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

Lincoln review

CSP: Lincoln Published: December 2022 Year of death: 2017 Extracted: 16 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 a history of controlling, manipulative, and violent domestic abuse by the perpetrator, exacerbated by his alcohol misuse. The victim faced significant barriers to disclosure, including cultural and religious factors, and agencies missed opportunities for earlier and more comprehensive intervention.

Home Office classifications

37 tags

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

  • Victim - housing issues
  • Victim - mental ill health
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Victim - immigration involvement
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Child - primary address same as victim
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - died by suicide
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - religious institution recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes

Extracted recommendations

16 recommendations pulled from the report · 9 matched to organisations in the index

Recommendation 1

Addressed to Lincolnshire Police

The business case for implementation of Operation Encompass is seriously considered and that the scheme is adopted as soon as possible

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

Recommendation 2

Addressed to Safer Lincolnshire Partnership

It is recommended the Safer Lincolnshire Partnership considers actively encouraging organisations to engage with the available work-place initiatives with a view to improving the support to employees who are victims of domestic abuse

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

Recommendation 3

Addressed to Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn

The Gynaecology Outpatient Clinic and Breast Care Service at Queen Elizabeth Hospital each identify a practitioner to complete the domestic violence champions training (delivered locally by Norfolk County Community Safety Partnership) and to attend the safeguarding champions’ group.

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

Recommendation 4

Addressed to Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn

That the Queen Elizabeth Hospital audits whether staff are routinely asking the question about domestic violence and abuse

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

Recommendation 5

Addressed to Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn

That the QEH Trust Domestic Abuse Policy is updated to include NICE guidance recommendations

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

Recommendation 6

Addressed to Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn

That the safeguarding children and adult team at QEH review the current provision of training around domestic violence and abuse against the NICE Quality Standards 2014

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

Recommendation 7

Addressed to Lincolnshire County Council

That Lincolnshire County Council reviews its absence policy with a view to providing more guidance on the action that should be taken if a member of staff does not comply with the policy and make contact personally. This review should consider how the school and unions can work together to ensure staff understand the need for the safe and well check

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

Recommendation 8

Addressed to The District Council

That the case management system and process is reviewed to avoid duplicate records and build in a check of details of other names known by

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

Recommendation 9

Addressed to The District Council

That the notes are maximised to:
• Capture the detail of the contact;
• Record of the risk assessment ;
• Capture and record supervision action in case notes.

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

Recommendation 10

Addressed to The District Council

That there is effective liaison with other service providers – for example, the risk of domestic abuse that is recorded in housing files was not shared with revenue and benefits Department at the time.

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

Recommendation 11

Addressed to GP surgery for Grant and Louise

That the surgery introduces a policy for adult safeguarding especially domestic abuse

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

Recommendation 12

Addressed to GP surgery for Grant and Louise

That GPs record in detail any conversations that they have with patients with depression and demonstrate on the record how they have looked at the possibilities of the underlying reason

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

Recommendation 13

Addressed to Diocese of Lincoln

That the statutory agencies work closely with the church to harness the willingness to establish better local relationships and to contribute to a better understanding by agencies of the role of faith communities in the lives of their members. It is recommended that the work begun to have a conversation about the churches’ teaching on being a ‘good neighbour’ continues

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

Recommendation 14

Addressed to LSAB | LSCB

That the safeguarding boards in Lincolnshire ensure they are engaged with the faith community in their safeguarding processes, so that churches can be included in the planning and assessment of families and individuals, recognising that, where people are very involved in their faith life, the church can provide a significant source of support and comfort and that Clergy and church officers could have active roles in addressing the support needs of their members

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

Recommendation 15

Addressed to Diocese of Lincoln

That the Diocesan Safeguarding Team completes its Parish Audits during 2018 to enable targeted support to be offered to Parishes who are struggling to mainstream good safeguarding practice within the ministry and mission of the local Church

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

Recommendation 16

Addressed to Diocese of Lincoln

That the Domestic Abuse module of the Church of England Safeguarding Training is delivered during the second half of 2018

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