Nottingham review

Agencies should undertake a training needs analysis in respect of domestic abuse related suicide and provide assurance that it has been done.

The Public Health Suicide Prevention Group should consider whether something should be put in place similar to the MARAC regarding the impact of domestic abuse on suicide.

The CSP should explore whether a structured and coordinated approach can be developed around the delivery of ‘safe messages’ by agencies to a survivor who is living with a perpetrator and to consider how the ‘Change that lasts’ project uses safe messages.

That the national recommendations about maintaining or expanding refuge spaces and there being a centralised referral system is supported by the CSP.

That in complex cases where there are mutual allegations, partner agencies should map incidents rather than looking at them in isolation in an attempt to establish who is instigating the abuse.

That Understanding and Responding to Domestic Violence and Abuse (URDVA) training includes more information about suicide and the impacts on it of domestic violence and abuse.

The force needs to evaluate the use of Voluntary attendance in respect of Domestic Abuse flagged crime, to ensure it is appropriately used and is effective.

Consideration should be given to the type of training GP’s and primary health-care require in order to identify victims of abuse and address their holistic needs appropriately.

That the NHS Nottingham City Clinical Commissioning Group recirculate the Primary Care Domestic Abuse Referral Team (DART) Notifications Good Practice Guidelines (by the Safeguarding Adult and Children Team) to all GP Practices across NHS Nottingham City Clinical Commissioning Group / Greater Nottingham Clinical Commissioning Partnership and that they are also made available on the Safeguarding Adult and Children Safeguarding Website.

That the News Fact Sheet Safeguarding Newsletter is re-circulated to all GP Practices in NHS Nottingham City Clinical Commissioning Group/Greater Nottingham Clinical Commissioning Partnership on the subject of domestic abuse and the risk of suicide amongst victims.

That GP Practices ascertain the patients preferred method of contact (e.g. via telephone, text or letter), when patients register at GP Practices and also when any member of the GP Practice staff reviews patient personal details.

That the IAPT services and Primary Care Mental-health Services are linked into the System One F12 project to ensure all GP’s, including locums are aware of services are available in the city.

Assurance is sought from primary care that all practice staff have access to domestic abuse training through the GP self-assessment checklist

That the Mental-health strategy for the Nottinghamshire Integrated Care System (ICS), which is currently under review, takes account of the learning from this DHR.

The automated ‘remote observer call’ system should be reviewed so as not to give a misleading impression that a caller has terminated a call when it had ended naturally.

That the regular action learning workshops continue for all DART/MARAC practitioners to share information and ideas about cases and the service provided.

That training will be reviewed to increase the understanding of the risk of suicide and the impact of poor mental-health for domestic abuse survivors.

Nottingham City Council should continue to explore different methods of contact with survivors and record why particular methods were not used.

DART workers should contact the survivor’s GP when a survivor has been assessed as ‘High-risk’ and telephone contact has been unsuccessful, to request that contact details of Adult Services and Women’s Aid are provided at the patient’s next consultation.

All WAIS staff should have a process within their service handbook on how to gain information from case notes and staff members working with a woman to prevent too many staff members contacting the woman and her having to repeat her ‘story’.

The Men’s Service should continue only to offer a service to male survivors and follow procedure to assess relationship dynamics.

The Men’s Service should identify how to improve timescales of referral checks and case notes.

The Men’s Service identify whether to engage with all referrals identified as perpetrators who acknowledge their behaviour to give advice on how to get support with their abusive behaviour.

The potential for bringing more clarity to the engagement with the service of men where it is unclear whether they are a victim, or a perpetrator should be explored.