Contains references to self-harm, sexual violence, domestic abuse and suicide. 

A talented hairdresser with a knack for convincing people to get dressed up in fancy dress for parties, Jessica Laverack (affectionately known as Jessie) was the youngest of three siblings, owned 52 pets at one point, and warmly jostled with her elder sister for their mother, Phyllis’s, attention, even as adults.

In the aftermath of traumatic events, life is often fragmented into “before” and “after”. That was Jessie’s “before”.

During the summer of 2017, Jessie, aged 33, fled more than 50 miles from her home in Rotherham in northern England to escape her ex-partner, after two occasions on which he had strangled her.

It was at this moment that a litany of failings from a supposed safety net of professionals, institutions and organisations started racking up, Phyllis, 68, a retired health visitor from East Riding, says she can see in retrospect.

South Yorkshire Police had attended the scene in Rotherham in May 2017 when Jessie’s former partner first strangled her – rendering her unconscious – but, according to Phyllis, were “treating Jessie as if she was lying” with “clear gaps in their training”. They referred Jessie to an Independent Domestic Violence Adviser, who then actioned a Multi-Agency Risk Assessment Conference (MARAC) – a review by voluntary and statutory organisations in which they discuss high-risk victims of domestic abuse – as standard procedure.

A few days after Jessie’s ex-partner was charged with common assault in May 2017, Jessie told her mother he had attempted to strangle her again. He had been released the morning after being arrested as Jessie had declined to press charges (a common occurrence in domestic abuse cases).

In place of their frightened daughter, Phyllis and her husband, who is also 68 and retired, went to Rotherham Central Police station to report the assault and, after what she sensed was reluctance from staff, was seen by a domestic abuse worker.

“I can remember what it looked like coming up the station, asking the person I was speaking to to record what I was saying, watching them write it down, everything. I had to insist that I wasn’t an overbearing mother and that they take me seriously,” she says.

At this point, Jessie decided to flee, moving to a new address in the northern English town of Beverley.

Unbeknownst to Jessie or her family, the MARAC process was shelved shortly after the initial meeting of organisations took place because Jessie was wrongly flagged as not being registered with a general practitioner (GP) at her new address, and the MARAC neglected to involve or share information with Jessie’s former GP,  so nothing could be passed on. This meant there was no longer a record of Jessie being at high risk of domestic abuse on her health records.

Though she can’t be certain, Phyllis believes that her daughter’s ex-partner then tracked Jessie down through bank statements listing her new address, after Jessie pleaded with bank staff to let her close the joint account she had with her ex-partner, according to Phyllis, without his permission. Although Jessie successfully took her own name off of the account, staff still applied her new address to the joint account documents. He began approaching her just months after she had fled, in late 2017.

Housebound by fear in Beverley, while self-medicating with alcohol and suffering from night terrors, Jessie reported to Humberside Police, both in person with her parents and on the phone on at least four occasions, that she was being stalked, harassed and living in fear, all at the hands of her ex-partner. But nothing was done.

Jessie was too frightened to answer phone calls from unknown numbers or attend appointments, which meant she had been removed from her support worker’s caseload before she fled, who had been appointed to her via her Rotherham GP to help with her anxiety. By the time Jessie moved to Beverley, she was increasingly using alcohol as a crutch and, because GPs can’t refer people to alcohol services, she had to attend a drop-in centre to receive support.

Without any trauma-informed alternatives and despite Jessie’s increasing agoraphobia as a result of her terror that her ex-partner might be waiting outside her new house, East Riding Partnerships Addiction Services told her that if she didn’t attend the drop-in, she wouldn’t be allocated a rehabilitation course with East Riding Adult Services. Too frightened to leave the house by herself for fear her ex-partner was waiting for her, Jessie’s mother was forced to wait at the drop-in centre for an appointment to come up, race back to the house to collect Jessie, and then return to the centre for the appointment.

In late 2017, Jessie attended the accident and emergency department at the hospital with her mother, feeling suicidal and having self-harmed. Despite this, her case was not referred back to MARAC, and her self-harm was recorded as “accidental”, even though her mother says she informed staff that she had recently fled domestic abuse. Instead of any type of formal support, the parting comment from staff was that Jessie was “lucky” to have a family who could help her.

With services and systems of support proving elusive, Jessie saw no escape. She took her own life one Friday in February 2018.

Her parents had arrived that morning to finish putting up the wallpaper they had picked out with her just days before.

[Jawahir Al-Naimi/Al Jazeera]

‘No one looked at the whole picture’

One in eight female suicides or suicide attempts occur as a direct result of domestic violence or abuse, according to the Women and Equality Unit of the United Kingdom’s Office for National Statistics (PDF), while recent data from the National Police Chiefs’ Council (PDF) shows that increasing numbers of domestic abuse victims end up taking their own lives. In four out of five cases where they do, the abuser was already known to the police.

While the far-reaching impact of the domestic abuse inflicted on Jessie was not accorded the weight it deserved while she was still alive, say her parents, myriad barriers and a poor understanding of the issues only seem to worsen after the death of a victim.

“It was one after the other – it’s like no one looked at the whole picture and saw that she’d been abused. It was just written off as suicide – from the post-mortem to the death certificate, there was no mention of the bruises on her or previous abuse,” Phyllis says.

Death certificate reforms only now coming into force across England and Wales will mean that an independent review will need to be carried out for all deaths, without exception, either by a medical examiner or coroner. If this had been implemented sooner, the domestic abuse Jessie suffered might have been recognised in her death, at the very least, and could have changed her death certificate.

As a result of her experience, Phyllis believes there is no clear pathway for families to obtain justice, and those who do take it upon themselves to try to find justice are met with inaccessible jargon and red tape.

“Life just wasn’t the same, and yet I was having to navigate this really complex system,” says Phyllis. “Night after night, I was researching, learning what words I was supposed to use, what words they used to me and what they meant. All these other people have a top legal team. Police do, health do. Yet they expect a grieving mum to be able to challenge them.”

As far as the police were concerned, it was cut and dried: a straightforward suicide. “Because she took her own life, it was classified as she had a choice, but living a life of domestic abuse isn’t a choice,” says Phyllis.

A few months after Jessie’s death, an inquest was set to take place to determine the cause. But with so many unanswered questions and Jessie’s abuser being the last known person to have been with her, Phyllis appealed to the coroner, who agreed that it should be delayed until Humberside Police investigated Phyllis’s concerns.

It took Phyllis five months to get Humberside Police to agree to investigate the role that domestic abuse had played in Jessie’s death through a Domestic Homicide Review (DHR) (soon to be renamed the Domestic Abuse-Related Death Review, after calls to recognise the role of domestic abuse), after continuous requests.

It is rare to secure a DHR without police deciding to carry one out of their own accord.

DHRs are usually conducted by Community Safety Partnerships (CSPs) – made up of police, local authorities, health partners and Probation Service – shortly after a death that may have resulted from violence, abuse or neglect. No one presented Jessie’s family with one as an option at any stage.

The first time Phyllis even heard mention of a DHR was when she was on the phone with a police officer and overheard South Yorkshire officers saying a DHR wasn’t their responsibility, as Jessie had died under Humberside Police jurisdiction.

A pre-inquest, which is held if there are issues of law or procedure that need to be determined by the coroner before a final inquest takes place, then determined that the DHR should be finalised before a full inquest could begin.

The government website says the DHR process should take about six months. But several years later, Jessie’s still isn’t complete.

As police and medical records started to come to light through the DHR process, Phyllis discovered that Jessie’s MARAC had been archived. A potentially life-saving flag to other professionals that Jessie was already at high risk had been completely missed.

After making an Independent Office for Police Conduct complaint about South Yorkshire Police’s handling of the domestic abuse Jessie experienced, police officers presented their findings to Phyllis, stipulating that the correct procedures had been followed. It was during this conversation that it became apparent that there was no record of her reporting the second attempted strangulation that Jessie had suffered, which Phyllis herself had made nine months before Jessie’s death.

[Jawahir Al-Naimi/Al Jazeera]

‘We nearly lost the house’

After four-and-a-half years of desperately trying to get authorities to understand the role that domestic abuse had played in her daughter’s death, and to investigate it, a date was finally set for a coroner’s inquest regardless of the DHR. Phyllis and her husband only narrowly avoided bankruptcy to make it happen.

“We nearly lost the house … We would’ve had to sell everything to finance the legal costs,” Phyllis says. “If I find this difficult, and I’m a reasonably educated lady, others don’t stand a chance. You have to have that financial backing.”

Despite six interested parties involved in the inquest (including Humber Teaching Foundation NHS Trust, South Yorkshire and Humberside police, and the GP Jessie received support from in Beverley) having fully funded legal teams, Jessie’s family were denied funding by the Legal Aid Agency.

Just a few weeks before the final hearing in 2022, Phyllis’s legal team successfully made a case to the coroner that Jessie’s death could indicate systemic failures to protect a life, and that Article 2 of the European Convention of Human Rights should then be exercised. This obligates the state to investigate the cause of a serious incident or suspicious death.

Following five days of evidence in the Guildhall Coroner’s Court in Hull in June 2022, the coroner leading the second inquest into Jessie’s death recognised that the underlying cause of Jessie’s mental illness was domestic abuse and that it had been further exacerbated by failures by multiple agencies. An open verdict was issued, meaning that the cause of death is not named, as there was not enough evidence of “Jessie’s intention to make a finding of suicide”.

While a direct causal link between Jessie’s death and the abuse she suffered couldn’t be drawn and her death certificate remains unchanged, the coroner stated that “processes and policies carried out” by the NHS, police and voluntary and statutory organisations involved in MARAC “did not seem to consider its relevance to the extent that is required”.

The coroner sent a report with recommendations for preventing future deaths to the Secretary of State for the Home Department, Secretary of State for Justice, and Secretary of State for Health and Social Care.

As a result, the government-linked domestic abuse and suicide for the first time in the UK in the latest Suicide Prevention Strategy, published in September last year.

The latest national suicide figures published by the Office for National Statistics at the end of August did not include domestic abuse-related suicides, however.

“Humberside Police has since implemented various additional training programmes for frontline officers, call handlers and staff,” as well as secondary risk assessing every domestic abuse incident, “which has been shared as good practice and adopted by many other forces”, Detective Superintendent Phil Booker told Al Jazeera.

In February this year, Humberside Police sent a written and verbal apology from three members of senior staff to Jessie’s family, acknowledging that they had failed to investigate Jessie’s death properly.

The Coroners’ Society of England and Wales was contacted by Al Jazeera but declined to comment, saying it was unable to speak about individual cases.

After it was contacted by Al Jazeera for comment on this story, South Yorkshire Police said in a written statement: “Our thoughts remain with Jessica’s family and loved ones and it is essential any learning which can be gathered from this is properly embedded into our approach.

“While South Yorkshire Police was not subject to any specific recommendations or actions within the Coroner’s Report or the Domestic Homicide Review, we have nonetheless transformed our approach to the policing of domestic abuse and have invested considerably in the training of officers and staff.”

The police force added: “In May 2017, officers charged a man, now 49 years old, with assault. However, due to evidential difficulties, no further action was taken.”

[Jawahir Al-Naimi/Al Jazeera]

‘No one represents the victim’

The inquest itself was yet another source of trauma for Phyllis and her husband, however.

Typically, the option to give evidence at a coroner’s inquest is open to anyone who believes they have information to offer. Phyllis was told by police officers and her lawyer that in cases like Jessie’s, the perpetrator of the abuse rarely takes up the offer. But Jessie’s ex-partner did. What’s more, he was allowed to cross-examine Phyllis during the hearing.

“We had to sit through five pages of him telling us that he and Jessie were in a loving relationship and wanted to get married. I watched him manipulate the Chair of the Inquest in the same way he did to Jessie,” Phyllis says. “I was told that I could be there [at the inquest] via video link instead, but why should I, at my daughter’s inquest, when he’s the perpetrator?”

Phyllis is currently working with the Chief Coroner of England and Wales to ensure that grieving family members can’t be cross-examined by perpetrators of abuse, as she was.

Meanwhile, the DHR process is still rumbling on.

Originally sent to the Home Office in 2022 following the inquest ruling, Phyllis asked to read the DHR and sent it back again for the Chair (who was appointed by the Department of Justice) to change. “It was appallingly written. There were so many bits where they missed an opportunity to say it how it is. Like, ‘he sexually forced himself on her’. No, he raped her.”

Phyllis has sent 16 pages of complaints throughout the two-year process, and although the regulations make no provision for it, she successfully argued for the right to proofread the final report to check for errors before it was published.

“The heartbreaking thing is, it’s still always me challenging this stuff. Everyone’s fighting to save their professional corner. No one represents the victim’s voice”, Phyllis says as her voice cracks.

The hidden truth

Keeping what she sees as the hidden truth about her daughter’s death at the fore has hardened Phyllis, she says. As she sees it, she has been forced to become “ferocious” and to learn how to gather the strength to enter rooms she would once have shrank away from.

“It cost me years of my life. I was so focused on getting justice for Jessica, I neglected my children, my grandchildren, my husband.” Phyllis trails off.

But, in the end, she could not let what happened to her daughter pass – she still speaks to the photograph she has of Jessie on her mantelpiece.

Retirement has been anything but restful. The dining table once dedicated to family meals is covered with court preparation documents, and she doubts she will have a minute spare for a great-grandchild due to be born any minute. She tries her best to speak to everyone who reaches out to her – from police and probation services, legal professionals, and countless other bereaved families going through a near-identical process.

Like Phyllis, other families seeking justice start out with the belief that the infrastructure for support works, or at the very least, exists, she says. It isn’t until they’re drowning in grief that they realise they’re also expected to build their own raft.

Shortly after Jessie’s death, Phyllis and her husband moved, in fear of Jessie’s ex-partner finding them. If she hears that her daughter’s perpetrator is in a new relationship that has signs of coercive control or physical abuse, she drives to the nearest police station and makes sure his new partner can access information on him under Clare’s Law, a scheme which enables police to disclose information to a victim or potential victim of domestic abuse about their partner’s or ex-partner’s previous abuse or violent offending.

Phyllis believes she is being listened to now, but it’s taken six years since her daughter’s death to get to this point.

“I’ve been retelling this story for years now. I’m used to it,” she says. “People always say Jessie would be proud, but she wouldn’t. She’d be so upset and heartbroken that we’re having to go through this.”

If you or someone you know is at risk of suicide, these organisations may be able to help.

In the UK and Ireland, contact Samaritans on 116 123 or email jo@samaritans.org.

For those bereaved by suicide after domestic abuse in the UK, contact Advocacy after fatal domestic abuse.