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
Swindon review
CSP: Swindon
Published: December 2022
Year of death: 2017
Extracted: 36 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 review identifies inconsistent inter-agency information sharing, particularly regarding consent and serious harm risk. It highlights delays in police and mental health responses to domestic abuse and suicidal ideation, alongside challenges in refuge provision and addressing the victim's complex reasons for not leaving or reporting abuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | In this DHR professionals from different organisations made conflicting decisions on whether to share with the police information relating to the victim, without her consent when they believed she was a risk of serious harm or death. Some (including Mental Health Services, and Hospital) ,following the ICO Codes of Practice and Care Act decided to share; others (including Swindon Women’s Aid and Hometruths) considered that the victim had mental capacity to make her own decisions. Another (GP) followed the General Medical Council’s Good Practice Guidance on handling Patient information(25/4/2017 onwards) paras 57-59; This divergence of opinion, adversely affected the support the victim received. The DHR Panel therefore recommends that the Home Office draws to the attention of Dept of Health, NHS England and ICO what happened in the victim’s case and works with those Departments to provide to practitioners clear guidance, which is in line with the ICO Code or Practice. | Home Office | Dept of Health | NHS England | ICO |
| 10 | 1. Develop locality Safety Alert highlighting this incident and the expected standards of record keeping in progress notes. 2. Disseminate locality Safety Alert and ensure all teams respond to state that the Safety Alert has been shared and understood 3. Monitor quality of progress notes on monthly basis in team though IQ Records Management audit. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 11 | Mental Health Services to develop clear pathways to support 111 advisors and clinicians to gain advice and support regarding possible referrals to Mental Health Services and enable appropriate direct referrals without service users in crisis having to go back to the their GP. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 12 | Book feedback session with the CA, listen to the case and get the CA to reflect on their actions. | CARE UK |
| 13 | Reflective statement addressing current and future practice, with particular attention to adequate safety-netting. | CARE UK |
| 14 | Clinician involved to ensure up to date with adult safeguarding training. | CARE UK |
| 15 | Clinical lead to raise mental health safeguarding with safeguarding lead to try and identify patterns in referrals. If there is a lack of appropriate referrals or a training need is identified, it will be raised with the national safeguarding lead | CARE UK |
| 16 | Ensure all staff are up to date with mandatory training - level 2 (health advisors) and level 3 (clinical advisors) | CARE UK |
| 17 | 111 Care UK leads to continue to contribute to discussions at a CCG level regarding the availability of mental health services | CARE UK |
| 18 | Consideration of the use of the DASH risk assessment: Where there is a known risk domestic abuse clinical ‘alerts’ must signpost staff to consider DASH risk assessments | Great Western Hospital |
| 19 | Agree ‘alert’ terminology on the electronic patient record to ensure when relevant, staff consider the use of DASH risk assessment | Great Western Hospital |
| 2 | That Community Safety Partnerships embed within their Domestic Abuse Strategies that IDVAs and DV practitioners receive training on legislation and practice relating to stalking and coercive control .This training should encompass technical abuse including the use of security and covert cameras, listening devices, vehicle tracking equipment and mobile phone apps. | Swindon Community Safety Partnership | Home Office |
| 20 | Specialist Safeguarding Supervision for all enquiry managers will include identifying if there has been appropriate involvement of service users in their safeguarding cases, focus on alleged DA and multi-agency arrangements. | Swindon Borough Council Adult Social Care |
| 21 | Making Safeguarding Personal (MSP): (initiative to ensure service users views throughout the safeguarding process) to be revisited to ensure direct involvement (rather than 3rd party) is a feature of all safeguarding cases – wherever possible | Association of Directors of Social Services |
| 22 | Making Safeguarding Personal (MSP): (initiative to ensure service users views throughout the safeguarding process) to be revisited to ensure direct involvement (rather than 3rd party) is a feature of all safeguarding cases – wherever possible | Swindon Borough Council Adult Social Care |
| 23 | A full action plan has been drawn up through the Local Safeguarding Adults Board (LSAB) following a Safeguarding Adults Review where Coercive Control was considered to be a factor | Swindon Borough Council Adult Social Care |
| 24 | Provide training to the Housing Options Team to ensure all cases involving domestic abuse are referred to the appropriate officer and that we should always seek agreement from domestic abuse victims to contact them at a time and via a way that is chosen by them. | Swindon Borough Council Housing Department |
| 25 | GP’s need to be trained in more detail about the implications of the Care Act 2014. The Swindon CCG is currently in the process of ensuring that all GP’s have this training. | Swindon CCG |
| 26 | A review should take place on whether the law / GMC guidance should be changed enabling a GP to contact the police if they believe that a patient is at high risk of serious harm or death if they go home to a domestic abuse situation even if no one else would be at risk other than the patient. | Home Office | Swindon CCG | GMC |
| 27 | Swindon CCG to continue to put together a Safeguarding Protocol that all surgeries are required to sign up to that will be kept up to date (by CCG) with new legislation. This would include domestic abuse information and what actions a GP practice should take on receipt of a MARAC report for one of their patients. | Swindon CCG |
| 28 | All personnel should be reminded of the policy that: 1. The “Missed Appointment Matrix” is to be followed for all clients – especially prior to closing. 2. Workers to double check hard copy file for client’s preferred method of contact and follow this course of action first. 3. If paperwork received from external partners – the allocated worker to be notified and given the paperwork before admin scan it to the document library to help ensure that potentially vital information is received. 4. A contact note should be put on record indicating a new document has been scanned. | Swindon Drug and Alcohol Service (CGL) |
| 29 | When a victim of domestic abuse contacts the Refuge and there are no places available, the person taking the telephone call should offer to check availability at other refuges and if safe to do so, phone the victim back rather that expect the victim to make several calls herself. | Swindon Women’s Aid |
| 3 | For agencies to be aware of all available civil and criminal justice options to tackle perpetrators of domestic abuse. | Swindon Community Safety Partnership Team |
| 30 | Swindon Women’s Aid require a structured Referral Pathway Protocol for those occasions when a survivor of domestic abuse moves to another service provider. | Swindon Women’s Aid |
| 31 | DA offence investigations to only be closed on the written authority of an inspector if the suspect has not been interviewed or arrested. | Wiltshire Police |
| 32 | Wiltshire Police should review victimless prosecutions to ensure 3rd party material is utilised effectively in the absence of victim testimony. | Wiltshire Police |
| 33 | Wiltshire Police should consider the viability of conducting a criminal investigation into offences committed against the victim by her husband. | Wiltshire Police |
| 34 | Consideration to be given to a stalking and harassment clinic. | Wiltshire Police |
| 35 | All high risk cases should be referred back to MARAC when another incident occurs regardless of whether an offence has been committed or not. | Wiltshire Police |
| 36 | When the police receives a call from a person with critical mental health issues which may indicate a risk of serious harm or death, in addition to referring the caller to the in-house mental health Street Triage Team the call should be treated as a Grade 1 call requiring an immediate response. | Wiltshire Police |
| 4 | Commissioned Local Swindon Domestic Abuse Services should have clearly defined processes for supporting victims who may want to stay in relationship and DASS referrals to other support services | Swindon Community Safety Partnership |
| 5 | For all members of the Swindon Intensive Team to be aware of patients who have a rapid access plan into services and to be aware of its purpose. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 6 | To ensure that the Swindon Intensive Team update RiO with any outcomes of multi-agency processes. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 7 | Ensure that the Swindon Intensive Team validate progress notes in real time. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8 | Named Professional for Safeguarding Children and Domestic Abuse to work alongside Swindon teams to ensure the use of the DASH risk assessment tool (following disclosure of domestic abuse) and understanding of the MARAC processes. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 9 | For teams to ensure that there is no disparity when documenting information regarding the same incident. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||