Southend-on-Sea review

All agencies need to consider their internal arrangements for training provision around the subject of coercive control, the effects of trauma within an inter-personal relationship and the key changes being introduced within the forthcoming Domestic Abuse Bill/Act.

The SETDAB to deliver a campaign to raise awareness of all professionals concerning the importance of professional curiosity and issues which need to be explored, particularly when dealing with adults who suffer with mental ill-health, and substance or alcohol misuse as they may be factors which heighten the risk of domestic abuse.

The Southend University Foundation Hospital Trust Emergency Department to review its procedures to ensure environmental privacy is optimised to promote disclosure from patients, particularly those who are in crisis.

All GP practices across SET, should be moving to electronic prescribing which has functionality for prescriptions to be tracked; this should be embedded as a routine check for all claims of lost prescriptions especially for vulnerable patients and drugs that can cause dependency/abuse. (The CCG medicines management team can support the dissemination of this information to all practices).

NHS Southend CCG should support Queensway Surgery to develop a process to ensure that all staff at the practice have safeguarding competencies relevant to their roles and responsibilities in line with the requirement set out in the Adult Safeguarding: Roles and Competencies for Health Care Staff First edition: August 2018. Clinical supervision records would provide an excellent reference point for monitoring, audit, and quality.

Queensway Surgery should ensure that all staff are aware of the function and application of the S1 vulnerable adults’ icon and undertake teaching / refresher sessions and an audit to provide assurance that it is being effectively used.

Queensway Surgery should review and revise the structure and function of the multi-disciplinary and safeguarding meetings so that the care of vulnerable adults has appropriate oversight by the team. This should include the allocation of a GP/Nurse to act as lead professional for the patient on behalf of the Practice.

Queensway Surgery should continue to explore with EPUT the sharing of relevant information about patients who are under the care of EPUT clinicians to ensure care pathways are managed effectively to achieve best quality outcomes for the patient.

The Clinical commissioning groups across SET to raise awareness of the 2019 Public Health England report on Prescribed medicines “Dependence and withdrawal of some prescribed medicines” and the recommendations contained within. To also ensure a process is put in place to obtain regular progress reports from the Director overseeing the CCG programme of work associated with the monitoring and prescribing of medications as defined under the report.

All Health and Social Care Professionals to disseminate the learning from this review, to raise awareness of practitioners of the complexities surrounding mental health and substance/alcohol abuse. Practitioners need to be aware that while they do not cause the abusive behaviour, they may be a contributory factor. This aspect should be considered in any routine assessment process when one of more of these factors are present.

The East of England Ambulance Service should raise the awareness of all telephone clinicians that any concerns raised during a 999 call, should be highlighted to the attending crew. (In this case there was the possibility that the patient was being coerced by the partner not to have an ambulance attend the scene following a report of an overdose.)

Essex Police should reinforce to relevant staff within the Force Control Room, the need to fully record within the THRIVE assessment their rationale for downgrading STORM Incident Response Priorities. In particular, the assessment should fully reflect the change in circumstances leading to the Priority regrading.

In cases where a 999-call reporting domestic abuse to the police is terminated prematurely, incidents should not be downgraded until contact has been re-established with the caller. This should be reflected in Essex Police Policy Guidelines.