Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0344, written 27 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2022 |
|---|---|
| Reference | 2022-0344 |
| Deceased | Jessica Laverack |
| Coroner | Lorraine Harris |
| Coroner area | East Riding and Hull |
| Category | Suicide (from 2015) · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for the Home Department Secretary of State for Justice Secretary of State for Health and Social Care 1 CORONER Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. CORONER’S LEGAL POWERS 2 I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 7th February 2018 an investigation into the death of Jessica Louise LAVERACK “Jessie”, age 34 years, was commenced. The investigation concluded at the end of the inquest on 27th June 2022. The conclusion of the inquest was: Narrative: Jessica Louise Laverack was vulnerable due to a history of domestic abuse and anxiety, her emotional distress caused alcohol dependence. On 2nd February 2018, Jessie was found The level of alcohol in her system would have impaired her cognitive function. The lack of an appropriate, co-ordinated approach to her issues, which was further hampered by inadequate information sharing, while not directly causative of her death, would have affected the state of her mental health and contributed to her decline. MCCD: 1a Hanging I have attached a copy of my findings of fact, and reasonings regarding conclusion. 4 CIRCUMSTANCES OF THE DEATH Jessie had a history of domestic abuse. She suffered from anxiety and had a history of alcohol dependence which was a way she coped with emotional distress. 1 Jessica reported domestic abuse, Jessie was advised to move home in order to keep herself safe. Her MARAC status was moved from Rotherham to Beverley. After hearing the case in a hearing where she was allocated, as was the norm, a maximum of 10 minutes her case was archived. There followed a series of incidents whereby her ex partner was attempting to obtain her address and was contacting her family. Between August and January while interacting with a number of agencies including the police she disclosed the fear that she was living in, she further reported on occasion suicidal ideation and she attended A&E with cut wrists. However, it was noted that she was motivated to get well. Her treatment focused on her alcohol use rather than an holistic approach to someone with a dual diagnosis. The matter was not referred back to MARAC as it was not deemed high risk There was not a structured co-ordinated approach to her care, and there was a lack of information sharing. There was contact with Jessie and her ex partner leading up to her death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required. (2) There is no system to appropriately identify and care for the vulnerable who do not meet the criteria of “high risk” which is covered by MARAC, evidence was heard that a large number of domestic homicide reviews cover victims who have not been rated as “high risk” (3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse. a. There is no one database which is accessible for all agencies to input their common concerns. b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable. It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues. (4) There is no single point of contact to oversee the collation of all 2 information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis. This is in both MARAC and for those who are vulnerable but do not meet the “high risk” criteria. (5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers. (6) Consideration to be given to whether the deployment of front line officers to deal with domestic abuse is appropriate, and whether this should be referred to police adult safeguarding in the same way that criminal investigations are often elevated to CID. (7) Evidence was heard that the DASH form may benefit from updating. (8) The processes of Humber police’s vulnerability hub and DARA forms which show a more proactive, collative approach, are not currently a nationally recognised method of working. (9) If not already in place, to consider complex case forums on a national level. as and other voluntary to whether GP’s (10)Consideration organisations/non-statutory organisations should be invited to MARAC (11) To consider better information sharing about the risks of sleep deprivation and its impact on mental health and suicide. (12) I was requested to consider placing MARAC on a statutory footing in line with an earlier RPFD , I merely highlight this report – 2019 Andrew Harris, Senior Coroner for Inner North London in the inquest touching the death of Donna Williamson, RPFD addressed to Secretary of State for Home Affairs and Secretary of State for Health and Social Care). 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your department have the power to take such action. Please note that this has been sent to 3 ministers as a joint approach to many of the issues is required. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd August 2022. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • The Victims Commissioner • The family of Jessica Louise Laverack “Jessie” via their advocates 3 • Humberside Police Service • South Yorkshire Police Service • East Riding of Yorkshire Council • Humber Teaching NHS Trust • MIND • • The Beverley Health Centre I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 [DATE] [SIGNED BY CORONER] 27th June 2022 Lorraine Harris 4
4 responses 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.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU 10th February 2023 Ms Lorraine Harris, HM Area Coroner for the City of Kingston upon Hull and County of the East Riding of Yorkshire The Guildhall Alfred Gelder Street Kingston upon Hull HU1 2AA Dear Ms Harris, Thank you for your letter of 27 June 2022 to the then Secretary of State for Health and Social Care, Sajid Javid, about the death of Jessica Laverack. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Laverack’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The Department recognises the links between domestic abuse and suicide. We are working closely with the Home Office on the implementation of its Tackling Domestic Abuse Plan. We will also continue to work closely with a range of partners across the suicide prevention sector to consider factors linked to suicide and actions that should be taken to address them as part of the recently announced national suicide prevention strategy. We expect this renewed strategy will include measures to tackle domestic abuse. Additionally, as near real time suspected suicide surveillance systems develop at a local and national level, the feasibility of improving data collection in relation to domestic abuse will be explored. Turning to your concerns around the need for better information sharing on the risks of sleep deprivation and its impact on mental health and suicide. It is difficult for the Department to comment on information sharing around this without knowing the specifics of Ms Laverack’s case. However, we recognise the link between poor sleep and mental health. Better Health- Every Mind Matters is a campaign and digital resource delivered by the Office for Health Improvement and Disparities to help people address common sub-clinical mental health problems, including sleep difficulties. It provides NHS-approved digital resources to help people get to sleep and to sleep better. If poor sleep is affecting an individual’s daily life or causing them distress, they are advised to call NHS 111 or talk to their GP. With regard to your concerns around the general lack of information sharing between agencies, healthcare professionals must believe there is a significant public interest and satisfy data protection law, and the ‘Common Law Duty of confidentiality’ when sharing any confidential patient information. This requires requestors to meet specific purposes on a case- by-case basis to ensure the confidentiality of this data is maintained. We know there is continued scope for better collaboration as we know there are times when access to health data can deliver better outcomes. We continue to work to improve appropriate data linkage to support the public’s health and wellbeing, making sure that any improvements in data access are appropriate, safe and legal, and transparent, to maintain public trust in how their data is used. The Health and Care Act 2022, which came into force on 1 July 2022, has enabled the establishment of integrated care boards and integrated care partnerships, providing an opportunity for greater understanding of local health needs of victims of abuse. Integrated care boards are required to set out how they will address the needs of victims of abuse in their joint forward plans. NHS England is developing guidance to assist integrated care boards, which will include promotion of effective pathways between community based domestic abuse and mental health support services as well as highlighting the partnership approach required between health, local authorities, criminal justice partners and the voluntary sector to ensure services are effective. The Department is also working with the Office for National Statistics to explore how insights from health data can improve our understanding of violence against women and girls, including domestic and sexual violence. The recently published Women’s Health Strategy includes a public commitment to this project. The new information generated will be used to improve services and experience of service for women and girls and inform interventions around violence against women and girls. I hope this response is helpful. Thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD
Amanda Solloway MP Minister for Safeguarding 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Ms Lorraine Harris, HM Area Coroner for the City of Kingston upon Hull and County of the East Riding of Yorkshire The Guildhall Alfred Gelder Street Kingston upon Hull HU1 2AA DECS Reference: MIN/0351265/22 20 July 2022 Dear Lorraine, Thank you for your letter of 28 June to the Secretary of State. I am grateful to you for circulating a Section 28 Prevention of Future Death (PFD) Report in relation to the tragic death of Jessie Laverack in 2018, and I am replying as the newly appointed Minister for Safeguarding. I fully understand the Coroner raising these issues with the Home Secretary and with the Secretaries of State for Health and Justice. Domestic abuse is a terrible crime, and the Government is committed to doing everything we can to tackle it. As you will know, the Government published its Domestic Abuse Plan on 30 March this year, building upon the Domestic Abuse Act 2021. We will wish to consider your Report carefully to see which issues may already have been addressed and which will require further action. I note that the Coroner has requested a formal response by Tuesday 23 August. I will look to ensure that officials provide you with a full response by that date to the important issues which the Report raises. Amanda Solloway MP
Ms. Lorraine Harris, HM Area Coroner for the City of Kingston upon Hull and County of the East Riding of Yorkshire The Guildhall Alfred Gelder Street Kingston upon Hull HU1 2AA 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 23/8/2022 Dear Ms. Harris Thank you for your letter of 28th June enclosing a Prevention of Future Death (PFD) report concerning the tragic death of Jessica Louise (‘Jessie’) Laverack on 2nd February 2018. You will have received a formal reply from Rachel Maclean MP, then Minister for Safeguarding, on behalf of the Home Secretary, confirming that Home Office officials would investigate the matters which you raised and respond before your formal deadline of 23rd August. Tackling domestic abuse is a government priority. As you will know, the government has taken a range of measures in recent years to tackle domestic abuse more effectively, including through the Domestic Abuse Act 2021. This is a truly game-changing piece of legislation which will transform our response to victims in every region in England and Wales and ensure perpetrators are brought to justice. The government published the Domestic Abuse Act 2021 Statutory Guidance on 8 July 2022 to support with the understanding and implementation of the definitions of ‘domestic abuse’ and ‘personally connected’ as set out in the Domestic Abuse Act 2021. The key objectives of the statutory guidance are to: • Provide clear information on what domestic abuse is and what impact is has on victims, including children; • Provide guidance to frontline professionals who have responsibilities for safeguarding and support victims of domestic abuse; and • Convey some of the best practice and encourage multi-agency working, recognizing that everyone has a role to play in support victims and survivors of domestic abuse. On 30th March, we published the cross-Government Tackling Domestic Abuse Plan. This was informed by the unprecedented 180,000 responses we received to our Tackling Violence Against Women and Girls Call for Evidence, and relevant data, literature, and input from experts. The Plan invests over £230 million into tackling this heinous crime. This includes over £140 million for supporting victims, £47 million of this will be ringfenced over three years for community-based services to support victims and survivors of domestic abuse and sexual violence, and over £75 million for tackling perpetrators. We will also explore ways to actively manage the most harmful perpetrators, including through considering the creation of a register of domestic abuse offenders. The Plan also highlighted the importance of enabling the whole system to operate with greater coordination and effectiveness, and included a commitment to invest up to £7.5 million investment into domestic abuse interventions in healthcare settings. Your report raises twelve matters of concern which we have grouped in three themes: Suicide linked to domestic abuse The Government is absolutely committed to developing the evidence base and interventions to prevent suicides linked to domestic abuse. It is devastating to know that those trapped by domestic abuse can feel so hopeless that they believe the only way out is suicide. In the Tackling Domestic Abuse Plan, we committed to continue to support a package of measures to tackle suicides which take place following domestic abuse. The commitments in the Tackling Domestic Abuse Plan include measures to update police guidance on suicide so that it explicitly includes references to domestic abuse and for the police to consider whether domestic abuse was a contributing factor in cases of unexplained deaths and suspected suicides. We also committed to continue to fund the Domestic Homicide and Suspected Victim Suicides Project, led by the National Police Chiefs’ Council, College of Policing (NPCC) and the National Policing Vulnerability Knowledge and Practice Programme (VKPP). The NPCC and VKPP Domestic Homicide and Suspected Victim Suicides Project alongside counting all domestic abuse related deaths which, as well as domestic murder by a (current or ex) partner, family member or co-habitee, also counts child deaths in a domestic setting, unexplained or suspicious deaths, and suspected suicides of individuals with a known history of domestic abuse victimisation. Later this year, the project will publish its second report with further analysis, recommendations and learning for agencies on risk factors and possible interventions for these complex cases. We will also be strengthening the Domestic Homicide Review statutory guidance for suicide cases to improve clarity for cases which should be referred for a Domestic Homicide Review and how to review these complex cases. The Domestic Abuse Act 2021 Statutory Guidance provides guidance to frontline professionals, who have responsibilities for safeguarding and support victims of domestic abuse, including health professionals. It sets out in detail the impact that domestic abuse can have on victims, both physical but also psychological. It also highlights that the psychological impact of domestic abuse can be so severe that it can lead to suicide ideation and attempt. The Department for Health and Social Care will respond separately on better information sharing about the risks of sleep deprivation and its impact on mental health and suicide. Police awareness, training and risk assessment Whilst the use of Domestic Abuse, Stalking and Harassment (DASH) risk assessment form and vulnerability hubs are an operational issue for policing, the Government is committed to ensuring the police are equipped to tackle domestic abuse effectively. The Home Secretary commissioned Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) to help police forces to keep strengthening their responses, and to further support the action we set out in our cross-Government Violence Against Women and Girls Strategy, which we published in summer 2021, and Tackling Domestic Abuse Plan. The Government has committed to ensuring all HMICFRS actions are implemented and we have taken decisive action. This will include, for example adding violence against women and girls to the Strategic Policing Requirement, meaning that it will be set out as a national threat for forces to respond alongside other threats such as terrorism, serious and organised crime, and child sexual abuse. In terms of training, the College of Policing has developed the Policing Education Qualifications Framework which is an important step in raising standards in policing, including in tackling violence against women and girls. Additionally, the College have developed a range of other training products, including the Domestic Abuse Matters programme. We committed up to £3.3m to support further rollout of the training. Multi-agency working and Multi-Agency Risk Assessment Conferences (MARACs) The MARAC model is designed to provide an effective multi-agency response to manage the risks to victims of domestic abuse. There is a concern that statutory duties can be a blunt tool and that making MARACs statutory risks fostering a culture of minimum compliance rather than genuine local ownership and accountability. More importantly, placing MARACs on a statutory basis also risks locking down a particular model of multi- agency working and may stifle the development of local, innovative models to manage safeguarding risks, such as those with complex needs. The Government believes the current MARAC model gives agencies flexibility in the actions they put forward to protect those at risk of harm from domestic abuse. The cases discussed at MARAC are, by their very nature, demanding and complex. We believe the MARAC process can provide an effective forum for managing those risks. The Domestic Abuse Act 2021 Statutory Guidance conveys what best practice in supporting victims looks like, including for multi-agency working and MARACs more specifically. The guidance sets out that MARACs should be attended by representatives from the police, Independent Domestic Violence Advisor (IDVA) services, housing, children’s services, the Probation Service, primary health, mental health, substance misuse service and adult social care. The Tackling Domestic Abuse Plan also recognises that the whole of society needs to work together to reduce the prevalence of domestic abuse, domestic homicide and suicides linked to domestic abuse. The Plan emphasised that collaboration and coordination between and within organisations must be improved and referenced MARACs as a successful example of multi-agency collaboration. The Department for Health and Social Care will respond separately on the new provisions of the Health and Care Act 2022. Yours sincerely Head of Perpetrator Delivery Team Interpersonal Abuse Unit
• Ministry of Justice Ms. Lorraine Harris Area Coroner for the County of the East Riding of Yorkshire and City of Kingston Upon Hull The Guildhall, Alfred Gelder Street Kingston Upon Hull HU12AA Rt Hon Edward Argar MP Minister of State I"" December 2022 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - JESSICA LOUISE LAVERACK Thank you for your Report to Prevent Future Deaths and the supporting findings of fact that you sent to the Justice Secretary on 28th June 2022. I am responding as the MoJ Minister for Victims. I apologise for the significant delay in acknowledging receipt and responding to your very comprehensive report into this terrible and tragic case. Tackling domestic abuse remains a priority for this government. Alongside implementing the final measures in the Domestic Abuse Act 2021, we are working with the Home Office to prioritise a number of commitments in the Tackling Domestic Abuse Plan including investing over £230 million of cross- Government funding into tackling this heinous crime. This includes over £140 million for supporting victims and over £81 million for tackling perpetrators. £47 million of this has been ringfenced over three years for community-based services to support victims and survivors of domestic abuse and sexual violence. Responsibility for the majority of the concerns raised in your report sits with the Home Office and Department of Health and Social Care and we have seen and support the response that the Home Office sent you on 23rd August. However, we have separately considered the third concern In your Report where you refer to a lack of information sharing between agencies, including no singular database for all agencies to input common concerns and a lack of robust policy of information sharing regarding both suicidal ideation, self-harm as well as identification of the vulnerable. It is not clear whether this particular case reached court, but I can confirm that MoJ is invited to contribute at Multi Agency Risk Assessment Conferences (MARACs) whenever the MARAC is in relation to a perpetrator or victim that we are working with. MoJ contributions might Include Probation Officers and Independent Domestic Violence Advisors who may have intelligence that could be shared with specialists from the statutory and voluntary sectors, sharing information on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners. We have recently done some work to improve probation staff awareness and understanding of MARAC and you may be interested to learn that we have also recently published a draft Victims Bill, which will improve the support offered to victims - including through strengthening the roles of Independent Domestic Violence Advisors. We are also continuing to work with the Home Office to explore ways to actively manage the most harmful perpetrators, including through considering the creation of a register of domestic abuse offenders. E https://conlact~moj,servlce.JusUce.gov.uk/ www.gov.uk/moj London SW1H 9AJ Thank you for sighting the Justice Secretary on your report and I can reassure you that we continue to work very closely with the Home Office and the Department for Health and Social Care to tackle the perpetrators and support the victims of this devastating crime, including where they are taking forward recommendations in your report where they are the lead department. • • ?-- -· ·7, ~Av- RT HON EDWARD ARGAR MP 2
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