On 26 April 2020 Georgia Barter, a long-term victim of domestic abuse, died in hospital after taking a fatal overdose of painkillers.Last week, in an extraordinary verdict, a coroner ruled that Georgia, 32, was unlawfully killed by her abusive partner.A court heard how GPs, nurses and police officers all had chances to intervene in Thomas Bignell’s violent campaign against Georgia, but failed to do so.At the conclusion of the hearing, there were gasps in the courtroom.It is believed to be only the second time in English legal history that a coroner has reached such a conclusion in the case of a suicide following domestic abuse, and the first time without a jury.

The coroner said she could not be certain whether Georgia intended to take her own life; she had told her mother that she just wanted the “physical and mental pain to stop”.The CPS has previously said there is insufficient evidence to bring charges.But Georgia’s family want this to be reconsidered following the coroner’s ruling that her death was unlawful.Bignell did not attend the inquest and when police tried to bring him in under a warrant, they couldn’t find himThis is Georgia’s story.“She had this amazing halo of golden curls,” Kay Barter says of her daughter.

“Which she hated, and everybody loved,The lollipop man at primary school used to call her Shirley Temple,”As mother and daughter, they were incredibly close,Georgia, she recalls, was “very loving, very kind, and caring”,“She’d ring me every day from work, three or four times a day, to see how I was.

She’d always tell me, every phone call, ‘I love you, Mum.’”Entering her early 20s, Georgia had a big group of friends, who she enjoyed going out with at night.She was close to her two sisters, and loved spending time with her family.Georgia had been a painfully shy child, so, at the age of four, Barter enrolled her in dance lessons.“And she shone,” Barter says.

“She loved it from the first lesson, and she gained in confidence because of that, and her happy time was being on stage and performing.“She won many, many medals over the years, but that was never who Georgia was.She just wanted to take part, she just loved being up there.”Georgia dreamed of being a professional dancer but knew the odds were against her, so she began working in recruitment instead.But, Barter says, “she always regretted not carrying on with her [dance] career”.

Georgia was also generous to a fault.She once noticed lots of small transactions leaving her bank account every month, and didn’t know where the money was going, until she realised they were all the charities she had signed up to donate to.And “she was so funny”, Barter says.“She was an amazing mimic, and we used to say she could be a standup comedian.Her sense of humour was just fantastic.

She used to have us all in hysterics.”When Georgia was 19, she was sexually assaulted by a man after a night out.Her attacker was later convicted and jailed, but Georgia was deeply affected by the assault, found the the trial traumatic – particularly cross-examination by his defence counsel – and was later diagnosed with post-traumatic stress disorder, anxiety and depression.Not long after, she was introduced to Bignell, then going by the name Ryan Johnson, by a friend, and the pair began a relationship, which, her mother says, quickly became very intense.The inquest at East London coroner’s court heard that throughout their 11-year on-off relationship, Georgia was subjected to domestic abuse and coercive control.

“There were many, many times throughout the relationship where I noticed he had marked Georgia,” Barter told the court.“He thought nobody could see it.” Once, she says, her daughter “looked like a victim of a road traffic accident”.Barter told the court that Georgia was controlled by Bignell financially.He would move her to live in different places, she would be forced to quit jobs and he would deprive her of basic necessities, such as food, hot water and electricity.

Evidence from a paramedic, James Lambert, detailed how Georgia had been taken to hospital in April 2020 after she told her sister she had taken an overdose.Lambert’s notes, read to the court, said she told him Bignell had kicked her and stamped on her face; her injuries were consistent with her description, the court heard.Lambert said Georgia had bruising on her arm consistent with grab marks.Addressing Lambert, as she read from his statement, the assistant coroner Dr Shirley Radcliffe said: “She told you he’d done this before, and was a violent man.”It was not the first time medics had treated injuries Georgia said were caused by Bignell.

A few weeks earlier, the court heard, she had arrived at a hospital in Kent bleeding, having told ambulance staff that Bignell had sexually assaulted her.Georgia left the hospital with the cannula still in her arm; it is believed she left with Bignell, the inquest heard.Hospital staff phoned Georgia and asked her to return, but she did not.The police were not informed.A nurse did make a safeguarding referral, which resulted in a call from a domestic abuse charity, but not until several weeks later.

A spokesperson for East Kent hospitals said: “We offer our condolences to Georgia Barter’s family.”In 2012, Surrey police were called to reports that Bignell had hit and kicked Georgia at a hotel.He was arrested and taken into custody, but was not charged in relation to the alleged assault.A spokesperson for Surrey police said they were not a named party in the inquest but “we will review any findings from the coroner if they are shared [with] our force”.The inquest heard the Met and Essex police received multiple reports about Bignell’s alleged abuse of Georgia, including once when a member of the public told Essex police that Bignell had made threats to kill Georgia.

Although Bignell was arrested several times, he was never charged with any violent offences against Georgia.A spokesperson for Essex police said on one of its three contacts with Georgia “the service provided by officers did not reach the incredibly high standards we would expect”.“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,” the spokesperson said.“In the six years since Essex police attended the third of the three incidents, we have made significant strides in the identification, awareness and response to coercive and controlling behaviour.”Bignell had at least one conviction related to violence against another woman, however no disclosures were made to Georgia under Clare’s law, which allows police forces to provide women with information about a partner’s violent past.

And when he was arrested in relation to alleged assaults on Georgia, officers apparently did not have either the capacity or the authorisation to check the police national database, so were not aware of the full extent of his alleged offending history across at least four police areas.After Georgia’s death, Bignell was investigated again and the Metropolitan police passed a file to the CPS, but it declined to charge him with any offences due to insufficient evidence.After Georgia’s family requested a review of the case, again, the CPS did not authorise charges.As the details of the couple’s relationship were laid out before the coroner, what appears to be a litany of missed opportunities emerged.Bignell was due to give evidence at the inquest into Georgia’s death but he did not appear.

A bench warrant for his attendance was issued but, the court heard, police had not been able to find him,His mother, Lesley, gave evidence, saying she had never witnessed any abuse of Georgia by her son,“It’s shocking if it’s true,” she told the inquest,“But I can’t believe that, knowing Tom as a character and a person,”The Guardian was not able to reach Thomas Bignell for comment.

Georgia had reported the domestic abuse with several different health services.At no point in the years before her death was a multi-agency risk assessment conference referral made – a meeting of professionals designed to safeguard someone at risk from serious domestic abuse.Such referrals can be made without the consent of the person concerned.In March 2020, Georgia visited a GP, Dr Jakir Ullah, and disclosed that she had been assaulted by her boyfriend.He offered to make a safeguarding referral, he told the court, but Georgia declined, and he said he did not want to make one against her wishes.

The year before, she had disclosed domestic abuse to another GP, Dr Philomina Mridha, who, again, had not made a safeguarding referral.Georgia had been referred to mental health services, but was on a waiting list for individual therapy.She had been offered group therapy, but did not feel this was suitable.“In that situation,” Barter says, “the last thing you want is to sit in a room full of strangers, and she was just put on another waiting list.“Also, she was assessed by the mental health team, and that’s when she was put on a six-month-plus waiting list, and she was advised to read a self-help book by Jeffrey Young, How to Reinvent Your Life.

”A spokesperson for the East London NHS foundation trust said: “We have reviewed the coroner’s report and acknowledge matters of concern raised.“We remain fully committed to learning from lessons in relation to mental health assessments and monitoring of risk while people are awaiting interventions.”The umbrella of public services that was meant to protect Barter’s daughter failed to do so, she says.“The failings are systemic.” Police officers and health professionals, she believes, failed to understand the extent of the impact that domestic abuse and coercive control can have on a woman’s life, health and presentation.

Barter says that, as a result of the abuse, Georgia had turned to alcohol, and often when the police turned up, she and Bignell had been drinking.This, Barter believes, is in part why her daughter’s cries for help were dismissed.“I believe there’s a systemic failure in the police force, not just in London, everywhere, and I believe that these young women, they’re judged,” she says.“Georgia said she felt judged.She felt ashamed and judged, and this is what the police forces made these women feel like.

“I still believe a lot of police officers believe these women are just as bad, because if they weren’t, why don’t they leave? If only they realised, if only they understood, the impact of coercive control on these women.”The coroner stated: “On or around 5 April 2020 [Georgia] had been assaulted by her long-term partner, who had been violent towards her on a number of occasions during their relationship.“There was clear evidence of her being an individual with a psychiatric history of post-traumatic stress disorder, anxiety and depression which had been exacerbated by her partner’s behaviour.”Inquests have a different burden of proof to criminal courts, finding on the balance of probabilities, rather than the criminal threshold of beyond reasonable doubt.There is no criminal due process and nobody is convicted or acquitted.

Bignell has not been charged with or convicted of any offences in criminal court in relation to his alleged violence towards Georgia or her death.Last year, research found that for the second year in a row, suicides following domestic abuse had outnumbered homicides by partners.The Domestic Homicide Project found that in the year to March 2024, 98 people were suspected to have killed themselves after experiencing domestic abuse, while 80 people were killed by a partner during the same period.Barter wants Bignell to face criminal prosecution for the alleged abuse of Georgia and her death.And she wants police and prosecutors in all cases to make more effort to prosecute alleged perpetrators of domestic abuse before a death.

“Justice hasn’t been done,” she says.“Justice hasn’t been served and he’s still a danger to women.He’s been doing this for so long, and there’s so many vulnerable young women out there, and the fact that he’s a DJ, he’ll have the opportunity to meet many young women.“The law must be changed and these suicides must be recognised for what they are.It’s not suicide.

These women are crying out in pain.They need to investigate why these women have become so desperate.“I hope this brings much-needed change, and the connection between domestic abuse and coercive control and suicide.This isn’t suicide; this is manslaughter.“And there are so many women that have lost their lives, and they’re too quick to put a label of suicide; they need to look at the bigger picture.

”There have only been a handful of cases in which the CPS has sought to bring a prosecution for manslaughter in such circumstances.The most recent was that of Keina Dawes.The 23-year-old hairdresser killed herself after two years of domestic abuse and violence, leaving a note on her phone that read: “I was murdered.Ryan Wellings killed me,” referring to her former partner.After a six-week trial this year, Wellings was cleared of manslaughter but found guilty of assault and coercive and controlling behaviour, and jailed for six-and-a-half years.

After the case, the assistant commissioner Louisa Rolfe, the National Police Chiefs’ Council lead for domestic abuse, said police forces would seek to charge more domestic abusers with manslaughter after their partners took their own lives.Kate Ellis, from the Centre for Women’s Justice, said: “It is suspected that more women actually take their own lives following domestic abuse than are killed by their partners – yet there is a serious failure on the part of authorities to record domestic abuse-related suicides, and there have been hardly any prosecutions for this crime.”It is believed there has only been one successful prosecution of this kind.In 2017, Nicholas Allen, then 47, was given a 15-year extended sentence for the manslaughter of Justene Reece, 46, who took her own life.She had left a note saying she had “run out of fight” after six months of threats from Allen, who had stalked her after she left him and moved to a women’s refuge