“The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs…”

The coroner’s concerns

1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of homebased risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided. 2. The inquest heard concerns from multiple witnesses about the lack of effective communication systems in place between the mental health services and the Metropolitan Police Service, in circumstances where there are dual forensic and mental health concerns. Whilst there are clearly higher-level meetings that take place between the trusts and the MPS, these do not address the needs of psychiatrists and police officers working on the frontline who are having to address pressing risk issues – both in assessing and in managing risk. Such liaison needs to be prompt – in some cases immediate. Liaison may be from the MPS to the Trust (for example in risk assessing missing persons) or from the trust to the police (for both risk assessment and how to best manage risk). The inquest heard that communication both ways was challenging. The challenges have increased since the introduction of the Right Care, Right Person policy has been introduced. In some cases, communication was not attempted at all, because of the assumption that the appropriate professional was unlikely to be reached. Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0129

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0