Page 13 - Adult C Overview Report - FINAL

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7.3. This review is therefore an opportunity to review the systems and processes that were in

place to support Adult C with the complex issues that she faced rather than a review of
whether her death was preventable.

Understanding and Managing Domestic Abuse

7.4. Adult C was known to have been in an abusive relationship with her ex-partner, (the father of
her child). Adult C appeared to have started problematic drinking during her pregnancy and
this escalated post pregnancy due to post-natal depression and difficulties around surgery
she required post-delivery.

7.5. After the breakdown of that relationship Adult C then moved into another abusive
relationship with a person who also had an alcohol dependency and mental health issues. In
recognition of the abuse that Adult C was experiencing, there was early involvement with
specialist domestic abuse services. It can be seen that domestic abuse was generally well
understood by those working with Adult C with evidence of some good support for her
throughout the timeframe of the review.

7.6. There was appropriate offer of refuge from DA1 and DA2 with Adult C only taking this offer
on one occasion.

7.7. Adult C was first mentioned at MARAC as mentioned above in section 5. This was again good
practice and in recognition of the seriousness of the abuse that Adult C was experiencing.
There is, however, some learning here. The GP was not asked for any information regarding
Adult C and minutes were not shared with the GP practice. The substance misuse service was
only partially aware of the MARAC and did not have a good understanding of the purpose of
MARAC; this organisation has made a recommendation related to the need for MARAC
training.

7.8. It was generally agreed during this review that there were misconceptions as to the nature
and remit of MARAC. In effect, MARAC is a risk management and safeguarding multi agency
panel, which assesses and evaluates up to date information surrounding risk post incident

(the incident that leads to the referral to MARAC). Agencies should not under any
circumstances delay any immediate safety measures or information sharing amongst key
agencies until it is heard at MARAC. A risk analysis and action plan are formulated for each
MARAC case. MARAC does not continue managing or coordinating each MARAC case. It is
heard initially and then discharged with an action plan. It will only be heard again in MARAC
as a Repeat MARAC case, if MARAC receives a referral and it is accepted within the 12 months
of the case initially been heard. Outside of the 12-month period a new MARAC referral will
have to be submitted and accepted.

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