The MATTERS OF CONCERN are as follows.
The inquest heard evidence that agencies involved in supporting her in the months leading up to her death had a limited understanding of how behaviours could be twisted in a coercive and controlling relationship to make it appear as if the victim was part of the problem. In this situation it was clear that Lee-Ann was the victim of so called “love bombing” which meant that she was barraged with messages from the perpetrator. The impact of that on a victim’s mental health was not recognised.

Her children had expressed their concerns to their school. The school had been proactive in sharing those concerns but there was little evidence that other agencies were then listening to “the voice of the child”. This meant that agencies who had direct contact with her did not have a full grasp of the situation or her vulnerability. The inquest was told that if information is not effectively shared and the voice of the child is lost there is an increased risk to the victim.
 
A feature of her vulnerability was her physical health and how dependent she was, as a consequence, on the perpetrator to help care for her. The additional vulnerability and impact of this was not recognised by agencies involved in supporting her. The inquest was told that where vulnerability is not properly understood the risk presented to a victim of domestic abuse increases.