A report into the brutal murder of young mum at the hands of her ex-partner concluded that there were 'missed opportunities' to protect her.
Regan Tierney, 27, was found stabbed to death by her dad at her Salford home in June 2019.
Her former boyfriend Daniel Patten, 31, was discovered at the same address with critical injuries and died in hospital two days later.
Police confirmed at the time of the incident that no-one else was involved and that they were treating the tragedy as a murder suicide, Manchester Evening News reports.
Miss Teirney had been abused by Patten for several years before she was eventually able to leave him and meet a new partner.
Her family allege Patten struggled to accept his relationship had ended.
Just days before her death, Regan made a phone call to police reporting that he had threatened to 'put her head on a stick,' believing she was in danger.
But a three-day delay to record the report by GMP meant that by the time the force made contact with her, Miss Tierney had 'lost confidence' and decided not to take the matter further.
A Domestic Homicide Review was commissioned by Salford Community Safety Partnership, following concerns about Regan's contact with GMP and other agencies prior to her death.
The report found that a number of opportunities were missed by services including GMP, GP practices, Bolton NHS FT services, Greater Manchester Mental Health Foundation, and Salford Royal NHS Trust.
During their 10-year relationship, Regan was subject to coercive and controlling behaviour, intimidation, verbal abuse, physical violence and threats, at the hands of Patten.
But despite disclosing that she had been the victim of domestic violence to several professionals, the review found that Miss Tierney was never referred to specialist domestic abuse services.
Just eleven days before her death, on May 25, 2019, Regan called police to report that Patten was being abusive to her whilst he was collecting their children.
The relationship had ended by this point but the pair remained in contact to arrange visitation with their two young children.
Miss Tierney told police that Patten had threatened to 'put her head on a stick' and that she believed he was a danger to her but not to the children.
The review found that the same evening, Regan's father, Dave Tierney called police to report the matter, however, the call handler 'refused' to take details from him.
Mr Tierney called back a short time later, but the call handler noted that he was 'rude' and may have been intoxicated, and refused to discuss the matter with him.
The report made by Regan was not 'serviced' by police until May 28, at which point she did not want to make a statement.
And by the time of her murder a few days later, officers from Greater Manchester Police hadn't followed up the incident with Patten, the report found.
"The actions of the call handler did not comply with GMPs Third Party Reporting Policy and represent a missed opportunity to offer safeguarding advice and add further information to the incident log," the review noted.
A panel concluded that had police attendance not been delayed, this may have changed the way Regan reported her concerns.
After the passage of time, the lack of contact from Patten "may have influenced" the way Miss Tierney "minimised the threat when she eventually spoke to with an officer," they said.
The review also found opportunities to protect Regan were missed by Bolton NHS Foundation Trust A&E after she presented with a broken nose in October 2012.
Miss Tierney told hospital staff that it was Patten who had caused the injury, but there was no consideration by staff at the trust to refer her to specialist domestic abuse services.
Greater Manchester Police also undertook a risk assessment with Regan following the assault, which was marked as 'standard risk,' but then increased to 'medium risk.'
The report found that given the "severity" of Miss Tierney's injuries, the risk could have been assessed as high which would have lead to a referral to MARAC - Multi-Agency Risk Assessment Conferences.
"This was a missed opportunity to safeguard (Regan)," it found.
Whilst Patten was eventually prosecuted for the assault, there were no risk assessments or safety planning put in place for Regan, the report added.
Regan had also made disclosures that she had been the victim of domestic abuse at the hands of Patten during a therapy session with Greater Manchester Mental Health Foundation Trust (GMMH).
The panel found there was "no attempt" to gather further information about Patten, or "any consideration" about referring her to a specialist domestic abuse service.
"This was a missed opportunity to explore current risks with (Regan) and to discuss and make a referral to specialist domestic abuse services and to share information with other services," the review concluded.
During her therapy sessions with GMMH, Miss Tierney also told professionals about Patten's coercive and controlling behaviour, the report found.
There were suggestions that Regan may have taken out a loan to pay for Patten's debts, and she also retracted reports of domestic abuse on more than one occasion.
The panel found that Regan was provided information by her therapist about the 'Women's Centre' but there was "no indication of any attempt" to explore the impact of Patten's behaviour on her.
"None of the agencies who were aware of domestic abuse explored the impact of coercion and control on (Regan)," they concluded
Miss Tierney also visited her GP on numerous occasions with what were described as 'risk indicators' for domestic abuse, including anxiety, depression, and postnatal depression.
The review found that neither her GP or other health agencies explored a "potential connection" between these presentations and the possibility that Regan was a victim of domestic abuse.
The panel also noted several examples of practitioners not recording information across a number of agencies.
The most significant example related to Patten's contact with the National Probation Service between 2012 and 2014.
"There are a number of examples of information not having been shared in a timely way or at a time when agencies may have been unable to receive it," the report concluded.
The review also stated that despite the known risk factors in their relationship, both Miss Tierney and Patten were actively involved in parenting children, which brought them into contact with each other.
A post-mortem examination found that Regan had died as a result of multiple stab wounds.
Police informed the Domestic Homicide Review Panel that indications are that Miss Tierney was murdered by Patten, who then attempted to take his own life by hanging.
He survived this attempt, but later died in hospital as a result of his injuries.
Following Miss Tierney's death, GMP made a referral to the Independent Office for Police Conduct (IOPC).
At the time the Domestic Homicide Review was published in September 2021, the IOPC's report had not been published.
In March 2021, the Home Secretary described GMP's treatment of Miss Tierney's case as 'deeply disturbing.'
It emerged that in a letter earlier in the year, Priti Patel told Regan's father, Dave Tierney: "Your daughter's death is a tragedy that should have been prevented."
The Home Secretary's letter appeared to link Regan's case to the underperformance which led to GMP being placed in 'special measures' by inspectors.
Miss Tierney was described by her family as a lovely young woman who had "everything to live for."
In a statement released following her death, they said: "She was a loving mum who loved family life, she will be greatly missed by her two children and family.
"Regan was taken from our lives too soon. She was a beautiful daughter, granddaughter, sister, niece, and an amazing mother. We will forever cherish the memories."
Mr Tierney previously told the M.E.N he still suffers from anxiety, depression and Post-Traumatic Stress Disorder from the ordeal of having found his daughter's body.
And Regan's two children have now been legally adopted by her sister Shannon.
Reacting to the Domestic Homicide Review, Mr Tierney said the findings had vindicated many of the concerns raised by his family.
"They have done this review and it has drawn on so many failings on the part of GMP," he said.
"We are happy with the report.
"They (GMP) classed her as a standard risk all the way they and they missed so many opportunities to pick up on things. They should have followed through."
A pre-inquest review into Miss Tierney's death is due to take place at Bolton Coroner's Court next month.
Councillor David Lancaster, lead member for environment, neighbourhoods and community safety, said the review was carried out by Salford Community Safety Partnership and looked at the interactions of many different agencies with the young woman involved.
“This was a tragic incident in which a young woman’s life was taken by a coercive, controlling and abusive partner. Our thoughts are very much with her family and friends,” he said.
“The lessons learnt from this tragic situation have been shared with all agencies. Whenever there is any suggestion of opportunities being missed, it is taken extremely seriously and the partner organisations continue to work together to learn from any mistakes that were made. Salford Community safety Partnership will continue to monitor progress against those actions.”
Detective Superintendent Chris Packer said: "Firstly our thoughts remain with this young woman's family and loved ones.
"Since her death, GMP has remained committed to working with partners to establish whether any more could’ve been done to prevent this tragedy.
"The findings of this review have been shared with all agencies, and we will carefully consider any learning identified.
"Domestic abuse remains one of the highest priorities for GMP, and we continue to adapt our approach and work with our partner agencies to ensure we are playing our part in protecting the vulnerable members of society."
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- Women can call The Freephone National Domestic Abuse Helpline, run by Refuge on 0808 2000 247 for free at any time, day or night. The staff will offer confidential, non-judgemental information and support
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