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 WarwickshirePublished: December 2022Year of death: 2017Extracted: 18 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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