A mother who died hours after reporting an assault by her partner to the police was unlawfully killed, an inquest jury has concluded.
Daniela Espirito Santo, 23, was found unconscious at her property in Chestnut Grove in Grantham, Lincolnshire, after calling police to report an assault by her then-partner Julio Jesus, who had been released on police bail, before she died in the early hours of April 9 2020.
The jury, which heard the inquest at Lincoln Coroner’s Court, returned its verdict on Wednesday and found she died as a result of “severe emotional stress” caused by an assault which led to sudden cardiac death.
The jury heard that shortly before midnight on April 8, Ms Espirito Santo dialled 999 but was told to ring 101 by the police call-handler instead.
Ms Espirito Santo was then kept on hold for eight minutes before anyone answered, and by the time they did, the handler could only hear her six-month-old baby crying.
Ms Espirito Santo suffered from a heart condition called myocarditis and died that night as a result of myocardial insufficiency “precipitated by an altercation”, the jury found.
Police interviews with Mr Jesus following his partner’s death confirmed he was “fully aware” of the seriousness of her condition and how dangerous it could be.
Ms Espirito Santo had called Lincolnshire Police multiple times between May 2019 and her death in April 2020 about the domestic abuse she endured with Mr Jesus.
He was arrested on April 8, the day before his partner’s death, after he allegedly pinned down Ms Espirito Santo and restrained her throat.
He was released on bail at 6pm that evening on the condition he did not go to her address or contact her, but he breached these conditions shortly after, the jury was told.
Dr Jacqueline Sebire, an assistant professor who has decades of experience in policing, previously told the inquest it was “inconceivable” that Mr Jesus was released on bail to live in his car around 200m away from where the assault happened.
Dr Sebire said there were other “missed opportunities” including the fact police officers did not identify or report Mr Jesus for coercive and controlling behaviour, and that incidents of domestic abuse were dealt with “in isolation”.
She added that key decision-makers’ domestic abuse training was outdated and that updating this would have been helpful in identifying coercive and controlling behaviour.
The jury spokesperson added: “If these actions had been carried out, then the former partner on balance would have remained in custody.”
Chief Constable Paul Gibson, of Lincolnshire Police, said: “Following the conclusion of the inquest into the death of Daniela Espirito Santo, our thoughts today are with her and her family and friends – in particular her two children.
“The jury have identified that Lincolnshire Police could have done more in our interactions with Daniela, and with her then-partner.
“We apologise to Daniela’s children, her family and her friends for the suffering they have endured since her death, and for where we could have done more.
“There is more work to be done in our prevention of and response to domestic abuse, along with the changes already made and we can speak about those later, for today we send our sincere condolences to Daniela’s family and friends.”
The family of Ms Espirito Santo said the inquest has “finally given Daniela a voice”.
They said: “Daniela was the most caring, loyal, heart-warming person. She was the light in a room. She would never judge anyone, ever.”
Coroner Paul Smith concluded the inquest by addressing her family and said: “It has undoubtedly been a very difficult three weeks for all of you, I’m aware.
“Nothing I, or the jury, can say today will change the tragic events of the 8th of April or take away the sense of loss I am sure you continue to experience.”