Ms R
- Date of review
- April 2025
- Reviewer
- Steve Chamberlain
- Owner
- Monuara Ullah, London Borough of Hounslow
Executive summary
This report has been anonymised to protect the confidentiality of the person who is the subject of the report and their family.
This review considers the care and support offered to and received by Ms R between January 2020 and her death in July 2021. It also considers earlier background information in so much as it is relevant to the events covered during the period of the review.
Ms R was a 37-year-old woman who was found deceased on a bench in a park in Southall. An individual was later convicted of her manslaughter. Ms R had a partner and three children, and at the time of her death her case was open to the mental health team and the drug and alcohol service. She was known to the local authority adult social care service but was not currently open to that service.
Children’s social care were involved and all three children were on the child protection register on the grounds of neglect. At the time of Ms R’s death, her children were staying with members of her extended family. The involvement of children’s social care is outside the remit of this review.
Ms R had previously worked in the sex industry and had experienced domestic violence in a previous relationship. She had ongoing difficulties with excessive alcohol consumption and was also taking illicit substances.
Ms R had experienced repeated emotional and psychological crises, and had been asking for help with her mental health and her alcohol use. However, her engagement with services was inconsistent and assessments for alcohol rehabilitation had been significantly delayed due to her inconsistent engagement from services.
At times of crisis, Ms R requested admission to inpatient psychiatric care, but this did not happen as it was not considered a helpful response by the mental health professionals, due to the nature of her mental health needs. The working diagnosis at the time of her death was complex post traumatic stress disorder (PTSD), and a previous diagnosis of depression had been removed.
Ms R was well known to the police service as a result of incidents in the street and at her home when she was intoxicated. A large number of Merlin police reports had been completed for both Ms R’s children, and Ms R in her own right. These reports were sent to the local authority and those reports relating to Ms R were forwarded to the mental health team.
Ms R did have a key worker based in the alcohol recovery team, but at no time did she have an allocated care coordinator or key worker from the mental health team. She was dealt with by the ‘unplanned contact team’ which in effect is the duty team, which deals with individuals on an ad hoc basis when they make contact with the service.
This meant there was no single professional responsible for overseeing Ms R’s case and no-one responsible for coordinating her care and support. As a result, Ms R did not have a care and support plan which addressed her concurrent mental health and substance use needs and led to significant limitations in relation to ensuring her risk assessment was maintained and kept updated.
It was clear that Ms R’s family, in particular her mother, was unhappy with the response of the professionals to her needs for care and support. Both Ms R and her mother had requested admission to inpatient psychiatric care during a period of crisis in 2020, but this was not felt by the professionals to be the appropriate response to the crisis and ongoing contact at home by the crisis team was provided. Alcohol detoxification or rehabilitation was discussed, although it was never clarified whether detoxification or rehabilitation would be necessary.
A potential rehabilitation placement was discussed during 2021, but Ms R’s inconsistent engagement meant that exploration of this referral was significantly delayed. Further complexities became evident regarding potential funding and finally it was felt that the placement was unlikely to provide the level of support that Ms R needed. This was particularly unfortunate, given the time that had been taken in identifying a potential placement.
Given Ms R’s inconsistent engagement with professionals, the expectation that she would complete self-referral processes was unlikely to ensure progress, and a more proactive approach by the professionals is likely to have been more effective. As mentioned above, the allocation of a care coordinator could have assisted more effective engagement and a different outcome.
There is no doubt that Ms R was a highly vulnerable individual with a long history of being subject to physical and sexual abuse. This vulnerability continued until her death. An adult safeguarding referral was made to the local authority following Ms R’s report of being raped two weeks previously, but despite Ms R’s links to both mental health and alcohol recovery teams, efforts by the local authority to contact Mrs R in the following week were unsuccessful and the referral was closed without her being seen or spoken to.
Given her background and risk profile, further consideration of referral to services specialising in violence towards women and girls may have engendered more effective engagement.
While there is ample evidence of communication between the various agencies with whom Ms R came into contact, there is limited evidence of strategic thinking or care planning between the agencies. Most communication related to notification of events
as they occurred, or referrals between agencies. Given the complexity of Ms R’s needs, this is likely to have impaired the ability to make effective plans to support her.
The creation of ten Merlin reports relating to Ms R during the last seven months of her life illustrate the chronic level of distress and disturbance she was experiencing. They also further illustrate the level of multi-agency involvement during this period. It is important for all agencies to come together in these circumstances to consider how best to respond to the issues being raised.
