Lessons will be learned from the death of a Northumberland mum who was killed by her daughter after a report revealed opportunities to help them both were missed.
Mentally ill Odessa Carey killed her 73-year-old mother before cutting off her head in April 2019. Her mum, who had the same name, was found dead on a bed at her home in Ashington and Carey was later arrested and charged with homicide.
Carey, then 35, was under the care of mental health services at the time of the homicide. She was convicted of manslaughter on the grounds of diminished responsibility after the court was provided with psychiatric reports. She was then detained under the Mental Health Act.
READ MORE: Odessa Carey death: National review into mental health tragedy set to be published in New Year
A Domestic Homicide Review (DHR) and independent mental health homicide investigation into the tragedy was completed in March 2021. DHRs are carried out whenever somebody aged 16 or over dies as the result of the actions of a partner or family member.
The report, published today, was commissioned by Northumberland County Council and NHS England. It examines the events leading to Odessa Snr's tragic death and highlights there are lessons to be learned in a bid to prevent future deaths and improve safeguarding.
The report said that there were many signs that Odessa snr was at risk from her daughter including Carey's threats and escalating mental disorder. It said Odessa snr was a consistent target for harm and that she was at greatest risk from Carey.
The report said that if Odessa snr had been provided with access to domestic abuse specialists, they would have been able to explain what was happening and what help she could receive. It added: "In our view [Odessa snr] was denied the opportunity to access this help."
The investigation also highlighted that information sharing amongst agencies was very poor. It said a Multi-Agency Risk Assessment Conference [MARAC] would have tied together information from health, from police and given Odessa snr an opportunity to speak in a supportive environment.
The report found that "there were several opportunities where safeguarding for [Odessa snr] should have been considered. As a result, there were missed opportunities across and between agencies to develop an in-depth understanding of the risks to [Odessa snr] and formulate a risk management plan."
A number of recommendations have been made on how agencies can improve. These include:
- NHS Northumberland Clinical Commissioning Group (CCG) must provide assurance that GP surgeries have the necessary knowledge and skills to recognise domestic abuse and use the systems in place to recognise and act on disclosures of domestic abuse.
NHS Northumberland CCG and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) should develop systems to ensure there is a shared care approach to the provision of physical and mental health care and treatment.
CNTW must ensure that families and carers are appropriately involved in care planning and risk assessment.
Northumberland County Council must ensure that a comprehensive domestic abuse strategy includes measurable outcomes from previous reviews.
Northumbria Police must ensure that police officers are appropriately trained to identify escalation in abuse and incorporate professional judgment to fully assess the threat, and harm and, if necessary, raise the risk level towards victims.
Where a risk to an adult has been identified, agencies should demonstrate within their records that they have considered risk in relation to adult safeguarding criteria. Where risk to family members is reported, risk assessment must be updated, and victim safety planning must become part of the risk management plan.
An NHS England North East and Yorkshire spokeswoman said: “We commission independent investigations to identify areas for improvement and will work with partner organisations where statutory processes overlap to ensure recommendations are addressed and shared with the wider mental health system.”
A North East & North Cumbria ICB spokesman said that lessons needed to be learned.
“Firstly, our sympathies go out to the family and friends of [Odessa snr] during this difficult time.," they said.
"Clearly, there are lessons to learn and we will work to ensure the recommendations made are actioned accordingly.”
Northumbria Police said the force already has additional training in place to strengthen officers’ understanding around identifying vulnerability.
Chief Supt Deborah Alderson, Head of Safeguarding at Northumbria Police, said: “Our thoughts very much continue to be with the victim’s family following this tragic case.
“We are committed to taking forward learning identified within the review and already have additional training in place to strengthen officers’ understanding around identifying vulnerability.
“As a force, protecting the vulnerable is our number one priority and we will continue to work with our partners to build on the work underway to safeguard our communities.”
In the report, the family issued a statement that called for better communication between various NHS services and caseworkers.
The family statement said: "As a family, we have sadly lost our mam who was a great caring loving woman who would go out her way to help anyone. But she was brutally and violently killed and taken from us by our younger sister who has suffered from mental illness issues for a number of years.
"But she also took our mam away from her sisters, brothers, nephews, nieces, grandchildren, and friends. We as a family believe that the healthcare system had failed us and our sister as well as our mam.
"Therefore, we believe that there should be better communications and reports and notes between various NHS services ie GPs, hospitals, CPNs and other caseworkers. And better structures for the understanding of the patient and their families.
"Hopefully learning from these mistakes for it not to happen again’.
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