Review highlights the importance of hearing the patient’s voice
A Safeguarding Adults Partnership Review* into the death of Irene (pseudonym) has today been published by the Norfolk Community Safety Partnership (NCSP) and the Norfolk Safeguarding Adults Board (NSAB) to enable lessons to be learned and shared as widely as possible to reduce the risk of such tragedies happening in the future.
Irene was 83 when she was killed by her husband George (pseudonym) before he took his own life in 2022. The couple were described as happy and devoted throughout their relationship and did not want to be parted from one another. In recent years, Irene had been living with a medical condition that had rendered her dependent upon her husband George.
The learning and recommendations coming from the review highlighted themes around supporting practitioners to feel confident to speak to patients about domestic abuse and the intention of suicide in a routine and safe way; acknowledging the consideration of Dignitas as a potential future risk of suicide; hearing the patients voice; the safeguarding implications of carers fatigue and the impact that has on both people; and challenging the unconscious bias around domestic abuse not happening in older adults.
The review recommendations form a multi-agency action plan that is overseen by the NCSP and NSAB to ensure that the lessons and recommendations are actioned and embedded to support and drive changes in practice.
Mark Stokes, Chair of the Norfolk Community Safety Partnership said: “The Review Panel and the members of the Norfolk Community Safety Partnership would like to offer their sincere condolences to Irene and George’s family and friends.
This review has been undertaken in order that lessons can be learned and shared from this tragedy and we appreciate the information provided by Irene and George’s family and friends.”
Walter Lloyd-Smith, Manager for the Norfolk Safeguarding Adults Board said: “On behalf of the Norfolk Safeguarding Adults Board I would like to offer our sincere condolences to Irene and George’s family and friends for their loss. NSAB and its partners are committed to using the lessons from this tragedy to improve the way we support people and their families. In particular, we want to encourage professionals to ask questions about domestic abuse in a routine and safe way, recognising and acting on any concerns they may have.”
The full review into Irene's death can be found here
* As the criteria had been met to undertake a Domestic Abuse Related Death Review (DARDR) and a Safeguarding Adults Review (SAR), it was agreed by the NCSP and NSAB that this review would be undertaken as a joint review, with the title of Safeguarding Adults Partnership Review to reflect the nature of the potential learning, and out of respect of the family who are clear that there had not been any incidents of domestic abuse prior to the final violent act by their father which resulted in both of their parents’ deaths.
Domestic Abuse Related Death Review
A Domestic Abuse Related Death Review (DARDR), formerly known as a Domestic Homicide Review, is a locally conducted, multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a relative, partner or member of the same household. DARDRs were established on a statutory basis by the Domestic Violence, Crime and Victims Act 2004.
A DARDR panel consists of key members of staff from statutory, non-statutory, third sector and charitable agencies who provide support for victims of domestic abuse. Working together in this way will ensure the voice of the victim is addressed through the lessons learnt and recommendations of this DARDR.
Safeguarding Adult Review
A Safeguarding Adult Review (SAR) is a multi-agency review process for all partner agencies to identify any lessons that can be learned from particularly complex or serious safeguarding adult cases where an adult at risk has died or been seriously injured, and abuse or neglect has been suspected.
The aim of the process is to learn lessons and make improvements, especially in the way we all work together to safeguard adults at risk; it is not to apportion blame to individual people or organisations.
How to find help and support
In an emergency always call 999. For further help and support please visit the following websites: