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

Nottingham review

CSP: Nottingham Published: December 2022 Year of death: 2018 Extracted: 22 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 review highlights challenges in identifying the primary aggressor in cases with mutual allegations, exacerbated by alcohol use and the victim's disengagement from services. It also notes missed opportunities in multi-agency information sharing, risk assessment, and a lack of resources for perpetrator support and long-term victim therapy.

Extracted recommendations

22 recommendations pulled from the report

#	Recommendation	Addressed to
10.2a	Where procedures outline expected discharge actions there is enough flexibility within services to respond differently when necessary.	Nottingham Recovery Network
10.3a	Adult Duty Workers who are responding to DART referrals must ensure they review history of case and do not respond to referrals in isolation, irrespective of risk rating.	Nottingham City Adult Social Care
10.3b	Adult Duty workers should ensure they attempt to seek out alternative telephone numbers to make contact and speak to relevant other agencies, when involved, to establish the victim’s safety.	Nottingham City Adult Social Care
10.4a	GP Practices to complete the ‘Groups and Relationships’ Template at every contact with individuals, in order to ascertain current partner/children/family dynamics details. This is especially important when it is known by GP Practice Staff that an individual is ‘Vulnerable’ and/or ‘At Risk of Domestic Abuse’ because it is vital that individuals are linked to each other in order to identify individual risks and to offer appropriate support, advice and action planning in a timely manner.	Greater Nottingham Clinical Commissioning Partnership
10.4b	‘Routine Enquiry’, pertaining to domestic abuse should always take place by all GP Practice Staff when it is known that an individual is ‘At Risk of Domestic Abuse’ and/or is ‘Vulnerable’ in any way.	Greater Nottingham Clinical Commissioning Partnership
10.4c	Any ‘Routine Enquiry’ discussions should always be fully documented in the clinical GP Records of the individual concerned, alongside documentation of support offered and any plan of action/follow up.	Greater Nottingham Clinical Commissioning Partnership
10.4d	An appropriate Risk Marker Flag pertaining to being ‘At Risk of/ Victim of Domestic Abuse’ should always be routinely entered into the GP records, as soon as the GP Practice are aware of this information (For example - via verbal disclosure from the victim or via DART or other agency notification).	Greater Nottingham Clinical Commissioning Partnership
10.4e	All voicemail messages left by GP Practice Staff should be fully documented into the GP Records of the individual concerned AND any messages left for victims of Domestic Abuse should contain only minimal routine information about health appointments and not relate in any way to domestic abuse/domestic abuse information because this may put the victim at further risk.	Greater Nottingham Clinical Commissioning Partnership
10.4f	All DART/MARAC Notifications received by the GP Practice should be entered into the GP Records of the Victim and into the records of the Perpetrator (if the Perpetrator is registered with the same GP Practice as the Victim).	Greater Nottingham Clinical Commissioning Partnership
10.4g	DART/MARAC Notifications should be forwarded to a Clinical Professional for review & action planning & documentation into the GP clinical records (of Victim and Perpetrator if appropriate) as soon as the information is received by the GP Practice.	Greater Nottingham Clinical Commissioning Partnership
10.5	Framework to undertake an organisational review of how information is shared between different services, including Opportunity Nottingham and Nottingham Recovery Network. This review has two objectives; firstly, to ensure that there are no systemic, organisational or cultural barriers to effective communication. Secondly to ensure that all services contribute to a shared analysis and understanding of risk.	Framework
11.1	All Agencies should review their policies for discharging people, to ensure that there is not a “one strike and you’re out” ethos. This would help people who present as high risk and struggle to engage with services on a consistent basis.	All Agencies
11.10	Local agencies from the Nottingham Domestic Homicide Review Assurance, Learning and implementation Group (DHR ALIG) should develop Practice Guidance on Multi-agency data sharing to ensure data is shared in a safe and lawful way.	Nottingham Domestic Homicide Review Assurance, Learning and implementation Group (DHR ALIG)
11.2	Agencies should consider whether individuals dealing with multiple disadvantages can be offered “open appointments” where it is safe to do so. Experience shows that services can then be reactive when individuals require input, particularly at a point of crisis.	All Agencies
11.3	When a service user withdraws consent to share information, the possibility that this has been prompted by a coercive partner should be considered, and the issue discussed with the service user. When a person is high risk for domestic abuse a decision should be made about consent and sharing with other agencies not just referring to the MARAC.	All Agencies
11.4	All MARAC agencies to be reminded that repeat referrals of any risk level within a 12-month period should be referred back to the MARAC. This point to be emphasised in on-going MARAC training.	All MARAC agencies
11.5	Where there are mutual allegations, it is important for agencies to consider the context and pattern of incidents to establish triggers and understand who is at greatest risk.	All Agencies
11.6	There is no local voluntary service for men who are identified as perpetrators and have not been convicted. Presently any male wanting support is referred to national Respect helpline, previously a face to face service was available in Nottingham. This should remain under review.	Local Agencies
11.7	All agencies should ensure they apply a strategic approach to the domestic abuse training provided by Equation; and ensure that the most appropriate staff are offered training and prioritise their needs.	All Agencies
11.8	MARAC practice should be reviewed to establish whether the gender disparity apparent in this case is symptomatic of a wider problem. This anomaly may be specific to this case but should be reviewed in similar cases where there are counter allegations of abuse.	MARAC
11.9	The provision for male survivors of domestic abuse is under-resourced and struggles to meet the current need (there is one dedicated Independent Domestic Violence Advisor (IDVA) for male survivors for County and City). Commissioning agencies should review the existing provision and seek additional funding or resources.	Commissioning agencies
12.1	The Home Office should consider revising the Current Domestic Violence Disclosure Scheme (DVDS) Guidance to address situations where there are mutual allegations and identification of the primary perpetrator creates barriers to agencies correctly identifying the risks to the most vulnerable person in those cross allegations. We recommend that where there are mutual allegations, the focus should be on the most vulnerable party (who is at most risk of harm).	Home Office
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗