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

South Warwickshire review

CSP: South Warwickshire Published: December 2022 Year of death: 2017 Extracted: 18 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 report highlights systemic failures by multiple agencies to identify and respond to the perpetrator's escalating coercive control, economic abuse, and stalking behavior towards the victim, alongside missed opportunities for professional intervention and support.

Home Office classifications

35 tags

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

  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Victim - immigration involvement
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family received draft report
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

18 recommendations pulled from the report · 10 matched to organisations in the index

Recommendation 1

Addressed to DACS

DACS review their referral process to include: 1a) Ensuring that referral forms are examined in detail and the appropriate risk assessment is made on the information available. 1b) In the case of a delay in DACS responding to a referral. The referring agency is to be informed by DACS of the delay with a special request that the referring agency advises the victim of the delay.

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

Recommendation 2

Addressed to All referring agencies

All agencies making referrals to DACS for victims of domestic abuse ensure that referral forms are followed up and enquiries made of DACS as to; a) the action DACS will be taking, b) how any time delay and back log will affect the victim and c) whether the referral is to be progressed by DACS or not, thus enabling alternative support to be arranged by the referring agency.

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

Recommendation 3

Addressed to Warwickshire CCG

Warwickshire CCG’s to ensure that all GP surgeries are compliant with the RCGP guidance issued in 2011, regarding adopting a more robust proactive approach towards domestic abuse within all GP surgeries.

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

Recommendation 4

Addressed to Warwickshire County Council

Warwickshire County Council to embark on a publicity campaign advertising by campaigns, posters seminars etc., the opportunities for victims of domestic abuse, their friends and family members in Warwickshire to locate help support and advice about domestic abuse support.

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

Recommendation 5

Addressed to South Warwickshire Community Safety Partnership

South Warwickshire Community Safety Partnership to liaise with the Solicitor’s Regulation Authority and the Law Society to raise awareness of potential missed opportunities and to encourage the training of Solicitors acting in the divorce arena of law so as to enable victims of domestic abuse to receive appropriate legal advice and to be signposted to specialist domestic abuse support services.

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

Recommendation 6

Addressed to Refuge

Refuge to maintain contact with National Association of Estate Agents to ensure continued support from NAEA in the distribution of domestic abuse literature to victims of domestic abuse as and when necessary.

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

Recommendation Addaction IMR 1

Addressed to Addaction

Addaction continue to ensure learning from incidents and to revisit the risk framework to ensure it is robust especially during initial contact, prior to full assessment.

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

Recommendation CWPT IMR 1

Addressed to Coventry and Warwickshire Partnership Trust

In order to ensure that CWPT staff are able to recognise the importance of using the DASH to understand the history of abusive behaviours in the context of current risk, a formal agency recommendation is that a greater emphasis is given to this during CWPT Level 2 Safeguarding Training and CWPT Level 3 Domestic Abuse training.

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

Recommendation CWPT IMR 2

Addressed to Coventry and Warwickshire Partnership Trust

Staff to be reminded via CWPT training that the ‘all user’ message facility should be made clear to patients at the beginning of any assessment and in the interests of continuity of care information will be shared with the client’s GP. Patients can then make an informed decision about the information they share with the assessing clinician.

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

Recommendation SWFT IMR 1

Addressed to South Warwickshire Foundation Trust

South Warwickshire Foundation Trust are compliant with NICE Guidelines - Domestic violence and abuse Quality standard [QS116] Published date: February 2016 and will continue to report and monitor incidents relating to this area and to take learning from incidents.

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

Recommendation SWFT IMR 2

Addressed to South Warwickshire Foundation Trust

Safeguarding Adults training has been updated to provide increased information for staff regarding domestic abuse, how to recognise and how to engage with routine enquiry.

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

Recommendation Warwickshire CCG IMR

Addressed to Warwickshire CCG

Focused and targeted IRIS awareness improvement in General practice by the Advocate Educators / Clinical lead within Warwickshire. This will be an ongoing piece of work over the forthcoming year.

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

Recommendation Warwickshire CCG IMR

Addressed to Warwickshire Clinical Commissioning Group Safeguarding Leads

Warwickshire Clinical Commissioning Group Safeguarding Leads will review the GP self-assessment safeguarding tool to include assurance on domestic abuse interventions. To be completed by 30.9.18

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

Recommendation Warwickshire CCG IMR

Addressed to Warwickshire Clinical Commissioning Group Safeguarding Leads

Warwickshire Clinical Commissioning Group Safeguarding Leads, in partnership with the Named GP, will deliver a tailored safeguarding programme to all practice safeguarding leads to ensure they can deliver enhanced knowledge on domestic abuse. Dates to be disseminated to safeguarding practice leads by 31.7.18

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