Page 7 - Adult C Overview Report - FINAL

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4.17. Adult C had been registered with the same GP from birth. The GP was treating her for her

alcohol dependent related physical health issues as well as other conditions as required. The
GP was not aware of any domestic abuse until this review was commissioned.

4.18. Adult C also came into contact with street wardens from the local authority community
support teams. Their contacts were out of the scope of this review, but learning has been
identified of the need to train street wardens in responding to domestic abuse incidents.

4.19. Adult C engaged very sporadically with all of the above services. It is of note, however that
there is no evidence that Adult C defaulted any hospital appointments. When Adult C was in
the refuge she went missing on occasions. This erratic engagement made effective support
very difficult for agencies.

5. KEY PHASES

5.1. There was an extensive history with many services who engaged with this review. It is,

however, the six months prior to Adult C’s death that will be looked at in depth, being a
period where it is believed that most systems learning will be gained. Review of systems older
than six months is likely to lead to learning that has already been identified from other
reviews and processes e.g. as discussed in 4.7.

5.2. The scoping period will be divided into three phases each covering two months.

Phase One – Month One and Two

5.3. During month one, Adult C attended the Accident and Emergency department with a cut to
her hand. Whilst in the waiting room Adult C had a witnessed seizure. Adult C was treated for
a superficial wound to the back of her left hand. The injury was reported as being sustained
following a disagreement with family and friends during which a bottle had been smashed
that had slightly cut her hand. Adult C subsequently cut this further with a broken piece of

glass.

5.4. Adult C was referred to the Mental Health Liaison Service. It was ascertained that Adult C was
reacting to social stressors, had no current active suicidal intent, and no evidence of an
ongoing mental illness. The plan was to update the DA services that were working with Adult
C and to share information with the GP, advising her to visit the GP within 7 days. Adult C was
also provided with useful numbers to contact in a crisis.

5.5. Adult C was admitted to a ward for monitoring of further alcohol withdrawal symptoms (the
cause of the seizure) and was seen by the substance misuse inpatient liaison team. Adult C
indicated her desire to reduce her drinking via an inpatient detoxification. Adult C was
advised that it was necessary to engage with psychosocial support for this to be successful,
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