A COMBINATION of factors were responsible for the death of Luisa Mendes, a coroner has ruled.
The 44-year-old’s body was discovered on October 25, 2012 at Christopher Taylor’s Briar Close home in Lillington where she was known to spend some nights each week along with another visitor, Nicholas White.
And following a three week jury inquest, assistant coroner for Warwickshire, Tom Leeper recorded a narrative verdict – where the circumstances of deaths are recorded without attributing the cause to a named individual – into Ms Mendes’ death.
He said: “On October 25, 2012 between 10am and 11am, Luisa Mendes was pronounced deceased at Briar Close.
“The death was due to a catastrophic bleed to the abdomen caused by a rupture to her spleen.
“The rupture was determined to be as a result of a deliberate application of force by a third party.”
On the day before Ms Mendes’ death, Warwickshire Police received an emergency call around 8.15pm but it was cut off before any details were given.
An operator returned the call and spoke with two men who said a woman was at the house who would not leave, while the woman claimed she had been assaulted.
The call was marked as a priority – requiring police to attend within one hour – and was transferred to a controller whose role was to dispatch officers to the scene.
But no-one was sent until the following morning and when there was no answer, the officer left. The police were then called back shortly before 11am following the discovery of her body.
During the course of the inquest, witnesses from the police control room accepted the call should have been categorised as ‘violent’ rather than ‘rowdy/nuisance’ and because it was graded a priority, police resources should have been deployed within one hour of the call.
The inquest heard the inspector and control room supervisor failed to notice the priority call had not been responded to within the hour.
A subsequent investigation by the Independent Police Complaints Commission (IPCC) criticised the police response and saw three police call handlers issued with written warnings.
And these criticisms were echoed by the jury, who found Luisa died from a ruptured spleen as a result of deliberate application of force from a third party after the calls from the police.
They said the failure to upgrade the emergency call to ‘violent’, an inadequate handover procedure and the errors or omissions of supervision of the police control room had also contributed to her death.
Pathologist Dr Nicolas Hunt told the jury Ms Mendes suffered from a rare condition that caused a build up of blood filled cysts on the spleen and this may have led her spleen to rupture spontaneously or over a period of time.
The court also heard how Ms Mendes was found to have cirrhosis – or scarring – of the liver, which was likely due to her alcoholism.
Both Mr White and Mr Taylor were arrested in connection with Ms Mendes’ death but were subsequently released without charge.
While in custody, Mr Taylor did confess to hitting Ms Mendes ‘four or five times’ in the stomach and ‘a few times’ in the head the night before she died.
Dr Hunt told the jury the blows from Mr Taylor could have contributed to the rupture ‘on the balance of probabilities’, but he could not be sure ‘beyond all reasonable doubt’ the injuries she sustained in the attack the night before her death were the reason why she died.
Following the verdict, Ms Mendes’ family said they hoped lessons would be learned.
Nancy Collins, a specialist lawyer at Irwin Mitchell, which represented Luisa’s brother Vitor, said: “The family feel strongly that more could and should have been done to help Luisa when she was at her most vulnerable.
“They hope that lessons will be learnt from the inquest and the various investigations to prevent other vulnerable individuals suffering in similar circumstances in future.
“The Domestic Homicide Review in particular flags some important issues in relation to domestic abuse. and the family hopes the review’s recommendations for domestic violence and abuse policies will be developed and updated on a national level by all agencies involved.”
Luisa’s brother, Vitor added: “We were all devastated and heartbroken by my sister’s death. We just wanted to find out exactly what happened and why the police didn’t help her when she needed them most.”
Commenting at the conclusion of the inquest, Warwickshire Police and Crime Commissioner Philip Seccombe, admitted there had been failings in the police’s response to the incident.
He said a formal apology had been made by Warwickshire Police to Ms Mendes’ family and significant work had been carried out to minimise the chances of a similar situation occurring again.
He added: “This was a tragic case and Warwickshire Police has fully acknowledged that there were failings in the way they responded to her call for assistance, which fell below the standards that both the force and the public would rightly expect.
“Since 2012, Warwickshire Police and partner agencies have also worked hard to improve the way in which they interact with each other when dealing with vulnerable people, alongside improvements to the services which support victims of crime.
“While progress to date has been significant, there is no room for complacency and work to improve the way vulnerable people are protected from harm is continuous.
“The public can also be assured protecting vulnerable people will underpin the whole of my first Police and Crime Plan when I publish it later this year.
“Similarly, the Chief Constable has stated that he is committed to ensuring that Warwickshire Police is ‘great’ at protecting vulnerable people.
“I will hold him and the force to account on that, as well as continuing to work with partner agencies to ensure that victims can be confident in the service and support they receive.”