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

Plymouth review

CSP: Plymouth Published: December 2022 Year of death: 2017 Extracted: 23 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 identifies concerns regarding the perpetrator's declining mental health, drug addiction, and history of domestic abuse towards his wife and children. Agencies lacked a holistic overview of the escalating risk, and there were challenges in assessing his fluctuating capacity and ensuring consistent engagement with support services.

Home Office classifications

48 tags

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

  • Children - present at homicide (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - physical disability
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - suicidal thoughts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by mental health services
  • Perpetrator - died by suicide
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family received draft report
  • DHR process - police recommendations
  • 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 - school recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

23 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to Safer Plymouth

Safer Plymouth to provide opportunities for the workforce to improve understanding around DA perpetration. This should include identifying pathways to access to appropriate perpetrator programmes.

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

Recommendation 2

Addressed to Plymouth GP Practices

Staff within Plymouth GP Practices should receive updated training with regards to Domestic Abuse. This should include understanding DA perpetration.

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

Recommendation 3

Addressed to Housing providers in Plymouth

Housing providers in the Plymouth should review and amend policy and practice to ensure best practice around domestic abuse is adhered to across the City. This will include promotion of DAHA accreditation and working towards a ‘Whole Housing Approach’.

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

Recommendation 5

Addressed to PATH

PATH to review their referral forms and include a section requiring referrers to declare that they have provided all relevant Needs and Safety Assessments and the copy of the homeless application.

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

Recommendation 6

Addressed to PATH

PATH to review the information that promotes the service that they deliver and implement a communications strategy.

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

Recommendation 7

Addressed to Devon and Cornwall Police

Devon and Cornwall Police to review the current mobile data technology to ensure frontline officers access to research subjects on their devices and to ensure a timely upload of DASH information onto force systems.

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

Recommendation 8

Addressed to Devon and Cornwall Police

Devon and Cornwall Police to remind all officers and appropriate staff of the need to inform victims of the purpose of the DASH risk assessment and its relevance in terms of risk to their situation at each recorded incident.

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

Recommendation 9

Addressed to School 2 | School 3

School 2 and School 3 must review their domestic violence policy to ensure that it includes advice a guidance regarding staff making disclosures of domestic abuse.

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

Recommendation 10

Addressed to School 2 | School 3

School 2 and School 3 must ensure that there is an effective risk assessment process in place where there are perceived or actual risks to staff, pupils or parents.

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

Recommendation 11

Addressed to School 2 | School 3

School 2 and School 3 must ensure that their DSL’s receive child abuse/ safeguarding update training.

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

Recommendation 13

Addressed to School 2 | School 3

School 2 and 3 should review supervisory policies and practice in relation to DSL management.

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

Recommendation 14

Addressed to Education

Education to undertake a review to establish the feasibility and implementation of live chronologies across the school’s network in Plymouth.

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

Recommendation 15

Addressed to Schools

Schools to ensure they review existing data collection systems to ensure that they detail the nationality and religious beliefs of parents and children.

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

Recommendation 16

Addressed to Safer Plymouth

Safer Plymouth must review the current domestic abuse communications strategy to ensure that it reaches all victims.

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

Recommendation 18

Addressed to Health

Health to review the existing communications strategy in relation to informing members of the public regarding mental health service access and gateways.

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

Recommendation 19

Addressed to Children’s social services

Children’s social services to ensure staff are trained in risk assessment in relation to domestic abuse in the home and the management of situations where high risk offenders refuse to leave premises.

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

Recommendation 20

Addressed to Children’s Social Care

Children’s Social Care to review their information exchange policy with GP’s in line with multi-agency safeguarding procedures.

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

Recommendation 21

Addressed to The perpetrator’s GP

The perpetrator’s GP to review its prescription policy to ensure it meets national recommendations.

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

Recommendation 22

Addressed to Safer Plymouth partner agencies

Safer Plymouth partner agencies should implement a quality assurance practice to ensure that information sharing processes between agencies are being adhered too.

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

Recommendation 23

Addressed to Police | Education | Local Authority

Police, Education and the Local Authority must review the current CARA training strategy in the City and provide update training where appropriate.

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

Recommendation 24

Addressed to Police | Education | Local Authority

Police, Education and the Local Authority must review exiting policy in relation to CARA, to ensure that there is clarity regarding who the information is shared with; whether victims and children are spoken with; how risk is managed; and that there are effective monitoring and escalation procedures in place.

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