A review into the death of a pensioner killed by her partner during a psychotic episode has recommended that more needs to be done to address risks of domestic abuse among the elderly and people suffering dementia in Cornwall.

Lesley Davies, 81, died in July 2018 after a violent attack by her partner Brian Downie near their home in Par.

Mr Downie was detained in a secure hospital unit after he pleaded guilty to manslaughter.

Following the incident a Domestic Homicide Review (DHR) was undertaken by the Safer Cornwall Partnership.

DHRs are carried out to help enable learning from homicides where a person has died as a result of domestic abuse. While the DHR was completed in January 2020 it was only published last month.

The review looked to consider the contact and involvement that agencies had with Ms Davies and Mr Downie between 2014 and 2018.

Ms Davies and Mr Downie had been living together since 2017 having both been previously married and having children from those previous relationships.

The report states that Mr Downie was being treated for epilepsy and that in the months leading up to Ms Davies’ death the episodes of epilepsy became more frequent and details were recorded in a diary kept by Ms Davies.

In July 2018 police were called to a street close to the couple’s home after neighbours witnessed Ms Davies being chased by Mr Downie down the street.

The report, which refers to Ms Davies as ‘Adult A’ and Mr Downie as ‘Adult B’ states: “They had then seen Adult B catch up with Adult A and on doing so he knocked her to the ground and had then started to violently assault her. One of their neighbours had tried to intervene but was unable to physically prevent Adult B from continuing the assault. In order to stop the assault this neighbour had to resort to hitting Adult B with a plank of wood.”

When police arrived Mr Downie was arrested. Ms Davies received treatment at the scene and taken to hospital but died as a result of head injuries sustained in the attack.

Mr Downie was assessed by mental health professionals and deemed unfit for detention and was transferred to a secure unit.

After the incident Mr Downie was diagnosed with suffering Lewy Body Dementia – the report states this was “a major contributing factor to his behaviour at the time that the homicide took place”.

On the date of the incident the report says that Mr Downie’s son had spoken to him and said that he “started to act strangely”. Mr Downie called his son again later that day and was again described as acting strangely, adding “he became increasingly concerned when his father repeatedly requested that he should call the police. Adult B stated ‘call the police armed’ before spelling out the word ‘armed’ and giving his home address”.

After that call Mr Downie’s son called the police and made his way to his home. Shortly after Mr Downie called the police and requested both the police and ambulance service.

It was around half an hour after that call that the assault which led to Ms Davies’ death occurred.

Those at the scene reported Mr Downie saying “he was going to kill her” and “she wanted me to kill her” and said he was very confused.

After he was arrested Mr Downie was constantly saying “I love you” and police officers said he was distant, agitated, confused and “very up and down”.

Mr Downie was also heard to say “this will make them stand up and listen that I need medical help”.

The DHR includes details of the diary entries by Ms Davies about Mr Downie’s seizures and mentions one in May 2018 when he became “very angry” with her and stated she was trying to get him to take the wrong tablets.

The report also found that as a result of her relationship with Mr Downie her sons believed she had become more insular.

The DHR found that other than health the couple had little involvement with other agencies with no contact with social services or the police.

Following admission to a mental health facility Mr Downie was described as presenting with psychotic features of delusional misidentification.

The DHR states that there is nothing recorded “that would suggest that Adult A (Ms Davies) was exposed to domestic violence or physical abuse at any stage in her life”.

Police considered whether Mr Downie had used “controlling or coercive behaviour” and in a statement to police one of Ms Davies’ sons “described how he had noticed that Adult B (Downie) was becoming controlling of his mother. He described this as being a slow process which had occurred over a period of four years and during that time Adult A (Ms Davies) had become less confident resulting in Adult B becoming more influential”.

The report states that Ms Davies had previously been outgoing and social, but after meeting Downie her relationship with others, including her sons, had changed.

Ms Davies’ family also stated that she would always wear bright colours but after meeting Downie she started to wear plain clothes.

The report states: “Adult A’s family felt that she was on occasions economic with the truth in respect of Adult B and that was shielding him from the family. Adult A would often take Adult B’s side and her family felt that he was controlling her emotionally and ‘brainwashing’ her.”

Police considered coercive and controlling behaviour but felt there was no evidence that this was having an impact on the relationship in terms of abuse.

The report states: “The panel did however recognise that whilst there was no recorded evidence held by agencies that there was coercive control in the relationship this may have been due to a lack of recognition by Adult A of the impact that Adult B was having on her life or the fact that she hadn’t reported it.”

They also state that the behaviour of Downie could be attributable to his medical condition.

The report said that due to minimal contact that either adult had with agencies “there was limited opportunity to enquire whether there were concerns about domestic abuse in the relationship”.

Ms Davies was not asked about any abuse in her relationship as part of any routine enquiry at her GP surgery and the GP said that this would not have been done as there were no risk factors or obvious vulnerability.

However the DHR has recommended to NHS Kernow that routine enquiry should be encouraged.

The DHR found that there were no failures in the medical treatment that Downie received and it highlights that he was “a complex case to fully diagnose” and it was not known that he had Lewy Body Dementia.

It found that: “No one could have foreseen the events that occurred in July 2018.”

The review has recommended that routine enquiry into domestic abuse should be reviewed across all services.

And it has recommended that Safer Cornwall should commission a review of the impact of dementia and associated conditions on domestic abuse in Cornwall and the Isles of Scilly.

Agencies have also been recommended to amend policy and practice so they recognise and deal with the impact of domestic abuse among the elderly and those suffering dementia related illnesses.