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.

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

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

37 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (between victims)
  • 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 - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation 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 - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

30 recommendations pulled from the report · 23 matched to organisations in the index

Recommendation 17.1

Addressed to Middlesbrough Community Safety Partnership

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.

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

Recommendation 17.2

Addressed to Middlesbrough Community Safety Partnership

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.

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

Recommendation 17.3

Addressed to National Probation Service | Durham and Tees Valley Community Rehabilitation Company

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.

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

Recommendation 17.4

Addressed to National Probation Service | Durham and Tees Valley Community Rehabilitation Company

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.

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

Recommendation 17.5

Addressed to Middlesbrough Community Safety Partnership

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.

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

Recommendation 17.6

Addressed to Middlesbrough Community Safety Partnership

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.

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

Recommendation 17.7

Addressed to Middlesbrough Community Safety Partnership | Durham Community Safety Partnership

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.

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

Recommendation 17.8

Addressed to Middlesbrough Community Safety Partnership

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.

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

Recommendation 17.9

Addressed to Teeswide Safeguarding Adult Board

The learning from this review should be shared with Teeswide Safeguarding Adult Board.

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

Recommendation 17.10

Addressed to Cleveland Police

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.

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

Recommendation 17.11

Addressed to Cleveland Police

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.

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

Recommendation 17.14

Addressed to Cleveland Police

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

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

Recommendation 17.15

Addressed to Cleveland Police

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.

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

Recommendation 17.17

Addressed to Cleveland Police

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.

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

Recommendation 17.18

Addressed to National Probation Service

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.

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

Recommendation 17.19

Addressed to National Probation Service

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.

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

Recommendation 17.20

Addressed to National Probation Service

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.

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

Recommendation 17.21

Addressed to National Probation Service

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.)

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

Recommendation 17.22

Addressed to National Probation Service

National Standards guidance to be recirculated to staff in order to reiterate the level of contact expected and guidance around practice and expectations.

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

Recommendation 17.23

Addressed to National Probation Service

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.

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

Recommendation 17.24

Addressed to Durham and Tees Valley Community Rehabilitation Company

To improve DTV CRC’s response and safeguarding of victims of domestic abuse

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

Recommendation 17.27

Addressed to Durham and Tees Valley Community Rehabilitation Company

Improved enforcement practice of Court Orders and defensible approach to absences.

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

Recommendation 17.29

Addressed to Durham and Tees Valley Community Rehabilitation Company

Improved Responsible Officer practice in regards to domestic abuse-related information and the overall context of risk and case management.

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

Recommendation 17.30

Addressed to Durham and Tees Valley Community Rehabilitation Company

To enhance the skills of practitioners to recognise escalating and dynamic risk factors and respond to these effectively.

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