Christine Williamson
18 Dec 2013 · Coroner John Ellery · Shropshire, Telford & Wrekin
The coroner's concerns
1. failure to identify vulnerable adult at risk
“A referral and assessment should have been made that the deceased was a Vulnerable Adult at risk from her husband”
2. lack of shared information and preventative measures
“An independent domestic homicide review has been undertaken and the author of the report gave evidence at the inquest including authors or representatives of the relevant individual management reviews”
3. inadequate timely multi-agency meeting
“The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical”