Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0111, written 27 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Mar 2019 |
|---|---|
| Reference | 2019-0111 |
| Deceased | Donna Williamson |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ms Janet Senior, Chief Executive, London Borough of Lewisham, Town. Hall, Catford, London SE6 4RU 2. Ms Sara Thornton CBE, QPM, Chair of the National Police Chiefs! Council, 1st Floor, 10 Victoria Street, London SW1IH ONN, 3, The Rt. Hon Sajid Javid, Secretary of State for Home Department, House of Commons, London SWI1A 0AA 4. The Rt. Hon Matt Hancock, Secretary of State for Health and Social Care, Richmond House, 79 Whitehall, London SW1A 2NS 5. Mr Mark Lloyd, Chief Executive Local Government Association, 18 Smith Square, Westminster, London, SW1P 3HZ CORONER Iam Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST I opened an inquest into the death of Ms Donna Williamson, who died on 13.08.16 in her flat a It was heard before a jury and concluded on 18" February 2019. The medical cause of death was: la Stab Wounds to the chest Tb Assault with knife by ex-partner The jury concluded that she was unlawfully killed. CIRCUMSTANCES OF THE DEATH Matters recorded by the jury included: 1. Donna Williamson was a 44 year old woman with a history of mental health and alcohol dependence issues. She had mobility issues as a result of a dual hip replacement and was considered disabled. She had a long history of domestic violence and abuse spanning over six years as a result of a volatile relationship. She was known and in contact with at least 14 statutory and voluntary sector | | organizations during the year of her death and was considered vulnerable and at risk by multiple agencies. 2. On 18" July 2016 the ex partner was charged with assaulting Ms Williamson and several police officers and released on conditional bail with conditions not to contact Ms Williamson or enter her borough. He was arrested on 6" August at her home for breaching these bail conditions. He was released from custody and bailed on the same condition on 8" August. 3. That her door remained insecure in part due to her reluctance to inform the landlord due to fear of eviction, this being known by many agencies without any plan how it was to be secured, which caused her anxiety. 4. The process of assessment of risk and facilitation and implementation of a safety plan through MARAC amounted to a system failure for chaotic non-engaging individuals. It had no statutory basis to insist on membership or ensure participants complete their actions. The Lewisham MARAC had insufficient processes to ensure all actions were accurately recorded, followed and tracked to completion. CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - 1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants. 2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value. 3, The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the ptiority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals. She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it. 4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge ot awareness of their professional and legal duties of disclosure. Many actions have been taken by organizations and individuals involved, in relation to other circumstances not reported here. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the circumstances of this death and are in a position to mitigate or prevent future deaths: The London Borough of Lewisham and Local Government Association with regard to concern I National Police Chiefs’ Council with regard to concern 2 The Secretary of State for Home Office, The Secretary of State for Health and Social Care and Local Government Association with regard to concern 3 and the Royal College of General Practitioners and The General Medical Council re concern 4. The full Record and detailed Domestic Homicide Review can be made available to Ministers if this is of assistance. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 May 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed, If you require any further information or assistance about the case, please contact the case officer, i" COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: Mother Senior Lawyer, Metropolitan Police Service Lawyer, The Crown Prosecution Service Lam also sending this report to the following, who may have an interest, or as prevention may involve their organizations: the charity Safelives, the Royal College of Psychiatrists and to the general practitioner. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coronet. [DATE] . [SIGNED BY CORONER] 27. 3.17 pb
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
RC Royal College of G P General Practitioners MB ChB MSc(Med) FRCGP DRCOG DIMC RCS(Eqd) oint Honorary Secretary Mr Andrew Harris Senior Coroner Coroner for Inner South District Greater London Southwark Coroner’s Court 6l0z 1 Tennis Street 5 ddy 5} South k qs =} Southwa AAD Ay 11 April 2019 Dear Mr Harris Preventing Future Deaths Report for Donna Williamson Date of Death (13.08.2016) (Case Ref:02160-2016) Thank you for your letter dated 1 April 2019 regarding this sad case. | am Tesponding to you on behalf of the Royal College of General Practitioners in my role as Joint Honorary Secretary. The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the ‘voice’ of GPs on issues concerned with education; training; research; and clinical standards. Founded in 1952, the RCGP has just over 53,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. The sharing of information when there are potential safeguarding concerns including domestic abuse is a key part of the responsibilities of a general practitioner. Whilst accepting that tensions regarding confidentiality can occur, in broad terms advice from a wide range of organisations is that the sharing of information is less likely to do harm than not sharing. The process by which the doctor is expected to follow is given in guidance by the General Medical Council and for your ease of reference, it is attached. | have also attached the document Adult Safeguarding: Roles and Competencies for Health Care Staff. This was developed by the Medical Royal Colleges last year and whilst not a contractual requirement, the expectation is that staff who have direct clinical responsibilities, such as general practitioners, would maintain a Level 3 competence. Pages 33 and 35 provide detail of the educational outcomes from training, which you will note is recommended to be on a three-yearly cycle. | have also enclosed a copy of the guidelines RCGP has published on the management of domestic abuse in general practice. Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 Finally, given the importance of this area of work, RCGP has recently published a Safeguarding Adults at Risk of Harm Toolkit. It includes a wide range of helpful information including a film outlining the key points and responsibilities of general practitioners. You can access it at: https://Awww.rcgp.org.uk/clinical-and-research/resources/toolkits/safeguarding- adults-at-risk-of-harm-toolkit.aspx | trust that this information is helpful and if you have any queries, please do not hesitate to contact me. Yours sincerely, Joint Honorary Secretary of Council Royal College of General Practitioners Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.regp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 Government Association Dr Andrew Harris Senior Coroner Southwark Coroner’s Court 1 Tennis Street Southwark SEt 1YD 19 June 2019 Dear 1D, Harris | am writing in response to the Regulation 28 report to Prevent Future Deaths which you sent on Monday 1 April 2019, in relation to the death of Donna Williamson on 13 August 2016. Your report notes that the Multi-Agency-Risk-Assessment-Conference (MARAC) process, in this case, was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals. As part of our response to the Government's Draft Domestic Abuse Bill consultation, we called on the Government to assess whether the MARAC model is working effectively and how this could be improved. In particular, we highlighted the high volume of MARAC cases, and the need for local authorities, the police and wider partners to have the necessary support and investment to respond to an increase in domestic abuse cases. Our response to the Government's consultation on the Draft Domestic Abuse Bill is available on our LGA website here: httos://www.local.gov.uk/sites/default/files/documents/LGA%20response%20t0%20the%20Domes tic%20Abuse%20Bill%20consultation%20-%2031%20May%20201 8-%20Final.pdf . The LGA has also highlighted the importance of sharing the learning from Domestic Homicide Reviews at a national level. We raised these points in our written evidence to the Home Affairs Committee as part of their inquiry on domestic abuse and in our oral evidence to the Joint Committee on the Draft Domestic Abuse Bill. LGA officers have highlighted these evidence sessions in our Chief Executive bulletin and our Community Safety bulletin. We. will continue to raise these points with the Government as the forthcoming Domestic Abuse Bill is debated in Parliament. With regards to concern (1) regarding the repairing and securing of the front door of private rented accommodation, your report identifies a duty on the local authority officer to repair the door if the landlord did not. | understand that LGA officers have requested additional information trom your office about which legislation this duty falls under. Clarity on this issue will help us to raise awareness of how to resolve such problems for privately renting vulnerable tenants. 18 Smith Square, London, SW1P 3HZ www. local.gov.uk Telephone 020 7664 3000 Email info@local.gov.uk Chief Executive: Mark Lloyd Local Government Association company number 11177145 Improvement and Development Agency for Local Government company number 03675577 Thank you for drawing this matter to m y attention and please do let me know if you wish to discuss this matter any further. Yours sincerely fl" Mark Lloyd, Chief Executive gine NOY 2 NS GaAs
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