GRANTHAM, England — Daniela Espirito Santo died after waiting on hold for the police to answer her call for help.
It was the seventh time in a year that she had reported her boyfriend to the police, including for death threats and for trying to strangle her. Two of those calls came in the hours before her death. The first was in the morning, after her boyfriend pinned her on the bed and pressed his forearm against her throat.
“Is this it?” Ms. Espirito Santo, 23, had gasped, according to a police report. “Are you going to kill me this time?”
The police took him into custody but quickly released him. He returned to Ms. Espirito Santo’s apartment and soon afterward she called the police to report that he had assaulted her again. The dispatcher told her that her situation wasn’t urgent, because the boyfriend had left. He directed her to a nonemergency hotline and hung up after 94 seconds.
Just over an hour later, Ms. Espirito Santo was pronounced dead; the cause was heart failure. She never spoke to the nonemergency dispatcher. Her call stayed on hold for eight minutes, and when the dispatcher picked up, the only sounds were the cries of her 7-month-old. The police later found her slumped on her sofa, not breathing, her distraught baby cradled limply in one arm.
Her death on April 9, 2020, made Ms. Espirito Santo part of a grim statistic, one of 16 women and girls killed in suspected domestic homicides during the first month of Britain’s lockdown — more than triple the number in that month the previous year, and the highest figure in a decade. But it also illustrates another flaw in British authorities’ efforts to address violence against women: the repeated failure of prosecutors to punish abusers.
Initially charged with manslaughter, the boyfriend, Julio Jesus, then 30, was eventually sentenced to only 10 months behind bars. The Crown Prosecution Service, the national public prosecutor, dropped its manslaughter charge because of complicating medical opinions about the condition of Ms. Espirito Santo’s heart, and convicted him on two counts of serious assault. He was released before England’s coronavirus lockdowns had ended.
“There was a litany of failures where once again a woman’s voice hasn’t been listened to,” said Jess Phillips, a Labour lawmaker who speaks for the opposition on domestic violence policy. “This case shows nothing is changing, even though victims keep being promised it is.”
Britain is suffering a crisis of violence against women that has worsened during the pandemic. But fewer than 2 percent of rape cases and 8 percent of domestic abuse cases reported to the police in England and Wales are prosecuted, even as complaints are rising.
The nation was shocked earlier this year when a police officer confessed to kidnapping, raping and murdering Sarah Everard, a 33-year-old marketing executive who was abducted while walking home in South London. The crime underscored the vulnerability felt by many British women and their concern that the police and prosecutors are failing to protect them.
Parliament recently approved new legislation on domestic abuse. But changing policing and public attitudes has proved difficult for decades. Failings and missed opportunities by the police often remain hidden.
Ms. Espirito Santo’s case fit that pattern. Her death in Grantham, a market town in the largely rural English county of Lincolnshire, received little outside attention and was regarded as a tragedy, not a scandal. An inquest into her death is in limbo. Lincolnshire Police — a small force covering a wide area with a sparse but often deprived population — refused an interview, as did the Crown Prosecution Service.
But an investigation by The New York Times lays bare the escalating abuse Ms. Espirito Santo reported, gives a rare insight into police failings and raises questions about the decision by prosecutors to drop the manslaughter charge. The Times has obtained a confidential 106-page report compiled by the Independent Office for Police Conduct, an official watchdog, into the Lincolnshire force’s handling of the case.
The report documents Ms. Espirito Santo’s ever more desperate interactions with the police, revealing a haphazard response as her situation worsened. It noted that some male officers felt sympathetic toward Mr. Jesus before releasing him on bail, including one who said his “biggest concern” was the boyfriend’s mental health.
Harriet Wistrich, a prominent lawyer and director of the Centre for Women’s Justice, said some police officers and prosecutors still hold outdated, misogynistic attitudes — such as seeing domestic abuse as private, or believing that women would leave if their situation were truly serious.
Last year, The Times reported on government failings on domestic abuse at the start of Britain’s lockdowns, which left victims trapped at home with abusers and isolated from family and friends. The rules were especially constricting for people with serious health conditions, like Ms. Espirito Santo, who had to pause her job at a nursing home.
“Daniela’s case is a scandalous failing by the police to recognize someone who was at an increasing risk of domestic homicide,” Ms. Wistrich said. “But it is sadly illustrative of many cases we see.”
Lincolnshire Police refused to answer even written questions, citing concerns about prejudicing a future inquest. A spokesperson for the Crown Prosecution Service said it was determined to improve the handling of crimes against women and girls and to “narrow the gap” between “reports of these terrible offenses and cases reaching court.”
Ms. Espirito Santo’s story — pieced together by The Times through the confidential report, other documents and more than a dozen interviews — is of a yearlong cry for help that went unheard.
“Everything happened because the police didn’t help Daniela when she rang,” said Isabel Espirito Santo, Ms. Espirito Santo’s mother. “If the police had helped more, I think she could still be here.”
Ms. Espirito Santo was pregnant with her second child when she first reported Mr. Jesus to the police. It was May 19, 2019, and she told officers that he had threatened to kill her, that he was violent and controlling and “excessively jealous.”
But she did not want to press charges.
It would establish a pattern that only ended hours before Ms. Espirito Santo died. Like many victims of domestic abuse, she was desperate for help but reluctant to invoke the law. Fear of retaliation was part of the problem, but she also worried about being a single mother. And she loved Mr. Jesus and hoped he would change, her mother said. (Mr. Jesus did not respond to questions from The Times.)
Just calling the police represented a step. Her mother had come to England from Portugal in 1999 in hopes of a better life. Ms. Espirito Santo’s childhood friend Charly Price-Wallace remembers her as the “most bubbly, in-your-face person,” someone with a mischievous sense of humor who once dreamed of becoming a flight attendant.
Long before that call, Ms. Price-Wallace said, her friend confided in her about problems. She said Mr. Jesus had emptied Ms. Espirito Santo’s bank account soon after their daughter’s birth to buy drugs. Once, Mr. Jesus beat Ms. Espirito Santo after she confronted him, leaving her with a “massive black eye,” Ms. Price-Wallace said.
“Most of the violence was down to him taking money for drugs and her questioning him,” said Ms. Price-Wallace, which corroborates Ms. Espirito Santo’s reports to the police.
Ms. Espirito Santo called the police three more times over the following months. In her fourth call, on Nov. 6, she said Mr. Jesus had pushed her and “grabbed her jaw and turned her head whilst restraining her arm,” according to the watchdog report; she had bitten his cheek in self-defense. A male officer said he “gave both parties words of advice.”
Then on Dec. 29, a “hysterical” Ms. Espirito Santo made her fifth call, telling the dispatcher that Mr. Jesus had “got in her face and grabbed her so hard she could hardly breathe” on Christmas Day, according to the watchdog report. The next day, she said, he had slammed her against a wall.
Two officers were dispatched as a “priority.” Because of staffing shortages, they arrived nearly four hours later. The lead officer noted that the couple had “communications issues” and that he was “not concerned.”
The police never acted on the escalating pattern. Ms. Espirito Santo’s reluctance to press charges was an obstacle, but the authorities are able to prosecute without a victim’s support. They could also have pursued civil options like a restraining order, or offered victim support services.
And the British authorities agree that the onus shouldn’t have been on Ms. Espirito Santo. In 2014, a policing watchdog’s examination of domestic abuse complaints stated that it was officers’ job to “build the case for the victim, not expect the victim to build the case for the police.”
‘Is This It?’
Fifteen hours before she died, Ms. Espirito Santo made her penultimate call to the police. It was 9:48 a.m. She told the operator that Mr. Jesus had thrown her on the bed and grabbed her neck, leaving a mark. He had left, but not before pinning her with the front door and threatening to kill her. When two officers arrived, she agreed to support a prosecution.
She told the officers that she had “lost count” of how often Mr. Jesus had assaulted her, often squeezing her neck so tightly that she struggled to breathe. She said that he sometimes slammed her against furniture, that he had once broken her finger, and that she was afraid he might kill her.
Two hours later, Mr. Jesus was arrested, crying as he was taken into custody. Later that afternoon, Ms. Espirito Santo called Ms. Price-Wallace and said the police had told her that Mr. Jesus would be released pending a charging decision.
“She was in tears, she was petrified, she was begging me for help,” said Ms. Price-Wallace.
“My last words to her were: ‘You need to get out, because he’s going to kill you,’” she said.
Before his release, Mr. Jesus promised not to visit Ms. Espirito Santo’s apartment or contact her. In police witness statements, the male custody officers described him as “remorseful,” with one adding that he seemed no “threat to anyone.” The same officer later said he “forgot” to record a bail address for Mr. Jesus, who had said he would stay with his sister, though he was known to be estranged from her.
Officers had also gotten a new directive to detain fewer suspects as a way to avoid spreading coronavirus. Mr. Jesus was freed at 6:04 p.m., with no police supervision. Twenty minutes later, he sent Ms. Espirito Santo a message on Facebook, violating the terms of his release.
“Why?” he asked.
“You’ve left bruises on me again,” she replied. “I just wanted us to be a happy family, but every time I try there is something.”
By 8:10 p.m., Mr. Jesus had arrived at Ms. Espirito Santo’s apartment, cellphone data shows. Three hours later, she made one last call for help. She said Mr. Jesus was on bail and had left her “hurt” and “covered” in marks. The police dispatcher did not check Ms. Espirito Santo’s address or ask her name, call transcripts show, meaning he was unaware of her previous calls for help.
He did confirm that Mr. Jesus had left, though the call would be over before the boyfriend’s car was seen leaving the area.
“So you don’t need an ambulance at all?” the dispatcher asked.
Ms. Espirito Santo seemed confused, replying “Yeah, no.” The dispatcher told her to call the nonemergency number.
After hanging up, the dispatcher checked Ms. Espirito Santo’s location and realized his mistake. Only then did he see that a police warning — a Critical Register Marker — had been placed on her address that morning. Any call from there was to be treated as “urgent.” He quickly dispatched officers but it was too late.
Soon after 1 a.m., the police visited Isabel Espirito Santo to tell her that her daughter had died.
“My god,” she remembered thinking. “What happened to my life?”
The ‘Perfect’ Crime
In spring, a couple of weeks before the trial was scheduled to begin, the police knocked again on Isabel Espirito Santo’s door and told her that prosecutors were dropping the manslaughter charge against Mr. Jesus for lack of evidence.
She wept. “I said to the police, this is one perfect crime,” she recalled. “Because Julio knows what happened — he knows that if he stresses Daniela, she could die.”
In 2015, Daniela Espirito Santo had been diagnosed with a cardiac condition involving an inflammation of the heart. A post-mortem examination on behalf of the authorities concluded that the assaults might have triggered her heart failure.
Under English law, an “unlawful and dangerous” act can qualify as manslaughter if it leads to a death, even if the killing was unintentional. Those found guilty can face up to life in prison.
But prosecutors decided to drop the charge after a cardiologist hired by Mr. Jesus’s lawyers argued that while the assault could have caused the heart failure, so could a verbal argument.
Prosecutors concluded that they could no longer meet the tests for a manslaughter conviction by proving that the heart failure was caused by an assault, a spokesperson for the Crown Prosecution Service said.
That was despite the fact Ms. Espirito Santo had reported an assault, not an argument, minutes before her death; despite Mr. Jesus’s admission that he had assaulted her that morning; and despite her history of domestic violence complaints.
The official watchdog report on Lincolnshire Police found that the “decision making of its officers may have influenced the circumstances of the events” around Ms. Espirito Santo’s death, if not caused it, and blamed officers for a “lack of detailed consideration of Mr. Jesus’s situation” on release.
Yet the report did not recommend disciplinary action and mentioned only one “potential learning recommendation” — for a formal policy around sending calls to the nonemergency number, a change that has been introduced. In a statement to The Times, the watchdog agency said it had also made “learning” recommendations for two officers on how they interacted with Mr. Jesus.
Nicole Jacobs, the domestic abuse commissioner, a new role created by the government, criticized the police and prosecutors for not having “a full understanding of domestic abuse, or a recognition of the seriousness of the abuse.”
“The events leading to Daniela’s death are shocking and tragic, but these failures are not rare,” Ms. Jacobs said. “In Daniela’s case there is ample evidence that abuse was escalating and that she was increasingly worried about her safety.”
Weeks after Mr. Jesus walked out of prison in March this year, Britain’s Parliament passed the Domestic Abuse Act. It was a response to growing outrage over failures in abuse cases. For the first time, the law established that nonfatal strangulation — which Ms. Espirito Santo repeatedly reported — is a criminal offense, bringing up to five years in prison.
Since such strangulation usually does not leave marks, the police often fail to recognize it as a serious crime. Prosecutors, in turn, do not bring more serious charges. Advocates for abuse victims have welcomed the law but say it will change little unless police and public prosecutors are educated in using it, and given proper resources.
On July 5, on what would have been Ms. Espirito Santo’s 25th birthday, her mother and two dozen others scattered her ashes at her favorite spot, a lake in the Lincolnshire countryside. Her grandmother gave a reading in Portuguese by the water’s edge. Her mother wept.
“I didn’t get justice in court,” she said. “But I believe in justice of the gods.”