Surrey coroner area

9 Nov 2020 · Coroner Caroline Topping · Surrey

The coroner's concerns

1. depression treatment gaps
“was being treated for depression by her general practitioner. She was prescribed anti-depressant medication. She had last been reviewed in February 2017. She was not open to secondary mental health provision.”
2. domestic violence and coercive control
“was the subject of a MARAC referral organised by the Surrey Police on the 14th June 2017 in respect of allegations of domestic violence and coercive control which made relating to her partner.”
3. exclusion from MARAC meetings
“general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017. General Practitioners are not routinely invited to MARAC meetings.”
4. communication failure of safeguarding measures
“The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner.”
5. lack of awareness of domestic abuse allegations
“The general practitioner responsible for treating mental health was not made aware of the allegations of domestic abuse and coercion that had made.”
6. care proceedings stress
“children were removed from her care in and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned.”

Stated action

“Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective”