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recurance

Jessica Laverack

27 Jun 2022 · Coroner Lorraine Harris · East Riding and Hull

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. lack of recognition of link between domestic abuse and suicide

    “The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required.”
  2. 2. lack of system to identify and care for vulnerable not meeting high risk criteria

    “There is no system to appropriately identify and care for the vulnerable who do not meet the criteria of "high risk" which is covered by MARAC, evidence was heard that a large number of domestic homicide reviews cover victims who have not been rated as "high risk"”
  3. 3. lack of single database and robust information sharing policy

    “There is no one database which is accessible for all agencies to input their common concerns. b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable”
  4. 4. lack of single point of contact to oversee collation of information and coordinate proactive approach

    “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. This is in both MARAC and for those who are vulnerable but do not meet the "high risk" criteria”
  5. 5. inappropriate deployment of front line officers to deal with domestic abuse

    “Consideration to be given to whether the deployment of front line officers to deal with domestic abuse is appropriate, and whether this should be referred to police adult safeguarding in the same way that criminal investigations are often elevated to CID”
  6. 6. need to update DASH form

    “Evidence was heard that the DASH form may benefit from updating”

Linked reports

Repeats an earlier warningDonna Williamson27 Mar 2019 · 3 years 3 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals.”
Original on judiciary.uk ↗

This 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.”
Full chain: Marac system ineffective for chaotic victims

Responses

2022-0344-Response-from-Home-Office-1.pdf ↗· Home Office

Stated action · 23 August

“I will look to ensure that officials provide you with a full response by that date to the important issues which the Report raises.”

2022-0344-Response-from-Home-Office-2.pdf ↗· Home Office

Stated action · 8 July 2022

“The government published the Domestic Abuse Act 2021 Statutory Guidance on 8 July 2022 to support with the understanding and implementation of the definitions of 'domestic abuse' and 'personally connected' as set out in the Domestic Abuse Act 2021.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error