Woman who took own life was unlawfully killed by domestic abuse says coroner

A WOMAN who tragically took her own life after a decade of domestic abuse was unlawfully killed, an inquest has ruled.

Georgia Barter, 32, had suffered around a decade of domestic abuse by her partner.

After being violently assaulted by him on or around April 5 2020, Georgia took a fatal overdose at her east London home. She died at Kings College Hospital on April 26 2020.

Although he cause of death was given as multi organ failure and liver toxicity caused by a paracetamol overdose, after a seven-day inquest that ended on October 2, Coroner Dr Shirley Radcliffe, sitting at East London Coroners' Court, concluded she was unlawfully killed and died as a result of domestic abuse.

It is understood to be only the second time such a finding has been reached at an inquest in relation to a self-inflicted death by a woman following domestic abuse.

Mother-of-three Kellie Sutton, 30, was found unconscious at the home she shared with abusive partner Steven Gane in Welwyn Garden City on 23 August 2017.

An initial inquest concluded Ms Sutton died by suicide but this was overturned in July 2023, to give the first ever verdict of an unlawful killing due to domestic violence after someone took their own life.

Ms Radcliffe has now written a Prevention of Future Deaths Notice to the Home Office amid fears police forces are still not able to access national information about alleged perpetrators of domestic abuse, as they are restricted to within their own force area.

She wrote: "She had come into contact with a number of police forces in southern England over the course of an abusive relationship. The concern I have is that there is difficulty for front line officers in police forces across the country to easily access the police national database to check on individuals who are suspected of domestic abuse. They are unable to easily identify if the individual has a history of reported domestic abuse in areas outside that forces’ borders. This would allow police to be more proactive in their dealings with victims of domestic violence. I understand that some forces have implemented changes to facilitate better exchange of information and access to the (Police National Database PND). However, I am concerned that there may be forces which continue to have limited access for front line police officers to the PND."

During the inquest, substantial evidence from senior officers at the Metropolitan Police and Essex Police was heard as well as expert evidence from two psychologists with specialist knowledge of domestic abuse and its impact.

A spokesperson for solicitors Deighton Pierce Glynn, which represented her family at the inquest, said: "Georgia was much-loved by her family and friends and dreamed of becoming a professional dancer. She began going out with her partner when she was around twenty-two years old and over the course of their relationship, her mother feared and fought for Georgia’s safety from domestic abuse.

"Georgia and her partner had repeated contacts over the years with various police forces and healthcare settings, including Georgia’s GP, mental health services, ambulance services and hospitals. The Coroner identified that there were missed opportunities for a multi-agency response to the domestic abuse that Georgia was subjected to, albeit she did not consider herself able to say that such a response would have prevented Georgia’s death."

The Metropolitan Police and Essex Police accepted more needs to be done to take positive action on domestic abuse. There were missed opportunities to arrest the perpetrator and to make a Multi-Agency Risk Assessment Conference referral.

A statement from Georgia’s mother, Kay, said: “This ruling won’t change anything for my family and I and it won’t bring my beautiful daughter back. Nothing will ever put this heartbroken mother back together again. My darling Georgia was a beautiful, kind soul whose generosity touched everyone around her. It took Georgia a very long time to ask for help because she felt judged and ashamed. In the end, Georgia did reach out for help but the support wasn’t there for her. All I want now is to shine a light on the epidemic of domestic abuse which is killing women."

Clare Hayes, family solicitor, added: "The coroner’s finding of unlawful killing vindicates Georgia’s mother’s fight for justice on behalf of Georgia and makes it a matter of public record that Georgia died as a result of domestic abuse. We have heard tragic evidence about the horrifying abuse that Georgia suffered over many, many years and the barriers to escaping a coercive and controlling relationship. This inquest has revealed evidence about the role of domestic abuse and importantly coercion and control in Georgia’s death that has much wider significance for how the state understands gender-based violence. It has also revealed that some of the agencies involved have made potentially far-reaching changes. This is testament to the tireless efforts of Georgia’s mother in seeking accountability and change following Georgia’s death. We hope that agencies will continue to work to ensure that on a very practical level steps are taken so that police officers and clinicians exercise professional curiosity when working with victims and survivors of abuse, to piece together a fuller picture and take available steps to prevent further abuse.”  

The Prevention of Future Deaths Notice, urging the Home Office to take action to open up domestic abuse intelligence to police forces nationally, has been copied to the Met Police.

Both have been contacted for comment.

The Home Office has 56 days to respond.

Essex Police also gave evidence at the inquest after she had contact with the force.

An Essex Police spokesperson said: "Since Georgia’s death in April 2020, the thoughts of everyone at Essex Police remain with her family and friends.

"Georgia lived in London but incidents were reported to Essex Police on three occasions, in 2018 and 2019.

"On one of those occasions, we found the service provided by officers did not reach the incredibly high standards we would expect. Our response was reviewed, and learnings were explored, with two officers given reflective practice.

"At the conclusion of Georgia’s inquest, the coroner did not suggest any failings by Essex Police caused or contributed to her death but did highlight missed opportunities from police forces and health organisations.

"In the six years since Essex Police attended the third of the three incidents, we have made significant strides in the identification, awarenesViolence Assessments s and response to coercive and controlling behaviour.

"We have moved from Domestic Abuse Stalking and Honour Based (DASH) to Domestic Abuse Risk Assessments (DARA) risk assessment models. DARA is designed for frontline police officers and is proven to reduces deaths from domestic abuse through better risk identification.

"We’ve created a central domestic abuse review team which carries out holistic secondary assessments of domestic incidents and can complete any referrals deemed necessary - including Clare’s Law disclosures - and we have proactive domestic abuse problem solving teams, which proactively target high risk perpetrators.

"We’ve also created a rapid video response team of officers which, when it’s appropriate to do so, are available to immediately engage with domestic victims remotely through a secure video link, to ensure evidence is captured as quickly and as safely as possible."