06 Oct Georgia’s inquest concludes Unlawful Killing resulting from domestic abuse

Before Assistant Coroner Dr Shirley Radcliffe

East London Coroner’s Court

22 September 2025 – 2 October 2025

CONTENT WARNING: This note contains themes of domestic abuse, sexual violence and self-harm.

By the time of her death, Georgia Barter had suffered around a decade of domestic abuse by her partner. After being violently assaulted by him on or around 5 April 2020, Georgia took a fatal overdose. She died at Kings College Hospital on 26 April 2020.

After seven days of very distressing evidence, the Coroner Dr Shirley Radcliffe concluded Georgia’s inquest on 2 October 2025. She found that Georgia was unlawfully killed and that she died as a result of domestic abuse. We understand Georgia’s inquest to be only the second time that such a finding has been reached at an inquest in the context of a self-inflicted death by a woman following domestic abuse (coming in the wake of the groundbreaking inquest that investigated the death of Kellie Sutton) and the first time by a Coroner sitting alone (without a jury). The perpetrator has not to date been convicted of any criminal offences relating to the matters that were within the scope of this inquest.

Over the course of the inquest, substantial evidence from senior officers at the Metropolitan Police and Essex Police was heard as well as expert evidence from two psychologists with specialist knowledge of domestic abuse and its impact. The Coroner expressed grave concern about the prevalence of domestic violence nationally and she has issued a Report to Prevent Future Deaths to the Home Secretary, seeking improvements to the way that the Police National Database is utilised saying: “[Front line officers] are unable to easily identify if the individual has a history of reported domestic abuse in areas outside the forces’ borders. This would allow police to be more proactive in their dealings with victims of domestic violence […] This is on a background of rising numbers of domestic violence cases in this country.”

Georgia Barter was a much-loved young woman by her family and friends who dreamed of becoming a professional dancer. She began going out with her partner when she was around twenty-two years old and over the course of their relationship, her mother feared and fought for Georgia’s safety from domestic abuse. Georgia and her partner had repeated contacts over the years with various police forces and healthcare settings, including Georgia’s GP, mental health services, ambulance services and hospitals. The Coroner identified that there were missed opportunities for a multi-agency response to the domestic abuse that Georgia was subjected to, albeit she did not consider herself able to say that such a response would have prevented Georgia’s death.

The report of an expert psychologist explained: “Victims of coercive control commonly report feeling extremely frightened of the perpetrator and full of self-doubt regarding whether or not what they are experiencing is severe enough to warrant care, support and intervention (commonly because “gaslighting” causes people to doubt or blame themselves). In order to feel confident enough to leave a coercive and controlling relationship (particularly with someone they are extremely frightened of), victims need ongoing support, validation and some kind of assurance that they will be safe and protected if and when they decide to leave. Inadequate support and validation provided by the police and other professionals providing assessment and support in these cases can result in victims deciding against pressing charges or continuing with a particular legal case”.

Both the Metropolitan Police and Essex Police accepted that more needs to be done to take positive action on domestic abuse. There were missed opportunities to arrest the perpetrator and to make a MARAC[1] referral. Evidence was given about sweeping changes that have been made, in particular by Essex Police, and the importance of deepening the understanding by the police of how, for example, Clare’s Law Right to Know disclosures can be enormously empowering for victims when they see how previous abuse mirrors what has happened to them. In healthcare settings, some of the changes included increased access to hospital or healthcare IDVAs[2] and the possibility of 24/7 access to domestic abuse safeguarding advice.

Georgia’s mother, says:

“This ruling won’t change anything for my family and I and it won’t bring my beautiful daughter back. Nothing will ever put this heartbroken mother back together again. My darling Georgia was a beautiful, kind soul whose generosity touched everyone around her. It took Georgia a very long time to ask for help because she felt judged and ashamed. In the end, Georgia did reach out for help but the support wasn’t there for her. All I want now is to shine a light on the epidemic of domestic abuse which is killing women. I say to the powers that be NOW IS THE TIME FOR CHANGE.”

The solicitor for the family, Clare Hayes, says:

“The coroner’s finding of unlawful killing vindicates Georgia’s mother’s fight for justice on behalf of Georgia and makes it a matter of public record that Georgia died as a result of domestic abuse. We have heard tragic evidence about the horrifying abuse that Georgia suffered over many, many years and the barriers to escaping a coercive and controlling relationship. This inquest has revealed evidence about the role of domestic abuse and importantly coercion and control in Georgia’s death that has much wider significance for how the state understands gender-based violence. It has also revealed that some of the agencies involved have made potentially far-reaching changes. This is testament to the tireless efforts of Georgia’s mother in seeking accountability and change following Georgia’s death. We hope that agencies will continue to work to ensure that on a very practical level steps are taken so that police officers and clinicians exercise professional curiosity when working with victims and survivors of abuse, to piece together a fuller picture and take available steps to prevent further abuse.” 

Frank Mullane CEO, Advocacy After Fatal Domestic Abuse (AAFDA), says:

“It is testament to the resilience of Kay, Georgia’s mother and Georgia’s family and to their love for Georgia, that some justice was achieved late last week in the inquest court. The family first secured a Domestic Abuse Related Death Reviews (“DARDR”) and then stood strong for so many years to ensure that the DARDR unveiled the truth and in detail, and that the inquest reached the right conclusion that Georgia’s death was unlawful killing. It has been an honour to work with Georgia’s awesome family and the brilliant Clare Hayes of Deighton Pierce Glynn to see justice served.”

The family are represented by Clare Hayes and Maja Pegler of Deighton Pierce Glynn, Counsel is Kate Stone of Garden Court North and they are also supported by Advocacy After Fatal Domestic Abuse (“AAFDA”).

If you are affected by the issues in this release, Samaritans are available 24/7. Call 116 123 free, email jo@samaritans.org, or visit www.samaritans.org.

[1] Multi-Agency Risk Assessment Conference

[2] Independent Domestic Violence Advocates

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