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29 April 2019, 13:18 | Updated: 30 April 2019, 06:16
Justene Reece's ex admitted manslaughter, controlling behaviour and stalking after she took her own life.
Staffordshire Police failed to cross-reference almost half the incidents involving a serial stalker who drove his ex-partner to take her own life by bombarding her with abusive voicemails, texts and Facebook messages.
Justene Reece took her own life following sustained harassment by her ex-partner, Nicholas Allen, who was jailed for 10 years at Stafford Crown Court in June 2017 after admitting manslaughter, engaging in coercive or controlling behaviour and stalking.
The 46-year-old woman was found hanged at her home in February 2017 after leaving a note saying she had "run out of fight" following six months of threats from Allen.
The Independent Office for Police Conduct (IOPC) said it looked at the effectiveness of Staffordshire Police's response to 34 incidents either directly involving or connected to the 46-year-old between September 2016 up until her death.
Of the incidents, 16 were not cross-referenced with any previous ones, and many of the remainder were only cross-referenced to one other incident rather than to a range of them.
The IOPC said seven of the 14 incidents reported by Ms Reece were not cross-referenced at all.
In six of 13 domestic incidents recorded, a mandatory domestic abuse risk assessment was not carried out, which was in breach of force policy, the IOPC added.
Staffordshire Police have now accepted training recommendations to improve the linking of incidents and crimes.
The force agreed that the performance of a retired senior officer was unsatisfactory in relation to advice given not to arrest Allen for a reported breach of a non-molestation order (NMO) in December 2016 - but concluded it did not amount to misconduct.
The IOPC said it was one of seven NMO breaches by Allen that Ms Reece reported to the force during the period under investigation.
Seven officers and a member of police staff are also set to receive management advice as their performance had not met expected standards in relation to issues such as call handling and not completing risk assessments.
IOPC regional director Derrick Campbell said: "Our sympathies are with the family of Justene Reece and all those affected by her tragic death.
"It is evident from our investigation that there were potential opportunities for the police to engage more robustly with Mr Allen.
"Officers were largely deployed to incidents appropriately, but a failure to cross-reference incidents led to them being treated in isolation, and a lost opportunity to recognise the scale of Mr Allen's offending."
Mr Campbell continued: "The bigger picture of the level of harassment and stalking being perpetrated was not properly seen by police.
"We took the view that the prevalence of inconsistent practice among call handlers in cross-referencing indicated a training issue for the force, rather than a series of unrelated errors by individuals.
"I am pleased that Staffordshire Police has accepted our learning recommendations that all staff and officers who use the relevant systems should be further trained in the effective cross-referencing of incidents and crimes.
"This case has shown its importance, along with effective research checks, in helping police to join the dots and safeguard vulnerable people."