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. .
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
Part of a Series
9 separate reports were issued from this inquest, each sent to different organisations.
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2019-0397
Sent to: College of Policing;No responses yet
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2020-0061
Sent to: Department of Health and Social Care; NHS England;All responded
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2022-0036
Sent to: Broadgate General Practice; General Medical Council;1 of 2 responded
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2022-0095
Sent to: Coventry and Warwickshire Partnership NHS Trust;No responses yet
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2023-0115
Sent to: Children’s Commissioner for England; Department for Education; Department of Health and Social Care;No responses yet
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2024-0031
Sent to: London Fire Brigade;All responded
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2025-0045
Sent to: Unite Group plc;All responded
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2025-0314
Sent to: 49 Marine Avenue SurgeryDepartment of Health and Social CareMoorbridge SchoolNorth East and North Cumbria Integrated Care BoardNorthumbria Healthcare NHS Foundation TrustAll responded
This report (None) is shown above.
Sent To
- Surrey County Council
Response Status
Linked responses
1 of 2
56-Day Deadline
5 Jan 2021
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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 .
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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.