Gloucestershire review

All agencies to ensure Domestic Abuse training for their staff includes in depth detail about economic abuse, and District Councils to ensure DA training is available to all staff in debt advice services locally.

Gloucester City Community Safety Partnership and Safer Gloucestershire to ensure stronger links between the SG executive, the countywide CSP/ delivery board for domestic abuse, and the health and wellbeing board.

Gloucester City Community Safety Partnership and Gloucestershire Safeguarding Children’s Partnership Executive (GSCP) to ensure that the mapping identified through the National Panels countrywide data which found that domestic abuse is present in 41% of all child fatalities and 42% of all serious safeguarding incidents nationally is applied countywide for wider understanding and learning of the implications of domestic abuse in front line safeguarding services.

Health professionals to seek to know who has parental responsibility for a child, as well as other adults who play a key role in that child’s life e.g. stepparents. Agencies should always ask, clarify, and document who the adult is accompanying a child to appointments or who is ringing the practice about a child. Details of the child’s birth parent should be recorded and the status of the child’s relationship with that parent should also seek to be recorded.

For all agencies to ensure the learning from the homicide timeline work is built into all DA training, and for Safer Gloucestershire to explore the best dissemination of Jane Monckton Smith’s formal training.

Primary Care should always discuss concerns about suspected or known issues of domestic abuse amongst the Multi-Disciplinary Team to ensure awareness of cases, and the opportunity to join up discussions or concerns about all children and household members, and their fathers and partners. Primary Care information will benefit from improved MARAC liaison (knowledge of domestic abuse incidents and contribution to MARAC research). All discussions should be noted within records.

There must be continued, consistent and strengthened links between the work of GDASS and Primary Care in order to maintain awareness of domestic abuse issues and the impact that this has on victims and children. This should include consideration of continued service provision for the GDASS pilot beyond March 2020.

Where there are out of hours’ attendances to unscheduled care settings (both for adults and children) GP Practices should have a clearly identified process in place that supports recognition for potential follow up to significant illness or injury. Specifically, the role of hospital paediatric liaison needs to be further clarified in relation to effectiveness and how this currently links with Primary Care.

Practice and learning from IRIS should be considered by the CCG as domestic abuse practice is developed for primary care settings.

To review the GCS Domestic Abuse Policy as the current focus is for staff to know what to do in the event of a disclosure. More guidance is required within this policy about the indicators of potential domestic abuse to enable effective signposting to specialist services.

GCS domestic abuse training needs to encompass all the indicators of domestic abuse which may be evident prior to a disclosure. This training model is for a continuous rolling programme available to all GCS staff, within both adult and children services.

Where there is a known history of domestic abuse within a relationship, GCS practitioners take every opportunity to explore this with the victim when safe to do so and demonstrate consistent professional curiosity. This should be reinforced within the domestic abuse training, group safeguarding children supervision, GCS Domestic Abuse Policy and all GCS staff forums.

Staff need to retain professional curiosity at all times and to ensure continued training is in place for Trust staff.

For the Trust to consider the tools and findings from DOHSC funded Pathfinder sites to ensure that they are maintaining and further developing best practice in relation to domestic abuse.

All schools in Gloucestershire to reassure themselves through refreshers or by implementing mechanisms that their staff understand domestic abuse and the context of professional curiosity in the wider family context.

All schools to agree a system with Children’s Social Care whereby receipt of key safeguarding information is recorded so that there is no doubt on whether that information has been received and acted upon.

That the learning from this review be incorporated into school safeguarding training to enable the difficult issue of the threshold between ‘behavioural’ and ‘safeguarding issues’ to be constantly reviewed by schools in the light of the evidence of this and other SCRs.

All GSCB domestic abuse training should help Social Workers to develop skills to engage children who may conceal domestic violence.

Social Workers to have updated training on patterns of domestic violence to better understand how Laura and her children were impacted upon by the abuse and what actions they would take as a result of the training.

To explore and challenge what has happened and why. For example, the school and Health Visitor were involved but the sharing of information about the children could have improved. A Multi Agency GSCB briefing on the outcome of this IMR to all partners and MASH.

The assessment of Parenting Capacity in Social Worker Single Assessments to be strengthened to include evidence based strengths, risks and vulnerabilities to children.

All Social workers, their managers and leaders to have workshop, team discussions (facilitated by practice learning team) on ACE’s wellbeing of parents and what resources are available for work with parents.

All Social Workers and their managers to attend a workshop or training on perpetrators of domestic abuse (with use of restorative practice methods) to ensure appropriate responses to perpetrators and awareness of current service provision.

All Social Workers and their managers to attend a workshop or training to include interviewing techniques to ensure the child’s voice is heard and identify the wide range of indicators of domestic violence and coercive control. Programme to be started immediately and outcomes reported to Gloucestershire Safeguarding Delivery Board.

Gloucestershire Constabulary should maximise the use of Body Worn Video in situations of suspected Domestic Abuse.

Gloucestershire Constabulary, in conjunction with the Crown Prosecution Service, should continue to recognise and progress evidence led prosecutions.

Gloucestershire Constabulary should ensure that officers at Domestic Abuse incidents recognise the evidence that can be provided by children and, where appropriate, seek to secure and preserve that evidence.