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
East Staffordshire review
CSP: East StaffordshirePublished: December 2022Extracted: 8 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
Agencies failed to recognise and understand coercive control and economic abuse, particularly the heightened risk during separation. This led to missed opportunities to safeguard the victim, with professional focus often on the perpetrator's mental health rather than the victim's safety.
Home Office classifications
28 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - housing issues
Victim - serious or life limiting illness
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - under 18 shared parental responsibility (between perpetrators)
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - mental ill health
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - suicidal thoughts
Perpetrator - suicide attempts
Perpetrator - serious or life limiting illness
Perpetrator - supervised by mental health services
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - digital stalking
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - police recommendations
DHR process - health services recommendations
DHR process - community safety partnership recommendations
DHR process - training recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
8 recommendations pulled from the report · 2 matched to organisations in the index
Addressed to
East Staffordshire Community Safety Partnership
East Staffordshire Community Safety Partnership should write to the Executive Director of Operations at Citizens Advice (enclosing a copy of the final report) to ask them to review whether their advisors receive appropriate training on domestic abuse (including information on coercive control and economic abuse).
Addressed to
Midlands Partnership NHS Foundation Trust
Midlands Partnership NHS Foundation Trust should evidence that clinical staff are adhering to the Carer Engagement Standards as well as the "Our Service User and Carer Charter".
Reassurance should be sought by Staffordshire Police that 'prevention interviews' following missing persons episodes consider safeguarding measures and referrals to appropriate services.
Addressed to
East Staffordshire Community Safety Partnership
It should be standard practice that as soon as the threshold for a domestic homicide review is met, a letter should be sent on behalf of the independent chair to request access to the perpetrator's medical records.
Addressed to
East Staffordshire Clinical Commissioning Group
The adult safeguarding training delivered by the Clinical Commissioning Group to primary care staff on domestic abuse should include coercion and control. This should be evidenced by research findings such as 'Counting Dead Women' 20 and 'Partner Femicide’.21
The GP Practice should seek additional support and training on domestic abuse, and it should include the signs of coercive control. This will ensure that the staff are aware of their duties to explore and document discussion following disclosures such as marital breakdown.
Addressed to
Domestic Abuse and Commissioning Development Board
The Domestic Abuse and Commissioning Development Board (DACDB) should seek assurance that training and development in relation to domestic abuse for GPs is meeting its objectives. The specific areas of development include coercion and control, escalation of risk linked to recent studies around the preceding steps to domestic homicide.
Addressed to
Domestic Abuse Commissioning and Development Board
The Domestic Abuse Commissioning and Development Board should assure the East Staffordshire CSP that awareness of domestic abuse (especially coercion & control and economic abuse) is being enhanced across a wide landscape of agencies particularly the Voluntary, Community and Social Enterprise (VCSE) community. This should further safeguard their service users and the public, in line with the findings of this review.