A summary of the issues identified, lessons learnt and actions taken in the review into the death of Mr C.
Unlawful killing of Mr C by his partner. The panel concluded that Mr C had been assaulted at least over a period of months and probably years. He was physically, emotionally and financially abused. The panel identified a key practice episode when Mr C did disclose, but professionals did not respond pro-actively, addressing his immediate health needs but not prioritizing his safety.
Mr C’s family knew of some of the abuse but were unable to convince Mr C to seek help or leave Mr Y. It may be that being an older gay man may have made it more difficult for Mr C to seek help and for professionals to identify the assault as domestic abuse. Mr C’s problematic alcohol use appears to have been allowed to mask the signs of abuse, even when he disclosed. The many health professionals that Mr C saw in the last year of his life did not pick up the signs of abuse or ask about it.
A range of lessons were identified, including ensuring that there is an improved understanding about domestic violence and abuse amoung: victim/survivors (so they are able to name the abuse), family (particularly on where to go for advice and information) and employers and unions (particularly on how to respond to concerns or a disclosure and offer proactive support). Additional lessons related to the need to improve: health and social care responses to patients and employees, commissioned services’ responses and communication between agencies and services.
A range of recommendations were made, with implications for individual agencies and the wider partnership around practice, training, partnership working and commissioning. These recommendations will be discharged into a city wide ‘combined action plan’ which manages the response to any common recommendations arising from local reviews.