Donna Williamson
PFD Report
Partially Responded
Ref: 2019-0111
Coroner's Concerns (AI summary)
The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC process's inability to protect chaotic, non-engaging individuals, alongside concerns about GPs' knowledge of disclosing confidential information.
View full coroner's concerns
In the circumstances it is my statutory to report to you. _
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 evidence that the local authority did not realize that they had a 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 ofthe importance of this 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 depending on the priority given by each organization: In this case agencies should have worked together to address risks in the context of her life environment and network August: safety complete duty duty gave being good
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 commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a 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 or awareness of their professional and legal duties of disclosure_ actions have been taken by organizations and individuals involved, in relation to other circumstances not reported here;
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 evidence that the local authority did not realize that they had a 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 ofthe importance of this 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 depending on the priority given by each organization: In this case agencies should have worked together to address risks in the context of her life environment and network August: safety complete duty duty gave being good
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 commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a 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 or awareness of their professional and legal duties of disclosure_ actions have been taken by organizations and individuals involved, in relation to other circumstances not reported here;
Responses
Noted
The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation. (AI summary)
The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation. (AI summary)
View full response
Dear Mr Harris Preventing Euture Deaths Report for Donna Williamson Date of_ Death (1308.2016) (Case Ref302160-20162 Thank you for your letter dated April 2019 regarding this sad case. am responding 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 js a 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 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 NWI 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp org uk Web Wwwrcgp org uk Patron: Hls Royal Highness the Duke of Edinburgh Registered charity number 223106 8dv 4313334 key likely
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 points and responsibilities of general practitioners: You can access it at: https IIWW Icgp Org Uklclinical-and-researchlresourcesltoolkitslsafequarding- 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 rcgp org.uk Patron: Hls Royal Highness the Duke of Edinburgh Reglstered charily number 223108 key
Local Government Association Dr Andrew Harris Senior Coroner Southwark Coroner's Court Tennis Street Southwark SE1 1YD 19 June 2019 Dear 9/ Itae$ am writing in response to the Regulation 28 report to Prevent Future Deaths which you sent on Monday 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: https /wwwlocal gov uklsites/detaultliilesldocumentsILGA%2Oresponse%2Oto%2Othe%2oDomes tic%o2OAbuse%2OBil%2consultation%20-%2031%20May%202018-%20Finalpdf The LGA has also highlighted the importance of 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 gral 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 from your office about which legislation this 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; SWIP 3HZ wwwlocal.govuk Telephone 020 7884 3000 Email info @local.gov,uk Chief Execulive: Mark Lloyd Local Govornment Assoclalion company number 11177145 Improvement and Devolopment Agency for Local Government company number 03675577 sharing duty
Thank vou for drawing this matter to my attention and please do let me know if yoU wish to discuss this matter any further:
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 points and responsibilities of general practitioners: You can access it at: https IIWW Icgp Org Uklclinical-and-researchlresourcesltoolkitslsafequarding- 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 rcgp org.uk Patron: Hls Royal Highness the Duke of Edinburgh Reglstered charily number 223108 key
Local Government Association Dr Andrew Harris Senior Coroner Southwark Coroner's Court Tennis Street Southwark SE1 1YD 19 June 2019 Dear 9/ Itae$ am writing in response to the Regulation 28 report to Prevent Future Deaths which you sent on Monday 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: https /wwwlocal gov uklsites/detaultliilesldocumentsILGA%2Oresponse%2Oto%2Othe%2oDomes tic%o2OAbuse%2OBil%2consultation%20-%2031%20May%202018-%20Finalpdf The LGA has also highlighted the importance of 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 gral 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 from your office about which legislation this 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; SWIP 3HZ wwwlocal.govuk Telephone 020 7884 3000 Email info @local.gov,uk Chief Execulive: Mark Lloyd Local Govornment Assoclalion company number 11177145 Improvement and Devolopment Agency for Local Government company number 03675577 sharing duty
Thank vou for drawing this matter to my attention and please do let me know if yoU wish to discuss this matter any further:
Sent To
- Department of Health and Social Care
- Home Office
- Local Government Association
- London Borough of Lewisham
- National Police Chiefs Council
Response Status
Linked responses
1 of 5
56-Day Deadline
4 Aug 2019
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
I opened an inquest into the death of Ms Donna Williamson, who died on 13.08.16 in her flat at It was heard before a jury and concluded on February 2019. The medical cause of death was: 1a Stab Wounds to the chest lb 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 history of domestic violence and abuse spanning over six years a8 a result of a volatile relationship. She was known and in contact with at 14 statutory and voluntary sector Square, Act" 18'h long least organizations during the year of her death and was considered vulnerable and at risk by multiple agencies_
2. On 18h 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"h August at her home for breaching these bail conditions He was released from custody and bailed on the same condition on &k
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 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 their actions. The Lewisham MARAC had insufficient processes to ensure all actions were accurately recorded, followed and tracked to completion
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 history of domestic violence and abuse spanning over six years a8 a result of a volatile relationship. She was known and in contact with at 14 statutory and voluntary sector Square, Act" 18'h long least organizations during the year of her death and was considered vulnerable and at risk by multiple agencies_
2. On 18h 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"h August at her home for breaching these bail conditions He was released from custody and bailed on the same condition on &k
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 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 their actions. The Lewisham MARAC had insufficient processes to ensure all actions were accurately recorded, followed and tracked to completion
Action Should Be Taken
In my opinion action should be taken to prevent future deaths 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 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_
Copies Sent To
27. 3. (9 Ani duty
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Operation Encompass cross-border extension
Southport Inquiry
Inter-agency benefit data sharing
Domestic abuse accommodation support
Sharing information about closed Prevent referrals
Southport Inquiry
Inter-agency benefit data sharing
Arrange emergency temporary accommodation provision
Grenfell Tower Inquiry
Domestic abuse accommodation support
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.