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

Middlesbrough review

CSP: Middlesbrough Published: December 2022 Year of death: 2018 Extracted: 30 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 systemic failures in inter-agency coordination, information sharing, and consistent application of domestic abuse policies. Agencies did not adequately supervise the high-risk perpetrator or respond effectively to the victim's escalating risks, missing opportunities for protection and intervention.

Extracted recommendations

30 recommendations pulled from the report

#	Recommendation	Addressed to
17.1	That Middlesbrough CSP should seek written assurance from all relevant agencies that the interface between MARAC, MATAC and MAPPA is understood and which process to apply in individual cases and to review whether it needs a ‘repeat incident’ MARAC referral criteria.	Middlesbrough Community Safety Partnership
17.10	The process in which Clare’s Law disclosure is made should be reviewed to ensure that requests are being processed in line with Home Office Guidance.	Cleveland Police
17.11	Message around the investigation golden hour to be disseminated. This is an action that is being replicated in the Crime Allocation and Improvement Rapid Response plan.	Cleveland Police
17.12	Training to be disseminated to all operational officers around evidence-led prosecutions.	Cleveland Police
17.13	All domestic abuse crimes should be reviewed by a supervisor prior to closure.	Cleveland Police
17.14	Training and guidance around the quality of supervisory reviews to be cascaded to all supervisors as part of the Crime allocation and Improvement Rapid Response plan	Cleveland Police
17.15	Domestic abuse policy to be updated in respect to the handling of “no reply” domestic abuse incident, or those where only one party has been spoken with.	Cleveland Police
17.16	Review of control room management and tasking of domestic incidents.	Cleveland Police
17.17	Clear guidance to be created and circulated around the ongoing management of DA investigations where there is a suspect who still needs to be traced. Where a suspect has not been arrested for a DA incident the requirement to arrest/trace them should be handed over to the Investigation Team.	Cleveland Police
17.18	Details of domestic abuse history obtained from Police systems are routinely recorded in the Non-Disclosure Section of OASys, as well as in the Case Management System in order to ensure that this information is flagged to any member of staff who may need to access the case record.	National Probation Service
17.19	Home Visit Guidance is reviewed and re-issued to all staff in order to reiterate the importance of home visits and the purpose of them in identifying and addressing risk factors, particularly where there is a history of domestic abuse. Staff should always be mindful of the potential risks to a victim when gathering information, making referrals, and recording and storing information. Systems and procedures must be put in place to ensure that risk to victims is minimised – which would include taking a cautious approach to discussing abuse directly with the victim and offender together in the same meeting.	National Probation Service
17.2	That each constituent agency of Middlesbrough CSP provides it with written assurance that staff in their agencies dealing with reports of anti-social behaviour understand that it can mask domestic abuse and/or that the underlying cause maybe domestic abuse.	Middlesbrough Community Safety Partnership
17.20	Information to be provided to staff in relation to the importance of clear and accurate recording on the case record of all offenders in order to ensure that all contacts and work undertaken are evident to any authorised individual accessing that record.	National Probation Service
17.21	Guidance to be re-issued to staff in relation to caretaking cases and the importance of good communication between staff and the expectations around enforcement when caseholders are unavailable/on leave. In addition to the timeliness of requesting caretaking. (Caretaking means someone else has to look after the case in the absence of the allocated member of staff.)	National Probation Service
17.22	National Standards guidance to be recirculated to staff in order to reiterate the level of contact expected and guidance around practice and expectations.	National Probation Service
17.23	Guidance to be reissued to staff in relation to information sharing with other agencies in particular the police and MARAC to ensure appropriate information is shared in order to manage risk effectively.	National Probation Service
17.24	To improve DTV CRC’s response and safeguarding of victims of domestic abuse	Durham and Tees Valley Community Rehabilitation Company
17.25	Improved response to safeguarding of adults.	Durham and Tees Valley Community Rehabilitation Company
17.26	Consistent response across DTV CRC team areas to MARAC	Durham and Tees Valley Community Rehabilitation Company
17.27	Improved enforcement practice of Court Orders and defensible approach to absences.	Durham and Tees Valley Community Rehabilitation Company
17.28	Improved effective management oversight of practice	Durham and Tees Valley Community Rehabilitation Company
17.29	Improved Responsible Officer practice in regards to domestic abuse-related information and the overall context of risk and case management.	Durham and Tees Valley Community Rehabilitation Company
17.3	That NPS and DTV CRC provide written assurance to Middlesbrough CSP that staff in their agencies have a good understanding of domestic abuse, including the ability to identify and respond appropriately when supervising offenders who are, or maybe, victims or perpetrators of domestic abuse.	National Probation Service \| Durham and Tees Valley Community Rehabilitation Company
17.30	To enhance the skills of practitioners to recognise escalating and dynamic risk factors and respond to these effectively.	Durham and Tees Valley Community Rehabilitation Company
17.4	That NPS and DTV CRC provide written assurances to Middlesbrough CSP that staff are provided with the training, tools and skills to meet their agencies standards when supervising victims and perpetrators of domestic abuse and that managers are supported by the processes, tools and skills to readily identify when the standards are not being met and take remedial action when they are aware this is the case.	National Probation Service \| Durham and Tees Valley Community Rehabilitation Company
17.5	That each constituent agency of Middlesbrough CSP provide it with written assurance that staff in their agencies dealing with victims of domestic violence, understand what DVPNs and DVPOs are and how they can be obtained.	Middlesbrough Community Safety Partnership
17.6	That each constituent agency of Middlesbrough CSP provide it with a written report that sets out how their agency engage with hard to reach victims of domestic abuse and those who have suffered previous trauma. This will identify learning needs as well as any good practice so that it can be disseminated locally and nationally.	Middlesbrough Community Safety Partnership
17.7	Middlesbrough CSP and Durham CSP should seek written assurance from Durham Constabulary and NPS that the failure to share information in this case has been resolved by new processes.	Middlesbrough Community Safety Partnership \| Durham Community Safety Partnership
17.8	Middlesbrough CSP should review the effectiveness and if necessary, strengthen the information provided to family, friends, neighbours and diverse communities about recognising the signs of domestic abuse and where they can go, if necessary anonymously, with such information.	Middlesbrough Community Safety Partnership
17.9	The learning from this review should be shared with Teeswide Safeguarding Adult Board.	Teeswide Safeguarding Adult Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗