The support given to a 30-year-old mother-of-three from the traveller community who took her own life after suffering sexual and domestic abuse was not always coordinated or sustained, a report has concluded.
North Yorkshire Safeguarding Adults Board (SAB) launched a review following the death of the woman, who the report refers to using the pseudonym Marie, in March 2023.
An inquest concluded that Marie had taken her own life.
The review, conducted by independent expert Jane Gardiner, included evidence from Marie’s mother, who said her daughter was “a proud traveller”.
It added that Marie was described by professionals and family as “spirited, loving, and devoted to her children”.
However, she had faced serious challenges in her life, including childhood trauma and sexual abuse, domestic abuse, substance use, mental ill-health, and the removal of her children.
Marie disclosed to agencies that her eldest child was conceived as a result of rape, and she had feelings of guilt that her uncle was in prison for killing the person who raped her.
The review found that Marie made several distress call to police several months before her death.
Police responded to five calls but five calls were then recorded as hoaxes.
The report said this classification, combined with a limited exploration of the wider context of the calls, may have contributed to missed opportunities for intervention.
It also found that late signs of “help-seeking behaviour” including self-referrals shortly before her death, may not have been fully recognised or followed up.
In several instances, a lack of timely information-sharing between emergency departments and community mental health teams, including after overdoses, was also noted.
The review concluded: “(Marie) was known to multiple services, but support was often fragmented, short-term, or focused on a single presenting issue.
“While there were periods of concern and intervention, these did not always translate into coordinated or sustained responses.”
The report said Marie’s identity as a traveller woman was important.
“Cultural stigma around substance use and mental health may have made it harder for her to ask for help, and services may not have fully recognised the cultural barriers she faced in doing so.
“Marie’s experiences reflect the ways in which trauma, cultural identity, social exclusion, and system-level gaps can intersect.”
The review concluded that no single agency appeared to have a full understanding of her needs or circumstances.
“This review reinforces the importance of multi-agency working that is joined up, culturally competent, and responsive to complexity.
“Marie’s story reminds services of a need to evaluate how they work with those individuals whose trauma may manifest as disengagement, whose cries for help may appear chaotic, and whose lives do not fit neatly into traditional service models.
“Her case reinforces the importance of seeing the person behind the behaviour – and recognising that those most in need are often the hardest to reach.”
The review made a number of recommendations, including ensuring that staff involved with safeguarding are competent at dealing with members of the Gypsy, Roma and Traveller community.
The SAB should also seek assurances that “trauma-informed practice” was embedded across all safeguarding partner agencies and that multi-agency case conferences for adults with complex needs were used consistently.
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