A summary of the issues identified, lessons learnt and actions taken in the review into the death of Mrs B.
Unlawful killing of Mrs B by her husband Mr B, who was tried and found guilty of murder. The panel concluded that there was nothing to indicate that Mr B might kill a partner as he did. There is no evidence that leads to a view that this event might have been predicted.
The review identified that neither person was well known to services, and nor were the strains within their relationship well known. Mr B had sought psychological support in the past and in the months before this act for his low mood in relation to bereavements he had suffered. He was identified as having a moderately severe depression. Mr B was offered a psychological intervention, but this was not taken up as it appears he did not see the appointment letter and, when discussed with his GP, he had expressed some concern about accessing the service.
Lessons learnt from this case are limited because the engagement of this couple was itself limited with statutory services, and there was no contact with any specific domestic abuse agencies. However, some specific practice issues were identified in relation to accurate record keeping, as well as how information on psychological interventions is made available to members of the public. Broader lessons learnt linked to the importance of ensuring that there is clear, accessible information available to victim/survivors, that there are clear referral pathways to ensure that help and support are available (in particular, from health) and the importance of wider societal awareness and understanding of domestic abuse.
Ensuring practice around recording is fit for purpose; Developing a referral pathway for victims of a domestic abuse incident; Ensuring the information available to victims of domestic abuse at or following an incident is fit for purpose; Ensuring that there is a consistent DHR process across Sussex, in both the commission and dissemination of reviews; Developing a consistent response to victims of domestic abuse in primary care settings; Ensuring the information on psychological interventions are fit for purpose; Developing a consistent response to victims of emergency care; Ensuring that businesses are better informed and supported in relation to domestic abuse; Ensuring that the communities are better informed about domestic abuse.