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

Buckinghamshire review

CSP: Buckinghamshire Published: December 2022 Year of death: 2019 Extracted: 9 recs

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

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review identified significant communication and process failures in mental health service referrals and care transitions, alongside missed opportunities for information sharing and safeguarding adult concerns by police and primary care. There were also issues with follow-up and partner engagement during the victim's mental health crises.

Extracted recommendations

9 recommendations pulled from the report

#	Recommendation	Addressed to
Oxford Health Recomm	The Service Manager will identify a more reliable system way of ensuring that the outcome of assessments is shared with GP/patient in a timelier way	Oxford Health
Oxford Health Recomm	The Trust is to inform the Agency Worker, who no longer works at the Trust, that some aspects of his work fell below the Trust’s expected standards, and the Trust will inform the agency through which he was employed.	Oxford Health
Oxford Health Recomm	Team Managers from City AMHT will work with Service Manager to review, update, and relaunch the Operational Guide within the team, and review standard operating procedures (SOPs) following the remodelling of the team.	Oxford Health
Oxfordshire CCG Reco	The Oxfordshire CCG will seek evidence from the GP Practice that issues raised about urgent mental health referrals have been addressed during in-house training with all Health Care Practitioners at the Practice.	Oxfordshire CCG
Oxfordshire CCG Reco	The GP Practice is to confirm that the new referral system has now been correctly implemented and there is a system for ensuring referrals processes are completed.	Oxfordshire CCG
Oxfordshire CCG Reco	OCCG and Primary Care Safeguarding Leads to share with the Suicide and Self-Harm Strategy Group the issues found in relation to non-engagement, and request support in developing some guidance around communication options in situations where a patient chooses not to engage.	Oxfordshire CCG \| Primary Care Safeguarding Leads
Oxfordshire CCG Reco	All learning from this Review will be incorporated in future training activities.	Oxfordshire CCG
Panel Recommendation	Oxford Health report progress on the Root Cause Analysis (RCA) confirming that the relevant recommendations are completed.	Oxford Health
South Central Ambula	Staff are to be reminded that any safeguarding issues or awareness of a colleague having safeguarding issues, should be highlighted to the safeguarding team so they will be dealt with in a confidential manner.	South Central Ambulance NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗