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

Derby review

CSP: Derby Published: December 2022 Extracted: 8 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 report identifies systemic failures in identifying and responding to escalating domestic abuse, particularly concerning the victim's mental health, substance misuse, and pregnancies. Agencies often responded in isolation, missing opportunities for multi-agency coordination and routine enquiry into abuse, and failing to adequately consider coercive control and cumulative risk.

Extracted recommendations

8 recommendations pulled from the report

#	Recommendation	Addressed to
1	All partners will ensure the multi-agency learning from the domestic homicide review QDCNH18 is shared and implemented across the workforce as part of continuing organisational engagement with the safeguarding agenda.	All partners
2	(a) Health partners across Derbyshire should provide assurance and evidence that the requirement to make “routine enquiry” is understood, is taking place at all relevant opportunities, and responses are being recorded with follow up planned if the enquiry could not be completed and (b) All other partners in contact with pregnant women should also provide assurance that professionals are enabled to routinely enquire sensitively about women’s experience of domestic abuse in order that they can be provided with the safe space and opportunity to disclose abuse to any professional should they feel able.	Health partners across Derbyshire \| All other partners in contact with pregnant women
3	The Derbyshire and Derby Safeguarding Children Partnership, after the re-promotion of the Pre-Birth Protocol through the briefing issued May 2020, should provide assurance and data that pre-birth assessments are being completed when risks are identified to improve outcomes for pregnant women, unborn children and their wider families.	Derbyshire and Derby Safeguarding Children Partnership
4	The Derby and Derbyshire Safeguarding Children Partnership and the Derbyshire Safeguarding Adults Board should review relevant policies and practice guidance to ensure the need for practitioners to be alert to long term patterns of abuse and cumulative risk factors/warning signs is adequately reflected and supports the development of a shared understanding of risks within past and current relationships and within families helping to provide a focus for effective multi-agency responses to domestic abuse.	Derby and Derbyshire Safeguarding Children Partnership \| Derbyshire Safeguarding Adults Board
5	Assurance should be provided by partners that all domestic abuse related multi-agency and single agency training includes information regarding additional risks and triggers of domestic abuse associated with pregnancy and that agencies identify key staff requiring training and that this is delivered/completed.	All partners
6	Referral criteria and explanatory notes for the Multi Agency Risk Assessment Conference (MARAC) process should be re-examined and updated as necessary and be widely circulated to ensure professionals are supported to consider the specific circumstances, vulnerabilities and risk factors of victims in order that individuals may benefit from their case being discussed at MARAC enabling appropriate safety plans to be developed. The new MARAC+ team will provide a progress report on changes to the Derbyshire and Derby Domestic Abuse and Sexual Violence Governance Board after 6 months of implementation.	Derbyshire and Derby Domestic Abuse and Sexual Violence Governance Board
7	A coordinated and collaborative approach should be the aspiration of mental health services including crisis, community and hospital teams, across areas and trusts, with other relevant organisations to enable seamless continuity of care focused on the needs of individuals, with specific consideration of history and current circumstances particularly when transfer and closure of cases is proposed, and when non engagement is a reason for closure.	Mental health services
8	All partners must evidence their organisational focus and practice in relation to the impact of domestic abuse and its cumulative harm on children and demonstrate their continued commitment to identify children living in abusive households as victims in their own right, to listen to their voices and to enable them to receive effective support.	All partners
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗