Source · Prevention of Future Deaths

REDACTED

Date: 9 Nov 2020 Coroner: Caroline Topping Area: Surrey Responses identified: 1 / 2 View PDF

The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.

Date 9 Nov 2020
56-day deadline 5 Jan 2021
Responses identified 1 of 2
Suicide (from 2015)

Coroner's concerns

AI summary
The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.
View full coroner's concerns
The evidence showed that:

1. was being treated for depression by her general practitioner. She was prescribed anti-depressant medication. She had last been reviewed in February 2017. She was not open to secondary mental health provision.
2. was the subject of a MARAC referral organised by the Surrey Police on the 14th June 2017 in respect of allegations of domestic violence and coercive control which made relating to her partner.
3. general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017. General Practitioners are not routinely invited to MARAC meetings.
4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner.
5. The general practitioner responsible for treating mental health was not made aware of the allegations of domestic abuse and coercion that had made.
6. children were removed from her care in and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned. .

Responses

1 respondent
Response to Surrey coroner area Prevention of future deaths report dated
9 Nov 2020 PDF
Action Taken

• Surrey County Council stated its practice for sharing information with partner agencies has strengthened since 2017. • Surrey County Council confirmed it has implemented an Improvement Plan to secure continuing improvement over time. • Surrey County Council now routinely notifies health colleagues, including the children's GP, when a child moves into its care. (AI summary)

View full response
Dear Madam, Inquest touching upon the death of Regulation 28 Report I refer to the Regulation 28 Report dated 9 November 2020. Thank you for providing Surrey County Council an extension of time for responding to the Report. I note the main concerns you have raised at section 5 of the Report and respond as follows; Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements. In relation to Point 6, Surrey County Council recognises the importance of informing agencies involved with a family about the removal of a child. Our practice has strengthened considerably since 2017 and Children's Services has implemented an Improvement Plan in order to secure continuing improvement over time. This includes improving the way in which information is shared with partner agencies. When a child moves into our care we routinely notify our health colleagues and this would ensure that the GP would now be informed. However, this would be the GP for the children, rather than the GP for the parents and we recognise the focus in this situation was on the needs of the mother and her increased vulnerability in the light of the removal of her children. This was a point of learning identified early within the Domestic Homicide Review and action was taken immediately to share this learning across our service and to strengthen practice. We now ensure that when we are making plans to remove children into our care we consider how to manage any increased risk to the parents. If the agencies working with them are part of the children’s core group we would always contact them. If they are not we would ask the consent of the parents to contact them, or support them to make contact with them themselves. This would include GPs as well as domestic abuse services or adult services. Our practice in recognising and supporting the needs of parents has been further strengthened by the rolling out of our new practice model. In circumstances where Children's Services are supporting a family under a Child in Need or Child Protection Plan, we have now implemented the Family Safeguarding Model. This was developed for families where there are issues around domestic abuse, adult mental health and substance use and with this we now have adult specialist workers within the Children’s Social Care teams. This includes domestic abuse practitioners, domestic abuse officers (seconded from probation), adult mental health workers and drug & alcohol support workers. The focus is to enable parents to meet their needs so that they are able to safely meet the needs of their children. The adult mental health specialists are equipped to understand the behaviours of parents, bring this focus to the work with the family, and to liaise with partner agencies working with parents. The adult mental health specialists also provide training to other colleagues in order to improve the approach to information sharing from the perspective of the parents on a wider basis. These specialist workers will often liaise with GPs or others supporting parents, and were

[Page 2] we to have a similar situation now the actions of these workers would ensure a very different experience for families. They are able to focus on the needs of the parents whilst the children’s social worker focuses on the needs of the child. This ensures a far more holistic approach. All practitioners and managers within our safeguarding teams have been provided with training on the Family Safeguarding Model and completing the parenting intervention programme, in order to focus on the family unit as a whole (including the parents). The implementation of Family Safeguarding has received significant funding from the Department for Education in Surrey and is part of our Improvement Journey. The effectiveness of the model, and the difference it makes to families is being independently evaluated by York Consulting. I trust this response meets the requirements of the Regulation 28 Notice. However, if there is anything further I can assist you with please do not hesitate to contact me.

Report sections

Investigation and inquest
An inquest into the death of was opened on 6th December 2017, resumed on the 12th October 2020 and concluded on the 14th October 2020. I concluded with a narrative conclusion that: died on the 29th November 2017 at . She had tied a ligature around her neck and died by hanging. She had drunk considerable amounts of alcohol and taken cocaine. It is not possible to determine whether she intended to kill herself.

I concluded that the medical cause of death was:

1a. Hanging .
Circumstances of the death
died at her home address having consumed a considerable quantity of alcohol and cocaine. She tied a ligature around her neck and died by hanging. It was not clear if this was a cry for attention or help and whether she thought she might be found in time.

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Report details

Date of report
9 November 2020
Coroner
Caroline Topping
Coroner area
Surrey

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Jan 2021.

Sent to

Domestic Abuse Management Board Surrey Police
Surrey County Council

Part of a series

10 reports
2019-0397 0 responses identified
2020-0061 All responses identified
2022-0036 1/2
2022-0095 0 responses identified
2023-0115 0 responses identified
2024-0031 All responses identified
2025-0045 All responses identified
2025-0314 All responses identified
2026-0245 All responses identified

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