A coroner has highlighted "failures or inadequacies" by Hertfordshire police which "may have contributed" to the death of a domestic violence victim, who was visited by officers just weeks before she died.

The victim, who this newspaper is not naming, took her own life in 2017, when she was just 30 years old, and died in Lister Hospital in Stevenage.

At her inquest, the jury determined she had hanged herself "after being subjected to months of controlling and coercive behaviour and domestic abuse by her then partner", Samantha Broadfoot, the assistant coroner for Cambridgeshire and Peterborough, said in a Prevention of Future Deaths Report to the chief constable of Hertfordshire Constabulary this month.

The jury found "that there were certain failures or inadequacies by Hertfordshire Constabulary which may have contributed to [her] death", the report continues.

Seven weeks before the mother-of-three died, a neighbour called the police because she was being "beaten up by her partner".

The police came quickly, but failed to speak to the neighbour who called 999, who was "in possession of significant further information about the incident, including that one of the children had witnessed it", the report says.

At the inquest, the police accepted that "the response fell below the expected standard in a number of respects, including body worn video capability, the failure to check up on the children, and that they showed a lack of professional curiosity and judgment relating to the Domestic Abuse, Stalking and Harassment process, and house-to-house inquiries not being completed", Ms Broadfoot said.

The jury found "numerous opportunities were missed" that led to "a failure to consider implementation of appropriate protective measures", she said. 

The jury said further investigation or action on the day may have led to further interventions that could have altered the final outcome.

After the victim's death, her partner was convicted of controlling and coercive behaviour, assault occasioning actual bodily harm, and common assault.

Ms Broadfoot said: "There was extensive and detailed witness evidence gathered by the police for criminal proceedings which demonstrated that her partner was abusive towards her - both physically violent on at least several occasions and by his controlling and coercive behaviour towards her, which included shouting, threatening, phoning constantly if she was out, isolating her from her family and friends and holding her bank card. 

"She lived in fear of her phone battery dying because if he couldn’t get hold of her he would 'go mad' and would become violent.
 
"I am satisfied from the evidence, which included text messages from her to friends, and from her to her partner, that she was very unhappy in this relationship but did not feel able to extricate herself from it, even though her friends were telling her he was abusive."

Ms Broadfoot warned the chief constable of Hertfordshire police that, in her opinion, "there is a risk that future deaths could occur unless action is taken".

Listing a raft of concerns relating to Hertfordshire police officers following her investigation, which took almost two years to complete, Ms Broadfoot said: "There was a lack of understanding of controlling and coercive behaviour, what it is, and the impact on victims.
 
"There was a lack of awareness of the link between domestic abuse and suicide.
 
"There was a lack of understanding by frontline officers of the circumstances in which a Domestic Violence Protection Notice could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the Domestic Abuse Investigation and Safeguarding Unit.

"In my opinion, action should be taken to prevent future deaths and I believe your organisation has the power to take such action."

The chief constable must respond to the report by June 24, detailing action taken or proposed to be taken, setting out the timetable for action.

T/Assistant Chief Constable Amanda Bell said: "[The victim's] death was an absolute tragedy and as a force we have made huge progress to better understand the complexities of coercive behaviour, which includes improved officer training and more robust reporting systems.

"The link between domestic abuse and suicide now features prominently in all our training around sudden deaths. There is now revised guidance for officers attending any report of a sudden death, and this includes looking at the domestic abuse history of the parties because we recognise that this link can exist.

"As a constabulary, our use of digital technology has developed since 2017, enabling our officers to have access to far greater information.

"At a national level, we have worked with DA Matters, who provide training to police forces, and with her family’s consent and support we used [the victim's] tragic death as a case study to ensure her story continues to educate officers on how they respond to domestic abuse incidents in the future.

"We now also have a civil order team within the Domestic Abuse Investigation and Safeguarding Unit, which reviews all domestic abuse reporting and looks for opportunities to proactively use Domestic Violence Protection Orders. There has been new guidance and training for officers and an increased focus in our constabulary’s performance meetings.

"We also encourage use of Clare’s Law, which allows the police to release information about any previous history of violence or abuse a person might have. We have a team specifically set up to focus on providing potential future victims of domestic abuse information to help safeguard them and others, preventing further harm from perpetrators of abuse.

"Following the inquest, we created a Vulnerability Information Portal. This is an app on officers’ phones where they can easily access information about subjects including coercive control, domestic abuse and suicide, plus many other safeguarding matters. It gives them practical advice on how to provide the best service to a victim at the first point of contact.

"We accept the findings of both the jury inquest and the Prevention of Future Deaths Report and are due to report back to the coroner in June.

"We will continue to strive to improve the way we support vulnerable victims, working with partner agencies and other sectors.

"Throughout the difficult years since [the victim] died, her family have supported our work and ambition to improve the way we investigate these types of often hidden crimes and they remain in our thoughts."