Refuge responds to NHS report into interactions with Mr S before he killed his pregnant ex-partner, Rachael Slack, their two-year-old son, Auden Slack, and himself, in June 2010

Friday 22 September 2017

Today, NHS England publishes an independent investigation report into the care and treatment of Mr S prior to the attack in 2010 which led to the tragic death of his pregnant ex-partner Rachael Slack and son Auden Slack. Mr S subsequently committed suicide.

Although the report identifies the importance of professionals taking account of the ‘experience and knowledge of those people involved closely with the person in their care’, Refuge is disappointed that it fails to take into consideration missed opportunities to identify risk to Rachael and Auden in the context of Mr S’s domestic violence.

Sandra Horley, CBE, chief executive of Refuge says: ‘‘The NHS is a vital gateway to support for abused women and children. Staff must be trained to identify domestic violence and protect victims. By taking too narrow a view of  Mr S’s risk to himself, the NHS did not spot widely recognised domestic abuse risk factors that could have shone light on the danger to Rachael and Auden Slack such as: separation being the most dangerous time for abused women; pregnancy and childbirth being times of increased risk; babies being at highest risk of homicide; that three quarters of domestic homicides occur during separation; and that abusive men who threaten suicide often kill their partners and children first’’.

Hayden and Melony Slack, brother and sister-in-law of Rachael Slack. Photography copyright: Julian Nieman for Refuge

Melony Slack, sister-in-law of Rachael and aunt of Auden, says: “Our family welcomes this thorough and thoughtful report which identifies meaningful lessons. Whilst we understand that the tragedy of seven years ago could neither have been predicted nor prevented, it is clear that many chances were missed in sharing vital information which could have provided a clearer understanding of the situation. We are reassured by the recommendations for improvements in communication between agencies, to seek to involve families in delivering appropriate treatment and to keep them better informed after such awful events. As a mother myself, however, I am dismayed to think of the stress Rachael must have experienced; not only was she looking after a young baby – and latterly, pregnant again – but she faced the additional stress of caring for Mr S without effective support in challenging home circumstances. Recognition of the role of carer has developed nationally since Rachael and Auden were killed and we hope to see similar improvements and changes which also take into account the risks faced by women like Rachael associated with fatal domestic abuse. ”

Sandra Horley 2017 headshotComment from Refuge chief executive, Sandra Horley CBE: full version

Sandra Horley, CBE, chief executive of Refuge says: “Refuge is pleased that the NHS has scrutinised its interactions with Mr S in the period before he committed suicide, just after killing his pregnant ex-partner, Rachael Slack, and their two-year-old son, Auden Slack, in June 2010.

‘‘We know that NHS staff do amazing work, often under very intense pressure. However, in order to prevent something like this happening again it is essential that they are trained, when assessing the risk to a patient, to also look much more carefully at the people living with – and around – that person.

“Although the NHS was not fully aware of the pattern of domestic violence and controlling behaviour Mr S was exhibiting, they did know that he was presenting as depressed and withdrawn, was judged a low suicide risk, and was the father of a new-born baby. They also knew that he was recently separated from his partner who was deeply distressed about his mental state; Rachael had taken Mr S to A&E herself and had contacted mental health services to ask them to help – all the while caring for a tiny baby. The situation must have been intensely stressful for her.

“By taking too narrow a view of Mr S’s risk to himself, the NHS missed well-known domestic abuse risk factors that could have shone light on the danger to Rachael and Auden (and also, later, to Rachael’s unborn child): risk factors such as separation being the most dangerous time for abused women and children; pregnancy and childbirth being times of increased risk; babies (including unborn) being at higher risk of homicide than any other age group; that three quarters of domestic homicides occur during a period of separation; and that abusive men who threaten suicide often kill their partners and children first.

“All of these are enshrined in standardised domestic violence risk-assessment toolkits which are recommended for use by health practitioners and it is widely known in the UK that two women are killed every week by a current of former partner. There is no excuse for ignorance in the 21st Century, with so much research available – especially in the NHS – which acts as a vital gateway to support for abused women and children. Staff must be given the training and support they need to identify domestic violence and protect victims.”

To receive photographs of the deceased and family, or to arrange an interview with Refuge and family members from 11am on Friday 22 September, please email press@refuge.org.uk or call 07799 712293.

See more: Rachael and Auden Slack wave goodbye

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