"Institutional misogyny" contributed to "clear warnings signs" being missed in the initial police investigation following the murder of showjumper Katie Simpson in Co Derry in 2020, an independent review has found.
Stormont Justice Minister Naomi Long paid tribute to the Simpson family for their "bravery and persistence" as a review found "systemic failings" by police following her murder.
The independent review led by Dr Jan Melia found that "not one (police) officer thought seriously about abuse/control" in the initial police investigation in 2020.
It concluded there was systemic failings in the police investigation and also criticised social services and the health service, making some 16 recommendations, many focused on training.
The 21-year-old from Tynan, Co Armagh, died in Altnagelvin Area Hospital almost a week after an incident in Gortnessy Meadows, Lettershandoney.
Police originally thought she had taken her own life.
It was not until the following year that Jonathan Creswell, the partner of Ms Simpson's sister, was arrested on suspicion of murder.
The trial of Creswell, 36, for the rape and murder of Ms Simpson ended in April 2024 after he took his own life following the first day of proceedings.
The report found 37 people, both female and male, have come forward to say they were abused by Creswell.
It found officers failed to identify inconsistencies in Creswell's account, neglected to preserve vital evidence, overlooked forensic scenes and opportunities, dismissed key witness statements and failed to secure/examine crucial digital communications such as text messages and phone records that might have revealed patterns of abuse.
It went on to find that police officers demonstrated a striking lack of professional curiosity, failed to employ an investigative mindset or consider the possibility of abuse/control, in spite of clear warning signs.
'No matter what you do, you will not get away with it,' says Katie Simpson's mother
In a foreword to the review's report, Ms Simpson's mother said it had been "hard to read", noting "so many things were missed, not done properly" and it felt like there was a "lack of care for Katie from the police".
Speaking at Stormont about her daughter, Noeleen Mullan said: "She might not have got the justice that she wanted, but I believe that people who think they're above the law, you’re not above God’s law.
"No matter what you do, you will not get away with it."
She added: "There needs to be definitely more safeguards around the equestrian world.
"I think girls’ love for horses is an awful drive for them and it’s very hard for young girls.
"I think other older girls that are in the industry really have to be looking around them, and looking after the young ones coming up, because there won’t be that many men who will."
'The failings are clear, we fell short,' says PSNI in apology
In a statement released this afternoon, PSNI Assistant Chief Constable Davy Beck said: "The review makes clear that we missed opportunities. Warning signs were not fully recognised early enough and we did not listen to some of those who raised early concerns. Let me be clear, they got it right and we were too slow to respond to their concerns; that was wrong.
"Patterns of coercive control were not sufficiently understood or challenged, investigative decisions did not always reflect the level of professional curiosity and rigour that should have been applied. The failings are clear, we fell short and for that, I am truly sorry.
"Policing depends on public trust. When we do not meet the standards expected of us, particularly in cases involving vulnerable women and children, domestic abuse and safeguarding, that trust is damaged. It is our responsibility to rebuild it."
The statement went on to say that the PSNI has been working to strengthen oversight and training.
Ms Long asked MLAs at Parliament Buildings to pause for a moment to remember Ms Simpson.
She said the independent review in the case "makes for uncomfortable reading", but pointed out it has been published in its entirety with the endorsement of Ms Simpson's family to allow all to read it and reflect on missed opportunities.
She described that transparency as vital.
"For too long abuse has been allowed to thrive in the shadows created by fear, silence, stigma and control," she said.
"We need to shine a light into those shadows. We need to remove the stigma and we need to speak openly and honestly about abuse. Avoiding these conversations does not protect victims, it entrenches harm.
"The only way we can truly pay tribute to Katie's memory is to learn the lessons from the circumstances that led to and, ultimately, resulted in Katie's untimely death."
The Katie Trust, set up in Katie's memory, welcomed the independent review as a "significant and necessary step toward transparency and accountability".
"What is set out within this report is not an isolated failure. It reflects a pattern we are now seeing across more than 100 families currently being supported by the trust - families left searching for answers, often in the face of unanswered questions, investigative gaps and systemic shortcomings," the trust said.
"The review also highlights broader concerns within the equestrian sector, reinforcing the need for a comprehensive review of practices while supporting the many dedicated and professional individuals working within it.
"This report must not be the end of the conversation, it must be the beginning of change."
The founder of The Katie Trust, James Brannigan, urged the PSNI to use body-worn cameras in all sudden death cases, saying: "There's immediate things the police can do today to make changes, to make things safer.
"The only police service not working with The Katie Trust at this point in time is the PSNI.
"Some of the cases that we have turned into homicides through our work has relied on body-worn footage."
