the application to the High Court‟.
1.19 He stated that the important questions raised by the family concerning what had or should have been done by those to whom Julia had expressed her fears including the police
5 Article 2 RIGHT TO LIFE Human Rights Act 1998 Chapter 42
1. Everyone‘s right to life shall be protected by law. No one shall be deprived of his life
intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary:
(a) in defence of any person from unlawful violence;
(b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained;
(c) in action lawfully taken for the purpose of quelling a riot or insurrection.
would be considered by the review. He went on to consider the family‘s objections to the terms of reference including the independence of the membership of the panel; and what the family perceived to be their lack of involvement in the review. In summary LJ Moses rejected the family‘s views concerning the lack of independence of the members of the panel and concluded that the terms of reference provided for the involvement of the family. He noted with regard to the matter of Article 2:
„…in my view the review, in combination with the inquest, which has already taken place, will fulfil any obligation, which may exist under Article 2 upon the State to initiate an inquiry.‟7
1.20 In October 2006 following confirmation of the judgement the WBSCP made arrangements to re-start the review. They appointed Verita to recommence the review and Mary Walker, an associate of Verita, replaced Brian Parrott as chair. She is an experienced reviewer who has contributed formerly to a wide range of service inspections, case reviews and inquiries.
1.21 Although in the interim Jim Gamble had been appointed as the Chief Executive of (The Child Exploitation and Online Protection (CEOP) Centre he agreed to continue with his commitment to the review. Christine Mann was a member of the newly constituted panel from October 2006 until the end of March 2007.
1.22 On January 25 2007 following consultation with members of the family the final terms of reference (see chapter 2 and appendix A) were agreed by WBSCP. Following consultation with members of WBSCP on the 23 January 2007, the WBSCP chair wrote on 30 January to the family solicitor and to the chair of the review panel confirming that the treatment of the bereaved family would be included in the review.
1.23 Following Christine Mann‘s resignation from the panel in March 2007 prior to her retirement from the Department of Health, it was not until September 2007 that the WBSCP was able to appoint her replacement to the panel. Christine Mann had been funded by the
7 Transcript of Judgement LJ Moses 31 July 2006 paragraph 29.
Department of Health and the delay was associated with WBSCP identifying funding for her replacement. That delay has contributed to the overall time required to complete the review.
1.24 Margaret McGlade was appointed to the panel in September 2007. Formerly a Director of Social Services she was the lead on domestic violence for the Association of Directors of Social Services.
1.25 For the expert members of the panel, the demands in time and commitment arising from the review have had to compete with the responsibilities of their full time occupations.
In this regard the availability of panel members has had a direct bearing on the timescale required to complete the review.
1.26 The Pemberton case is complex in terms of the individual circumstances of the incidents, the nature and scope of the concerns raised by the family about agency responses before and after the deaths and the length of time, almost five years, since the deaths. The circumstances that preceded both the commissioning of the review prior to the implementation of the national policy on homicide reviews and those that led to the Judicial Review by Lord Justice Moses have also contributed to its complexity.8 We consider that the Pemberton review should be regarded as an exception to the model set out in the Draft Guidance9 rather than as a template for future Domestic Homicide Reviews.
1.27 In preliminary discussions between the chair and representatives of the Home Office and the chair of WBSCP the term ‗light touch‟10 was used to describe the nature and scope the Pemberton review. We do not consider this description is appropriate in the context of domestic homicide reviews.
1.28 The review has been funded by the Home Office and the agencies represented on the WBSCP Sub Group; Thames Valley Police, Berkshire West Primary Care Trust and West Berkshire Council. Following confirmation of the terms of reference from the WBSCP chair we
8 See Chapter 12
9 Guidance for Domestic Homicide Reviews under the Domestic Violence, Crime and Victims Act 2004.
Home Office Consultation Document June 2006
10 On 17 March 2005 an Adjournment Debate took place in the House of Commons concerning the murder of Julia and William Pemberton - the term ‗light touch investigations‟ was used by Paul Goggins MP to describe the proposed domestic homicide reviews
commenced work in February 2007 for completion in May 2007. It was quickly apparent that this timescale was not consistent with the process required to meet the scope and requirements of the terms of reference nor in the context of the previous challenge to the review process. As noted previously the timescale for the review has also been affected by the time taken to identify a replacement for Christine Mann and other demands on the availability of panel members.
1.29 It was important at an early stage of the review for us to meet with those family members who wished to contribute. We have been greatly helped in undertaking this review by the information and insights provided by Julia and William‘s family and friends; we appreciate that this will have been a stressful and distressing experience. Their expressed commitment has been to ensure that learning from the review should be used to prevent the deaths of victims of domestic violence in the future and to improve services.
1.30 We are grateful for the cooperation of the agencies, their staff and individual professionals who have contributed to the review. We recognise and appreciate that for those who were involved with Julia, William or Alan this will have been a stressful experience.
1.31 We met with Dr Carolyn Hoyle, who has undertaken research into various aspects of TVP‘s performance including domestic violence. We also took the opportunity to meet with Roxane Agnew Davies, a clinical psychologist with knowledge of domestic violence in relation to health provision and the chair met with Davina James–Hanman, the Director of Greater London Domestic Violence Project. We are grateful for the useful insights, knowledge and experience they shared with us.
1.32 The review has excluded consideration of how Julia and William died or who was culpable; that was a matter for the Coroner.
1.33 The review was finally completed in November 2008. The following table is based on oral and written information we have received during the review.
Key Dates:
14 September 2002 Julia and her brother reported to Thames Valley Police that Alan had threatened to kill her.
16 September 2002 Julia met with Thames Valley Police Domestic Violence Co-ordinator.
17 September 2002 Julia obtained an Injunction including non-molestation and occupation order with Power of Arrest.
20 September 2002 Alan served with the injunction.
20 April 2003 Locks at Old Hallowes were super glued and the incident reported by Julia to Thames Valley Police.
15 May 2003 Alan delivered Julia‘s Affidavit applying for the Injunction annotated with abusive remarks to Old Hallowes and Julia and her brother took it to Newbury Police Station and reported history of continuing threats.
28 May 2003 Alan wrote to William enclosing further copy of the annotated affidavit.
9 June Julia met with Thames Valley Police Domestic Violence Co-ordinator.
10 June Sovereign Alarm fitted at Old Hallowes.
7 July 2003 Hearing for renewal of non- molestation – Alan gave undertaking and was granted permission to park on the drive when collecting William or C19 for contact.
18 November 2003 Alan shot and killed William and Julia and then himself.
28 and 29 September 2004 Inquests into the deaths of William, Julia and Alan Pemberton.
17 March 2005 Adjournment Debate in the House of Commons concerning the murders of Julia and William Pemberton.
6 June 2005 Deputy Chief Constable Thames Valley Police presented report requesting West Berkshire Safer Communities Partnership to commission Domestic Homicide Review.
19 September 2005 Terms of Reference agreed by West Berkshire Safer Communities Partnership.
October 2005 Application made for Judicial Review by Julia‘s family to have decision to commence review quashed on grounds that the state‘s obligations under Article 2 of ECHRA would not be fulfilled by the proposed review.
24 July 2006 Hearing before Lord Justice Moses; 31 July 2006 Judgement.
October2006 Following confirmation of the judgement arrangements were made by West Berkshire Safer Communities Partnership to re- start the review.
30 January 2007 Review Panel received final Terms of Reference.
1 February 2007 Review Panel requested agency internal management reviews and arranged meetings with members of Julia‘s family.
April 2007 Review on hold following retirement of Christine Mann.
September 2007 Review restarted.
November 2008 Completion of Report.