How system failure and missed warning signs contribute to domestic abuse deaths
This article is part of Safe Haven Education’s professional awareness series examining how coercive control is identified across policing, health, legal, and workplace systems.
Each year in Parliament, the names of women killed by men are read aloud by Jess Phillips to mark International Women’s Day.
The list is long. It grows every year. Each name represents a life lost to male violence against women and girls.
But there is another group of victims whose names are rarely spoken in public: women who died by suicide after experiencing sustained domestic abuse and coercive control. Their deaths are often treated as separate from abuse. The evidence increasingly shows they are not.
The Numbers
In the year ending March 2024, the Domestic Homicide Project recorded 262 domestic abuse-related deaths in England and Wales. Of those, 98 were classified as suspected victim suicides following domestic abuse, and 80 were intimate partner homicides.
Read that again.
For the second year in a row, more victims of domestic abuse died by suicide than were killed by a current or former partner.
These are not statistics about strangers. They are statistics about patterns. Patterns that were often visible before the deaths occurred.
On average, a woman is killed by a man every three to five days in the UK. Around half to three fifths of women killed by men are killed by a current or former partner, depending on the year. Domestic abuse organisations have estimated that around 30 women attempt suicide each day in England and Wales as a result of experiencing domestic abuse, and that every week, three women die by suicide following abuse.
At least 40% of women killed by a current or former partner had left, or were in the process of leaving, at the time they were killed.
We do not talk about this enough. And when we do, we often talk about it wrong.
We call these deaths tragedies. We call them shocking. We describe them as if they arrived from nowhere.
They did not arrive from nowhere.
In almost every case, the story had already been there for months, years, sometimes decades. And in almost every case, somebody already knew part of it.
The Perpetrators Were Already Known
Here is what the evidence consistently shows, and what makes these deaths so devastating: the people responsible were not invisible.
In analysis of Domestic Homicide Reviews, 60% of perpetrators had a previous offending history, meaning they had already been in contact with police. Three quarters had abused previous partners, and one third had abused family members.
In the period between September 2021 and October 2022, 59% of perpetrators who had an intimate partnership with the victim had been known to at least one agency before the killing.
Across domestic homicide data, four in five perpetrators were known to police before the homicide occurred, with three in five known specifically for domestic abuse incidents.
The victims had also sought help. In analysis of 46 Domestic Homicide Reviews, nearly all victims- 98%- had received some form of support from a service prior to the homicide, and 52% had had some form of contact with police.
They had told someone. The question is what happened after they did.
Domestic Homicide Reviews repeatedly show that these deaths rarely occur without warning. In most cases, multiple professionals had contact with the victim or perpetrator in the months or years beforehand.
Coercive Control: Present from the Start
Femicide is not a sudden loss of control. Suicide following domestic abuse is not a mental health crisis disconnected from what was done to someone. Both are endpoints of a process.
Research has consistently identified that the prevalence of coercive and controlling behaviour, non-fatal strangulation, and separation is even higher in suspected victim suicides following domestic abuse than in intimate partner homicides.
In Femicide Census analysis, the most commonly reported types of abuse present in cases were emotional and psychological abuse in 53% of cases, coercive control in 41%, physical abuse in 27%, and threats in 26%.
Coercive control is frequently a central mechanism driving these deaths. It is the systematic, sustained dismantling of a person’s sense of self, their confidence in their own perception, their relationships, their finances, their ability to imagine a future outside the relationship. By the time a woman takes her own life, the abuse that drove her to that point has often spent months or years ensuring she believed she had no other options, that no one would believe her, and that she was to blame.
As research from the domestic violence sector has documented, victims describe the process in terms that go beyond fear of violence: complete entrapment, an inability to see any way out, the sense that the perpetrator’s behaviour is so persistent and so total that there is no space left for agency of any kind.
Killing someone with a weapon is a single act. Destroying someone’s self-worth, their self-image, their trust in their own mind, is a sustained campaign. The outcome can be the same. The accountability rarely is.
The Separation Trigger
The data on timing matters and is not well enough understood publicly.
A significant proportion of women killed by former partners are killed in the months immediately following separation. Research consistently shows the period after leaving is among the most dangerous, with risk of lethal violence elevated significantly in the weeks and months that follow.
Leaving is the most dangerous moment. It is also the moment when many victims, having finally found the courage to go, encounter a system that treats the relationship as resolved. The abuse does not resolve. It intensifies.
Post-separation coercive control, financial sabotage, use of children as leverage, harassment, threats, and escalating violence are all documented patterns in the period following separation. Key risk indicators present in perpetrator histories in cases that ended in death consistently include coercive and controlling behaviour, mental ill health, alcohol and drug use, and separation or the ending of the relationship.
Separation is itself a risk factor. It should trigger heightened professional attention. Too often it triggers the closing of a file.
The System Failure
The pattern visible across these cases is not randomness, but systemic failure.
These deaths are not inevitable. They are the result of failures that are identifiable, reviewable, and in many cases already documented in the Domestic Homicide Reviews that follow each killing.
Police responses to reports of domestic abuse have long been identified as inconsistent across forces. Too often victims report that police have failed to take action against perpetrators or to implement proactive protective measures.
Organisations including Refuge are calling for any suicide involving a known history of domestic abuse to be investigated as a potential homicide from the outset, accompanied by mandatory trauma-informed police training and improved multi-agency collaboration.
The 2023 Suicide Prevention Strategy for England was the first such strategy to formally acknowledge domestic violence as a risk factor for suicide at population level. That this acknowledgement did not come until 2023 tells you something about how long this connection was overlooked in official frameworks.
Police forces across the UK are now exploring the use of manslaughter charges where a perpetrator’s abuse is found to have caused their partner to take their own life, following cases including that of Kiena Dawes, who died by suicide at the age of 23 after experiencing prolonged psychological abuse.
That legal development is significant. It names what has always been true: that a death by suicide in the context of sustained coercive control cannot be understood as a purely private tragedy. It is a consequence of what was done to someone.
What This Means in Practice
Every professional who encounters a victim of domestic abuse is potentially encountering someone in the period before one of these statistics is created.
This includes workplaces. Domestic abuse does not remain outside the office. It appears as patterns that are often misinterpreted as performance or conduct issues: sudden drops in productivity, unexplained absences, repeated lateness, visible anxiety, changes in behaviour, financial stress, or a partner who repeatedly contacts the workplace. Without awareness of coercive control, these signs are easily misunderstood. In the worst cases, victims enter disciplinary or capability processes at the very moment they most need support.
In Domestic Homicide Reviews, workplaces are rarely the agency expected to intervene. But they are often one of the last places a victim still has contact with the outside world.
The GP who notices the pattern but does not ask. The mental health practitioner who treats the anxiety without asking about the relationship. The HR manager who initiates a capability process without considering what might be driving the performance decline. The police officer who attends the call and records it as no further action. The family lawyer who sees the fear but focuses on the legal process.
In analysis of Domestic Homicide Reviews, the agencies most frequently identified as having lessons to learn are mental health services, GPs, and police. These are the frontline. These are the people who saw something. The question the reviews ask, again and again, is what they did with what they saw.
Coercive control does not announce itself. It presents as something else: mental health difficulties, relationship problems, performance issues, unexplained absences, anxiety, withdrawal. These are the signs. What is missing, in almost every case where a death follows, is someone with the framework to connect them.
A Final Note on Language
We do not call these deaths what they are often enough.
A woman who takes her own life after years of having her reality systematically dismantled, her confidence destroyed, her support networks severed, and her sense of self eroded to nothing, did not die by suicide in the way we typically understand that term. She died as a consequence of what was done to her.
The Femicide Census exists to count the women killed by men. The Domestic Homicide Project now counts those who die by suicide following abuse. The numbers, taken together, represent the full scale of what coercive control does when it is not named, not interrupted, and not stopped.
These deaths do not happen in isolation. They happen at the end of a pattern. And the pattern, in almost every case, was already visible.
© Safe Haven Education. This article is part of a domestic abuse awareness and professional development series. All statistics are sourced from published UK research, ONS data, Domestic Homicide Project reports, Femicide Census publications, and statutory Domestic Homicide Reviews. For training, consultancy, or speaking enquiries, contact Deniz Erdem, Founder, Safe Haven Education: deniz@safehaveneducation.org
If you are in crisis or need support, the National Domestic Abuse Helpline is available 24 hours a day on 0808 2000 247.