BSAB publication of 'Melissa' Serious Case Review

The Bristol Safeguarding Adults Board has today (28 Sept) published a Serious Case Review in the case of Melissa Mathieson, an 18 year old woman who was murdered in 2014 by a 19 year old man. Both young adults were placed in an independent care home in Bristol by their respective local authorities elsewhere in the UK shortly before Melissa’s death.

The review highlights some learning of national significance, which the BSAB will ensure is widely shared both locally with key professionals and providers, and nationally with relevant regulatory bodies and government departments. The review identifies some areas of practice which need to change and gives recommendations to help keep people safe. It is not the purpose of the review to place blame.

Louise Lawton, chair of the Bristol Safeguarding Adults Board, said: “Melissa’s death was particularly shocking and had a profound impact on everybody involved. The loss that Melissa’s family have suffered is immeasurable and their involvement in this process has been essential to creating a full picture of Melissa’s life and the circumstances surrounding her death.

“On behalf of the Board I would like to apologise to Melissa’s family for the delay in publishing the findings. This review was particularly challenging as it involved many organisations from outside of Bristol. The themes arising are relevant across the country and many of the recommendations for the Board focus on raising issues at a national level. In particular, the review looks at how agencies work across county borders, the transition between children and adults services and the use of risk assessments.

“How potentially dangerous people are cared for and managed is another area of focus, as is ensuring organisations are using professional language which both sides understand when individuals are moving between services. Information sharing is also shown to be vital. The BSAB will be monitoring all the recommendations made to ensure that poor practice is identified and responded to. In Bristol the Board will be hosting a learning event for organisations to look at the national themes arising from the review.

“Sadly the review found that Melissa’s death could have been prevented if better processes had been in place. At the heart of this review is a vulnerable young woman who lost her life and I hope that the findings will help stop something like this from happening again. Everyone has the right to live safely in their community and if you have concerns about the care than someone is receiving contact your local safeguarding team.”

The full BSAB response to the review can be found here