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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	DACS
2	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.	All referring agencies
3	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.	Warwickshire CCG
4	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.	Warwickshire County Council
5	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.	South Warwickshire Community Safety Partnership
6	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.	Refuge
Addaction IMR 1	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.	Addaction
Addaction IMR 2	Addaction risk and safeguarding assessment to include a review of past and current risks.	Addaction
CWPT IMR 1	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.	Coventry and Warwickshire Partnership Trust
CWPT IMR 2	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.	Coventry and Warwickshire Partnership Trust
SWFT IMR 1	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.	South Warwickshire Foundation Trust
SWFT IMR 2	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.	South Warwickshire Foundation Trust
Warwickshire CCG IMR	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.	Warwickshire CCG
Warwickshire CCG IMR	Re-circulation of the Duluth power and control wheel and RCGP Domestic abuse toolkit to all Warwickshire practices. This will be completed by 31.7.18.	Warwickshire CCG
Warwickshire CCG IMR	Review of the training and education of Registrars in relation to Domestic abuse and IRIS. Discussions to be held by the 31.7.18	Warwickshire CCG
Warwickshire CCG IMR	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	Warwickshire Clinical Commissioning Group Safeguarding Leads
Warwickshire CCG IMR	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	Warwickshire Clinical Commissioning Group Safeguarding Leads
Warwickshire CCG IMR	Dissemination to all Primary care teams of the DASH risk assessment tool. To be completed by 31.7.18	Warwickshire CCG
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗