Aliny Godinho

1. 1. Domestic Abuse Team training gaps

   “In the course of the inquest the evidence revealed matters giving rise to concern. A number of those concerns were satisfactorily addressed by evidence received to address the”

2. 2. Officer non‑compliance with policy

   “I found that failures by the Officer in the Case, to implement the Domestic Abuse Policy and Procedure in relation to the investigation of [the deceased]'s complaint, contributed to the death.”

3. 3. Inadequate supervision of Domestic Abuse Team

   “I found that [the deceased]'s death was contributed to not only by the failures of the Officer in the Case, but also by those of her supervising sergeant.”

4. 4. Lack of monitoring and auditing of Domestic Abuse Team

   “I was told that there is no system in place to monitor and audit the performance and effectiveness of the Domestic Abuse Team.”

5. 5. Call centre misrouting of domestic abuse reports

   “The evidence at the inquest revealed that, on three occasions, reports made to Surrey Police concerning the perpetrator's conduct were incorrectly passed to the Metropolitan Police, and without sufficient information first being adduced and risk assessed.”

6. 6. Cultural risk oversight in domestic abuse investigations

   “I found that there was a failure to take account of the risk arising from the fact that the perpetrator was from Brazil, where there is a considerably higher incidence of domestic homicide than in the United Kingdom.”

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