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

North Yorkshire review

CSP: North Yorkshire Published: December 2022 Year of death: 2018 Extracted: 18 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 missed opportunities in risk assessment, information sharing, and multi-agency coordination, particularly regarding child protection and stalking. Agencies struggled with consistent identification of high-risk domestic abuse and ensuring follow-up actions, compounded by the victim's fluctuating engagement and the perpetrator's coercive control.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
1	All front-line professionals who may encounter domestic abuse situations should receive training in risk assessment using the recognised ‘DASH’ model.	North Yorkshire Community Safety Partnership \| All agencies involved in the DHR
10	The Community Safety Partnership should encourage and measure the training of staff within both the ‘Responsible Authorities’ (RAs) and the ‘Duty to Cooperate’ (DTC) agencies on the new MAPPA E Learning package.	North Yorkshire Community Safety Partnership \| Responsible Authorities (MAPPA) \| Duty to Cooperate agencies (MAPPA)
11	The Community Safety Partnership should carry out a review of the MARAC operating procedures within North Yorkshire. Where practices are working well staff should be recognised. The frequency of MARAC meetings should be considered together with the administrative support available to support the Chair ensuring actions are completed in a timely manner and accurately recorded. The CSP should provide visible governance to encourage regular attendance by all agencies with reporting back to the CSP on annual attendance levels. Above all, the CSP should provide leadership to demonstrate to agencies that ALL organisations should be fully committed to this partnership process.	North Yorkshire Community Safety Partnership \| All agencies involved in the DHR
12	All professionals working directly with victims should receive training in stalking and harassment and particularly around identification, risk assessment and safety planning.	North Yorkshire Community Safety Partnership \| All agencies involved in the DHR
13	This Domestic Homicide Review has included information and participation across two Community Safety Partnerships -North Yorkshire as coordinators and Leeds (where the perpetrator resided during periods of the review). It is good practice to share all learning and recommendations with colleagues within the ‘Safer Leeds’ Partnership.	North Yorkshire Community Safety Partnership \| Safer Leeds Partnership
2	The Community Safety Partnership to ensure there are protocols in place between the police and Crown Prosecution Service to ensure any high-risk case of domestic abuse that meets the evidential threshold is not discontinued without good reason. That rationale of the decision together with a plan to protect the victim is in place should be recorded.	North Yorkshire Community Safety Partnership \| North Yorkshire Police \| Crown Prosecution Service
3	All professionals should receive appropriate training to recognise Child Protection situations. The training should include (a) Putting the child at the centre of their thinking irrespective of the reason they are involved. (b) An appreciation of the different levels of child welfare concerns (‘Child Protection’ and ‘Child in Need’).	North Yorkshire Community Safety Partnership \| All agencies involved in the DHR
4	All agencies review their processes for closure of incidents involving vulnerable people. This system to include checks and balances to ensure any necessary safeguarding referrals are submitted.	All agencies involved in the DHR
5	In high risk cases of domestic abuse, professionals within a support role should consider the benefits of making direct face to face contact with the victim rather than on the telephone. This should not be discontinued simply because the victim does not consent. Ideally this would be a joint home visit with IDAS and a police DAO, ensuring the victim is aware of all services available while simultaneously ensuring safety of staff.	All agencies involved in the DHR
6	The Community Safety Partnership should satisfy itself that adequate training programmes are delivered which highlight to professionals: (a) The recognition of domestic abuse and its complexities, ‘push-pull’ factors and pressure on victims (b) Local procedures in place such as DASH risk assessments, the MARAC process, DVPN and DVDS provisions. (c) The ECHR competing articles that both protect the confidentiality of victims / patients but also recognise the duty on all professionals to ‘protect life.’ Specifically, this should include balancing the requirements of Article 2 (‘the right to life.’) and Article 8 (‘the right to a private and family life.’)	North Yorkshire Community Safety Partnership \| All agencies involved in the DHR
7	The Community Safety Partnership should review its Information Sharing Protocol for information exchange between professionals who are working in the field of domestic abuse and other areas of safeguarding. The revised ISP to be clear on the need for balance between confidentiality and protecting vulnerable people from significant harm and thus give professionals confidence in making referrals in challenging circumstances.	North Yorkshire Community Safety Partnership
8	All agencies involved in protecting the vulnerable should have a ‘flagging’ system in place to ensure their systems alert attending professionals of previous domestic abuse linked to a victim, perpetrator or address.	All agencies involved in the DHR
9	Agencies should cross reference their patients / clients with married names / change of name / other aliases to ensure opportunities for identification of vulnerable people are not missed.	All agencies involved in the DHR
Ensure that during ‘	Ensure that during ‘Daily Management meetings’, consideration is given for the serving of Domestic Violence Protection Notices / Domestic Violence Protection Orders (DVPNs / DVPOs) for offenders in custody when no further action is being proposed. A breach of a DVPO carries a power of arrest and consideration of a custodial sanction.	North Yorkshire Police
GP Practice staff	GP Practice staff should routinely record names of partners and link to clinical records to enable a clear understanding of who potentially poses a risk to the patient.	NHS Vale of York Clinical Commissioning Group
North Yorkshire Poli	North Yorkshire Police should review the decision to appoint only police staff to the role of DAO. The IMR author believes a more blended mix of experiences would give a more comprehensive service to victims.	North Yorkshire Police
The CCG to provide	The CCG to provide GP practices across the city with a template safeguarding policy which encompasses the most up to date information and resources. This will standardise practice and promote an understanding of safeguarding, including domestic abuse.	Leeds Clinical Commissioning Group
The Force Control Ro	The Force Control Room make Domestic Abuse Officers (DAOs) aware of all incidents involving high risk victims. This will afford the DAO the opportunity to review the incident and make a further risk assessment.	North Yorkshire Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗