East Sussex County Council Criticized After Vulnerable, Abused Woman Dies

East Sussex's local authority has been criticised for failing in its support for people suffering complex combinations of abuse, homelessness, mental health issues and substance dependency.

The county council today admitted the findings, which came from an independent review following the death of a 41-year-old woman in December 2017.

They also said information about serious cases was not checked for patterns of violence and abuse, which meant police only responded, afterwards, to individual incidents — the bigger picture was being missed.

It also highlighted how any prison sentences, undertaken by the vulnerable person, could make the victim only more vulnerable upon release, and hindered progress that individuals may be making with the support of community teams.

The person concerned, named Ms. C by the report, died after a drugs overdose.

The Safeguarding Adults Review, commissioned by the East Sussex Safeguarding Adults Board (SAB), also found there was a lack of accommodation readily accessible for women with a combination of needs related to chronic trauma, drug and alcohol abuse, homelessness and domestic violence and abuse.

It also found that services were not joined up or tailored to the needs of women like Ms C.

The review, which examined agencies involved in Ms C’s case, also identified barriers to collating third party information of patterns of domestic violence and abuse which meant police only responded reactively to individual incidents.

Following the review, East Sussex County Council has pledged to continue with improvement it had already begun, in the ways support services can be accessed by vulnerable women dealing with drug and alcohol dependency, homelessness, mental health issues and domestic violence.

The local authority said Ms C was also involved in a volatile and violent relationship from 2015.

She suffered significant levels of domestic violence and coercive control, which were particularly severe during the last 12 months of her life, the period which this review focused on.  

She experienced periods of homelessness, struggled with mental health issues and alcohol and drug dependency which, at times, resulted in her becoming involved in criminal behaviour. 

The review, which examined agencies involved in Ms C’s case, also identified barriers to collating third party information of patterns of domestic violence and abuse which meant police only responded reactively to individual incidents.

Although recognising that short term prison sentences can be unavoidable in some cases, the report highlighted the disruption these cause to the progress individuals may be making with the support of community teams, leaving women more vulnerable on their release.

Accepting the findings, the authority said the SAB has produced a formal response to the review and will develop an action plan to address the learning and support improvements to services.  

Graham Bartlett, the chair of East Sussex SAB, said:

“We welcome this report, which like most SARs was born out of tragic circumstances.

"Our sympathies go to Ms C’s family along with our thanks for their contribution to the review which will help us identify what we can learn from her sad death.

“Since 2017, there have been changes and improvements in services and legislation which go some way to assuring the board that there are now more options to support women with complex needs fleeing domestic abuse and violence who need to access accommodation and support.

“We remain committed to working with the agencies involved in the case to take the learning forward to effect real improvements for women like Ms C.

“The Board continues to seek assurance from organisations in East Sussex about changes they have made since the death of Ms C, including multi-agency working, the relationship and coordination between services in safeguarding women with multiple complex needs and tackling those areas where joint working could be improved.”

The full report and SAB response can be viewed at: https://www.eastsussexsab.org.uk/documents/adult-c-sar-published-december-2020-2/ 

According to the County Council, the East Sussex Safeguarding Adults Board (SAB) is a multi-agency partnership made up of statutory and voluntary partners and lay members, established to promote wellbeing and oversee safeguarding adults work across the county.

Formerly known as Serious Case Reviews, Safeguarding Adults Reviews (SARs) are now a statutory duty under the Care Act 2014 for SABs to undertake.

This is when:

• An adult dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
• An adult is still alive but has experienced serious neglect or abuse and there is concern that partner agencies could have worked more effectively to protect the adult.

The purpose of having a SAR is not to reinvestigate or to apportion blame. Instead it is to:

• Establish whether there are any lessons to be learnt from the circumstances of the case, about the way in which local professionals and agencies work together to safeguard adults,
• Review the effectiveness of procedures,
• Inform and improve local inter-agency practice,
• Improve practice by acting on learning, and,
• Highlight good practice.