The Victim was found dead at her home by her daughter. Her death appeared to have been a result of strangulation by her husband, who was suffering from dementia.
The Victim was her husband’s principal carer. Her health was significantly impacted upon by a number of chronic diseases.
No criminal charges were brought as a result of the Victim’s death. The Victim’s husband is now a resident of a secure memory loss unit.
Iodem were asked to review the care which both the Victim and her husband received from their multi-partnered GP Practice. The Iodem Team had access to a GP Practice Manager, in addition to the clinical members of the Team.
Following interviews with the Victim’s family, social workers and members of a wider clinical team in secondary care, Iodem were able to establish that there was learning in relation to communication and information sharing.
At key points, referrals for the Victim and her husband had been considered to secondary services but not made for a variety of reasons. Concerns amongst staff about Data Protection meant that information from the Victim’s family was not fully understood or shared appropriately, and its significance was lost in the assessment of risk and need for support.
The Victim’s status as a carer was not recognised, and a carers assessment was not performed. Despite being present at consultations involving her parents, the couple’s daughter was not included in the overall decision-making process regarding her parent’s risks and needs. As a result, the risks the couple faced were not understood and there were missed opportunities to intervene.
A key aim of a DHR is to try and understand the experiences of a victim. The recommendations which were made in relation to this DHR were targeted at improving communication and information sharing, by focussing on the interface between services and the individuals with whom engagement is needed.
In this case, administrative staff played a role, and the recommendations made by Iodem were practical and achievable. This included the application of a reflective process to critically examine factors that might help or hinder access to support for a couple in a similar situation to the victim and her husband.