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

Warrington review

CSP: Warrington Published: December 2022 Year of death: 2018 Extracted: 24 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 inconsistent agency responses to domestic abuse, including missed opportunities by GPs and ineffective multi-agency risk assessment conference (MARAC) processes. Failures in managing the perpetrator's bail, prison communications, and timely arrest after recall also contributed to the tragic outcome.

Home Office classifications

40 tags

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

  • Victim - alcohol misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - depression
  • Victim - self harm
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - psychosis
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • 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 - 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

24 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 19.1

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership to raise the profile of domestic abuse services within the Borough with emphasis on raising awareness of where to get advice and access to help and support.

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

Recommendation 19.2

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should put in place processes by which it can gain assurance that. 1. MARAC actions are meaningful and contribute to the safety of the victim. 2. Agencies are held to account for the delivery of agreed actions. 3. Effective MARAC co-ordination arrangements are in place.

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

Recommendation 19.3

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should seek assurance from it’s constituent agencies and the commissioners of Pathways that the purpose and status of a VPA is consistently understood across the partnership.

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

Recommendation 19.4

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should seek assurance from its constituent partners and third sector agencies that they commission that an appropriate mechanism is in place to ensure that domestic abuse and safeguarding policies are embedded in practice.

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

Recommendation 19.5

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should seek written assurance from HMP Altcourse that the failure in internal communications which led to the perpetrator’s restraining order not being recorded and his subsequent ability to communicate with the victim in breach of the restraining order has been effectively resolved.

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

Recommendation 19.6

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should seek assurance from its constituent partners that there are no inappropriate barriers to sharing information with the third sector partners.

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

Recommendation 19.7

Addressed to Warrington Community Safety Partnership

Warrington Community Safety Partnership should seek assurances from all agencies and commissioned third sector agencies that they are fully engaged in local domestic abuse training.

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

Recommendation 19.8

Addressed to Warrington Community Safety Partnership | Warrington Safeguarding Adult Board

Warrington Community Safety Partnership and Warrington Safeguarding Adult Board should consider the feasibility of developing a coordinated case management/information sharing approach to the care of high intensity service users, who for whatever reason engage in risky behaviours that are not captured by other safeguarding processes. The two boards are best placed to collaborate and facilitate discussion around this with a view to agreeing and implementing a multi-agency protocol.

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

Recommendation 19.9

Addressed to Torus New Leaf

When clients are being assessed for the 1-2-1 mentor scheme this assessment should include asking questions about domestic abuse as well as safeguarding issues.

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

Recommendation 19.10

Addressed to Warrington CCG

Ensure that staff at GP practices understand the indicators of possible domestic abuse and how to ask about domestic abuse in a sensitive way and manage any disclosures made. Consideration should be given to commissioning the IRIS model locally to raise awareness of the issues surrounding domestic abuse and how to refer women to IDVAs.

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

Recommendation 19.11

Addressed to Warrington and Halton Hospitals NHS Foundation Trust

Staff should receive targeted domestic abuse training with a focus on recognising controlling and coercive behaviour.

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

Recommendation 19.12

Addressed to Warrington and Halton Hospitals NHS Foundation Trust

Targeted DASH completion and assessment training should be provided with a focus on enabling staff in recognising domestic abuse situations; they should be equipped with the knowledge of how to escalate situations in which there is danger even when the victim does not know/realise danger is present, or does not consent to receiving support in high risk situations.

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

Recommendation 19.13

Addressed to Warrington and Halton Hospitals NHS Foundation Trust

Staff should be made aware of their statutory and professional obligations and reminded of their professional responsibilities with regard to documentation and record keeping.

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

Recommendation 19.14

Addressed to Pathways to recovery (Change, Grow, Live)

Pathways to identify two additional staff members as MARAC deputies who will receive the local induction to MARAC, including shadowing a MARAC session, and training from the lead Pathways MARAC representative on record keeping.

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

Recommendation 19.15

Addressed to WBC Adult Social Care

WBC Adult Social Care to undertake an audit of cases to confirm the effectiveness of recent strength-based approach training including the use of and clarity around service user outcomes.

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

Recommendation 19.16

Addressed to WBC Adult Social Care

WBC Adult Social Care to ensure the integration of the Skills for Care Knowledge and Skills Statement for Practise Supervisors within its supervision policies and procedures.

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

Recommendation 19.17

Addressed to WBC Adult Social Care

WBC Adult Social Care to ensure that supervisors review each case when there is a transfer between case managers to maintain direction and focus.

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

Recommendation 19.18

Addressed to WBC Adult Social Care

WBC Adult Social Care to raise awareness of the use of multi-agency frameworks to escalate and share risks in relation to capacitated adults, including the lessons identified in the recent Safeguarding Adults Board audit.

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

Recommendation 19.19

Addressed to Cheshire and Greater Manchester Community Rehabilitation Company (CGM CRC)

CGM CRC to improve the knowledge, understanding and effective use of Through the Gate (TTG) guidance and procedures for relevant staff.

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

Recommendation 19.20

Addressed to Cheshire and Greater Manchester Community Rehabilitation Company (CGM CRC)

CGM CRC to deliver SARA3 training across the organisation and across all operational grades of staff.

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

Recommendation 19.21

Addressed to Cheshire and Greater Manchester Community Rehabilitation Company (CGM CRC)

CGM CRC to develop and embed Quality Assurance and continuous improvement in relation to EMO arrangement.

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

Recommendation 19.23

Addressed to Cheshire Constabulary

Cheshire Constabulary to raise awareness amongst officers of the importance of submitting a VPA in cases of breaches of bail when the bail conditions have been imposed as a result of a domestic incident.

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

Recommendation 19.24

Addressed to Cheshire Constabulary

Cheshire Constabulary to consider making use of the current legislation around the harassment and intimidation of witnesses when a remand is sought for the perpetrator of domestic abuse. (Para 17.9)

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