North Yorkshire review reveals gaps in support for vulnerable woman

North Yorkshire Safeguarding Adults Board Review Following Woman’s Death

The North Yorkshire Safeguarding Adults Board (SAB) launched a review after the death of a woman referred to as Marie in March 2023. An inquest determined that Marie had taken her own life.

Details of the Review

The review was conducted by independent expert Jane Gardiner. It included evidence from Marie’s mother, who described her daughter as “a proud traveller.” Family and professionals characterized Marie as “spirited, loving, and devoted to her children.”

Marie faced serious challenges in her life. These included childhood trauma, sexual abuse, domestic abuse, substance use, mental ill-health, and the removal of her children. She disclosed to agencies that her eldest child was conceived from rape. Marie felt guilt because her uncle was in prison for killing the person who raped her.

Police Response and Missed Opportunities

The review found that Marie made several distress calls to the police months before her death. Police responded to five calls, but they were later recorded as hoaxes. The report stated that this classification, along with limited exploration of the calls’ context, may have led to missed intervention opportunities.

It also noted that late signs of “help-seeking behaviour,” including self-referrals shortly before her death, may not have been fully recognized or followed up. There were instances of delayed information-sharing between emergency departments and community mental health teams, especially after overdoses.

Conclusions of the Review

The review concluded that Marie was known to multiple services, but support was often fragmented, short-term, or focused on a single issue. The report stated, “While there were periods of concern and intervention, these did not always translate into coordinated or sustained responses.”

Marie’s identity as a traveller woman was highlighted as significant. The report mentioned, “Cultural stigma around substance use and mental health may have made it harder for her to ask for help.” It also noted that services may not have fully recognized the cultural barriers she faced.

“Marie’s experiences reflect the ways in which trauma, cultural identity, social exclusion, and system-level gaps can intersect,” the report stated. It concluded that no single agency seemed to fully understand her needs or circumstances.

Recommendations

The review emphasized the importance of multi-agency working that is joined up, culturally competent, and responsive to complexity. It stated, “Marie’s story reminds services of a need to evaluate how they work with those individuals whose trauma may manifest as disengagement.”

The review made several recommendations. These include ensuring that staff involved with safeguarding are competent in dealing with members of the Gypsy, Roma, and Traveller community. The SAB should also seek assurances that “trauma-informed practice” is embedded across all safeguarding partner agencies.