Donna Williamson
27 Mar 2019 · Coroner Andrew Harris · London Inner (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. unrepaired door in private rental property
“No one agency took responsibility for repairing and securing the door”
2. victim not informed of suspect's bail release
“There was a failure to inform the victim that the suspect had been released on bail”
3. MARAC system ineffective for chaotic victims
“The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals”
4. lack of GP knowledge about disclosure duties
“Key information about the risk to the victim was secured by the police from the suspect's GP”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals.”
Later report
“There is no single point of contact to oversee the collation of all 2 information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis.”
Responses
2019-0111-Responses.pdf ↗· Department of Health and Social Care
Stated action
“We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals.”