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.”

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.

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.

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.”

www.thehotline.org. In the United Kingdom, call 0808 2000 247, or visit www.nationaldahelpline.org.uk.

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