Recurring concern

Unreliable use of the MARAC process for domestic abuse risk management

First to latest report 25 Jan 2019 — 18 Nov 2020

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
4

What this concern includes

Includes failures of the dedicated MARAC process for domestic abuse risk management, including recognising cases that meet referral criteria, making referrals, sharing relevant information, convening or using the conference, agreeing actions and ensuring resulting risk-management arrangements are communicated and followed up.

What is not included
  • Excludes general domestic abuse risk assessment, investigation or safeguarding failures where MARAC referral or operation is not the identified deficient control.
  • Excludes generic multi-agency communication, coordination or meeting failures without an explicit MARAC connection.
  • Excludes failures in recording or cascading MARAC information after the MARAC process has operated adequately when the concern is limited to a separate record-transfer or communication process.
  • Excludes other multi-agency risk-management frameworks and conferences unless the assertion explicitly concerns MARAC.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Alfie Gildea · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use the MARAC framework when appropriate

    Wider context from the report

    “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”

    Source location

    Alfie Gildea · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain authority to appoint the recruited Domestic Abuse Coordinator to promote a consistent force-wide MARAC approach.

    Verbatim wording from the response

    “MARACs are set up on each of the districts with a local case management team employed by GMP providing the administration for the meetings. A Domestic Abuse Coordinator has been recruited and is currently awaiting authority to be appointed. The new appointee will take responsibility for ensuring a consistent approach to MARAC is taken across the force.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 7 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

    Verbatim wording from the response

    “I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
    Page 1 · response
    Published 24 December 2020

    Open published response

  2. Surrey

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The deceased died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to involve general practitioners in MARAC meetings

    Wider context from the report

    “3. ████████ 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. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Assist Surrey Police with its detailed review of MARAC workings.

    Verbatim wording from the response

    “Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

    Source location

    Response to Surrey coroner area - Prevention of future deaths report
    Page 1 · response
    Published 7 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Surrey Police, as MARAC lead agency and chair, is responsible for reviewing and improving MARAC workings; Surrey County Council will assist.

    Verbatim wording from the response

    “Points 1-5 relate specifically to the MARAC. Surrey Police are the lead agency and chair the MARAC. Surrey County Council does have a responsibility to ensure that our relevant employees attend and are prepared for MARAC meetings. I am aware that the police are carrying out a detailed review of the workings of the MARAC. Surrey County Council is actively assisting with and contributing to that review from a Children's Services perspective. Surrey County Council is committed to working as required with Surrey Police as the lead agency to effect the necessary improvements.”

    Source location

    Response to Surrey coroner area - Prevention of future deaths report
    Page 1 · response
    Published 7 October 2022

    Open published response

  3. Inner South London

    AI-generated summary

    Ms Donna Williamson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals

    Wider context from the report

    “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals. She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it. ”

    Source location

    Ms Donna Williamson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Call on Government to assess the effectiveness of the MARAC model and identify improvements, including support and investment for responding agencies.

    Verbatim wording from the response

    “Your report notes that the Multi-Agency-Risk-Assessment-Conference (MARAC) process, in this case, was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals.”

    Source location

    2019-0111-Responses
    Page 3 · response
    Published 9 June 2019

    Open published response

  4. Manchester North

    AI-generated summary

    Anne-Marie Nield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer appropriate domestic abuse cases to MARAC

    Wider context from the report

    “5. Risk assessment and the exercising of professional judgement in relation to the level of risk were inadequate and ongoing/dynamic risk assessment was not carried out. A referral to MARAC was not made and DVDS not offered to the deceased, again without expectation. ”

    Source location

    Anne-Marie Nield · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide training on DVDS, risk identification, DASH, RARA, risk levels and MARAC processes.

    Verbatim wording from the response

    “As indicated by ████████ in the course of her evidence to the inquest, there were grounds on which a MARAC referral could have been made in Anne-Marie’s case. It is further accepted that use of, and disclosures pursuant to, the DVDS scheme have improved significantly in the intervening period. As part of the IPLDP initial and consolidation training and the Specialist Adult Abuse Investigators Course, training is provided on the DVDS scheme, as well as on risk identification, assessment and management by means of structured teaching on DASH. This includes the explanation of the RARA model and the definitions of Standard, Medium and High Risk. At the conclusion of the IPLDP, student officers also receive a further four hours training around risk identification and assessment and are then qualified to finalise their own cases that they deem to be “Standard Risk”.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 4 · response
    Published 25 January 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026