About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review

Doncaster review

CSP: Doncaster Published: December 2022 Year of death: 2017 Extracted: 22 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
Agencies failed to identify domestic abuse, including financial exploitation, within the relationship, lacked professional curiosity regarding disclosures of sexual abuse, and did not consistently share information or apply safeguarding procedures. This led to an incomplete understanding of risk and inadequate support for the victim.

Home Office classifications

33 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - mental ill health
  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by probation services
  • Aggravating factors - sexual abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

22 recommendations pulled from the report · 1 matched to organisations in the index

Recommendation 1

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership conducts a domestic abuse campaign highlighting the different aspects of domestic abuse – including financial abuse, and referral pathways.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership updates domestic abuse website with more information about how family/friends and colleagues can support victims and perpetrators of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership ensures that agencies policies and procedures identify all aspects of domestic abuse and that all staff are aware of their roles and responsibilities in respect of implementing these policies.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership share the Domestic Homicide Review report with its substance misuse group to ensure that the learning is incorporated into practice, and the importance of professional curiosity highlighted.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership incorporates the learning from this Domestic Homicide Review to into the new sexual abuse training currently being developed.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Safer Stronger Doncaster Partnership | Doncaster Safeguarding Boards

That the Safer Stronger Doncaster Partnership produces a Joint Domestic Abuse protocol with the Doncaster Safeguarding Boards highlighting the importance of professional curiosity and risk assessment and how to deal with disclosures of sexual abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Doncaster Clinical Commissioning Group

That Doncaster Clinical Commissioning Group disseminate the learning from this review to all GP’s in respect of the requirement to fully explore and document within patient records where anti-depressants are prescribed, including where there is a diagnosis of depression.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Doncaster Clinical Commissioning Group

That Doncaster Clinical Commissioning Group ensures that the learning from this review is incorporated into the domestic and sexual abuse training delivered to GP’s.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership determines whether its risk assessment tools, and agencies use of them, are effective when dealing with relationships where money and or drugs are exchanged for sex, and whether new interventions are needed.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership continues to promote the message that the risk to victims of domestic abuse increases when the power dynamics changed in favour of the victim.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to Safer Stronger Doncaster Partnership

That the Safer Stronger Doncaster Partnership ensures that agencies referral pathway for victims of sexual abuse is accessible for all victims.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.1

Addressed to RDaSH

To educate drug and alcohol staff and raise awareness on identifying and signposting when trauma /domestic violence is disclosed during clinical contact with patients.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.2

Addressed to South Yorkshire Community Rehabilitation Company

Provide practitioner refresher briefings for working with a range of familial abuse, including broader typologies, relating to adult safeguarding and including financial abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.3

Addressed to South Yorkshire Community Rehabilitation Company

Provide practitioner refresher briefings for working with substance misusers - to reinforce the need to address and not lose sight of broader risk management issues due to the continuous focus on substance abuse for example other relationships, associates and accommodation.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.4

Addressed to South Yorkshire Community Rehabilitation Company

The learning from this review to be disseminated to all staff involved in this case, including in their Supervision, to ensure that the lessons identified are embedded into practice.’

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.5

Addressed to Sheffield Diocese

Learning to be disseminated to all those involved in this review within the Sheffield Diocese, ensuring any welfare needs are taken into consideration.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.6

Addressed to Sheffield Diocese

The National Safeguarding Team to be made aware of learning from this review in relation to male victims of domestic abuse and for a review to be undertaken of their policy in relation to male victims of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2.7

Addressed to Sheffield Diocese

Appointment of an Independent role within parishes, for cases when it is identified that the Safeguarding Officer is also the clergy’s spouse and there is a potential conflict of interest.

Verified wording from the published review · Original review (PDF) ↗