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Statement in response to joint review into the death of ‘Margaret’

Cornwall Council accepts the findings of the combined Domestic Homicide Review and Safeguarding Adults Review published today (January 26, 2021) into the death of an 88-year-old woman who died in February 2017.

The joint review is published by the Cornwall and Isles of Scilly Safeguarding Adults Board and the Safer Cornwall partnership after detailed involvement with the woman’s family.

To protect her identity the report refers to her as ‘Margaret’ which is not her real name.

The report states that Margaret was found deceased at home by a GP and adult social care case coordinator. Her husband was charged with murder and later diagnosed with Alzheimer’s disease and deemed unfit to stand trial. He was convicted of murder.

Cornwall Council portfolio holder for adults Cllr Rob Rotchell said: “We apologise to Margaret and her family and friends and give them our heartfelt condolences. We recognise the distress that the incident and this subsequent review brings, particularly so long after Margaret’s death.

“This report looks in close detail at the circumstances leading up to Margaret’s death and highlights how organisations which supported her needed to improve to identify and act on serious concerns around domestic abuse, isolation and welfare earlier so that incidents like this could be prevented. 

“In the four years since this review started, we have carefully reviewed and learnt fully from its findings and implemented all its recommendations, improving how our health and care professionals share and escalate safeguarding concerns and better equipping them with the skills and expertise to spot the signs of domestic abuse at an early, preventative stage.”

The Safeguarding Adults Board and Safer Cornwall, made up of agencies including Cornwall Council and Devon and Cornwall Police, have put in place and started implementing a joint action plan in response to the review. These actions include:

  • Setting up a consistent approach to reporting concerns through one source, the High Risk Panel, to protect individuals potentially at risk. Made up of Cornwall Council’s adult social care services, NHS Kernow Clinical Commissioning Group, Royal Cornwall Hospitals Trust, Devon and Cornwall Police and other agencies, the panel enables professionals to discuss detailed support for individuals who are causing high levels of concern or at risk of self-neglect and need a focussed and co-ordinated approach across several agencies in order to protect and support them.
  • Creating a new, primary care identification and referral system so that all primary care staff have increased awareness of domestic abuse signs and can identify and respond to concerns earlier.
  • New training in identifying domestic abuse in older people so frontline staff from all agencies can identify and escalate concerns earlier and start interventions swiftly to protect individuals at risk.
  • Reviewing internal Council processes and safeguarding guidance for staff working with vulnerable people so issues of consent are clearer.
  • Piloting a new, Safer Cornwall programme in Newquay to give specialist support to older people affected by domestic abuse, including new staff training, support systems, better awareness and communication and adapting service provision.

Helen Charlesworth May, Joint Accountable Officer for Public Health and Care for Cornwall Council and NHS Kernow, said: “My deepest apologies go out to Margaret’s family. We would also like to thank them for taking part in the review to help us identify what needed to change locally to prevent domestic abuse.

“This case underlines how older people can become isolated very quickly if their health or social circumstances begin to deteriorate and they are at even greater risk if they are unable to seek help because of their isolation. All our services need to vigilant in identifying the signs of domestic abuse in older people which can be hidden, particularly when additional vulnerabilities such as dementia are present.

"We have worked to significantly increase our health and care practitioners’ understanding of early signs of isolation, domestic abuse, deteriorating physical health or mental health such as dementia, and welfare concerns, so they can take action on any concerns at an early and preventative stage.”

Rob Nolan, Cornwall’s portfolio holder for public protection and environment, said: “It is imperative that our services are alert to the signs of domestic abuse across all age groups and this is key to reducing domestic abuse across Cornwall.

“Having additional needs such as dementia makes a domestic abuse sufferer even more vulnerable. Our aim is for all our services to be able to identify domestic abuse much earlier, intervene quickly and effectively and prevent escalation.”

The Domestic Homicide Review and Safeguarding Adults Review is viewable here.  


Story posted on January 26, 2021