Lincoln review

The Safer Lincolnshire Partnership should ask partners for assurance that information sharing agreements are in place and being adhered to by all agencies.

The Safer Lincolnshire Partnership is fully aware that agencies in Lincolnshire have taken part in scoping an options appraisal to look at interventions/provisions which improve communication, information sharing and integrated working amongst agencies. The Safer Lincolnshire Partnership should ask partners to ensure as an outcome from this scoping exercise, that there is a process in place to share information, including the ability to analyse information and take appropriate action that provides individualised safeguarding plans as appropriate.

The Lincolnshire Suicide Prevention Steering Group, with the assistance of Public Health, need to update the Lincolnshire Suicide Prevention Strategy to include specific reference to Domestic Abuse and ensure it is ambitious and should seek to have a ‘Zero Suicide Ambition’.

In the short term, the Lincolnshire Suicide Prevention Steering Group request that all statutory agencies sign up to this suicide prevention strategy. In the longer term all agencies whether statutory or voluntary sign up to the suicide prevention strategy.

The Suicide Prevention Steering Group should consider implementing a process to review all or at least a proportion of suicides similar to the process already in place for reviewing childhood deaths. This will enable agencies to share and learn lessons with the intention of preventing future suicides, in particular those that involve Domestic Abuse.

The Safer Lincolnshire Partnership, have completed a mapping exercise, in relation to adopting a process that is similar to a Multi-Agency Risk Management Process (MARM). The Safer Lincolnshire Partnership should add endorsement to the running of a pilot in one of the District Areas in Lincolnshire. (Applying this robust process should guarantee all reasonable steps are taken to ensure safety, by a multi-agency group of professionals. This model would include those at risk of harm as a result of self-harm/self-neglect, to improve consistency of approach if the pilot is successful across the whole County).

The Safer Lincolnshire Partnership through the Domestic Abuse Core Priority Group, should use this death as a case study in current and future Multi Agency training and guidance highlighting the lessons learnt within the review as well as ensuring agencies reflect this in their own single agency training; a. Consider the heightened risk that there is to the victim at the time of or immediately following separation. This should also cover the risk of physical harm, from the perpetrator of the DA, but also note the risk of self-harm through suicide as in this case, where the combination of risks for the victim was high. b. This review of training should ensure it includes the risks associated with coercive and controlling behaviour. c. The training review should incorporate the knowledge that in this case the source of the mental health issues was Domestic Abuse and this needed addressing first in order to effectively treat the mental health symptoms.

The Safer Lincolnshire Partnership should through their Domestic Abuse Core Priority Group consider with their partners, producing and publishing a learning bulletin (newsletter) for practitioners which raises awareness of minority communities/religions within their areas. This would include what culture and/or religion means to the individual, and how they may need to support change in their professional practice to ensure they consider individuals specific needs. This same bulletin (newsletter) should also raise awareness of domestic abuse in the minority communities/religions within their area.

The Safer Lincolnshire Partnership should ask the Domestic Abuse Core Priority Group to consider the development of a Domestic Abuse pathway for East Midlands Ambulance Service in Lincolnshire. East Midlands Ambulance Service already have this in place in other Local Authority areas.

The Lincolnshire Partnership NHS Foundation Trust to provide assurance that they have in place a process that considers any safeguarding matters upon location of bed whilst that patient is in receipt of out of county care. This will ensure that information is shared with the providing placement and Lincolnshire’s agencies. Also, that safeguarding matters will be considered when prioritising support when that patients care is moved back into Lincolnshire County.