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
Sheffield review
CSP: Sheffield
Published: December 2022
Year of death: 2017
Extracted: 19 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 identified concerns regarding the ineffective processing of urgent mental health referrals, a lack of consistent GP care, and insufficient assessment of the victim's needs as a carer. There was also a failure to routinely enquire about domestic abuse and to see the victim alone, alongside issues with information sharing between agencies.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Sheffield CCG to influence GPs to enquire about domestic abuse and substance misuse every time that a patient presents with mental health issues. | Sheffield Clinical Commissioning Group |
| 1 | When early intervention mental health services cease once a need for secondary mental health services is identified, consideration needs to be given to what will ‘bridge the gap’. | Sheffield Health and Social Care NHS Trust |
| 1 | The Sheffield Safer and Sustainable Communities Partnership to seek assurance from SHSC NHS Foundation Trust with regard to the following: - future service redesign safeguards against any adverse impact upon service delivery - timely and robust processes for referrals made to CMHT which incorporates the learning from this DHR. | Sheffield Safer and Sustainable Communities Partnership | SHSC NHS Foundation Trust |
| 1 | Consideration should be given to selective domestic abuse enquires being made in cases of presenting acute mental illness within A&E, for the patient and for any partner accompanying them. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 2 | Sheffield CCG to encourage GPs to assess the risk of harm to others from those who have disclosed self-harm thoughts. | Sheffield Clinical Commissioning Group |
| 2 | Consideration should be given to selective domestic abuse enquires being made in cases of presenting acute mental illness within Liaison, for the patient and for any partner accompanying them. | Sheffield Health and Social Care NHS Trust |
| 2 | For the Sheffield City Council Public Health ACE workstream to consider the learning from this DHR | Sheffield City Council Public Health ACE workstream |
| 3 | Sheffield CCG to influence GPs to recognise that those supporting people with mental health diagnoses are informal carers and should be offered support. The CCG will encourage GPs to document regular enquires about their patients care needs and caring responsibilities. | Sheffield Clinical Commissioning Group |
| 3 | For the SSSCP to explore options for promoting local community awareness of domestic abuse and neighbourhood watch initiatives. | Sheffield Safer and Sustainable Communities Partnership |
| 4 | Sheffield CCG to encourage GPs to consider sharing information about caring responsibilities (and any potential risks to the carer) for patients who are being referred for Psychiatric assessments. If the carer is registered with a different GP practice then this could be done either with the patient’s consent or without disclosing the potential perpetrator’s details. | Sheffield Clinical Commissioning Group |
| a | in cases of ongoing mental ill-health, good practice would be for a patient to be seen by the same General Practitioner | Sheffield Clinical Commissioning Group |
| b | in cases of ongoing low mood, and misuse of medication, talking therapies should always be offered by the General Practitioner | Sheffield Clinical Commissioning Group |
| c | when early intervention mental health services cease once a need for secondary mental health services is identified, consideration needs to be given to what will ‘bridge the gap’. | Sheffield Health and Social Care NHS Trust |
| d | the Sheffield Safer and Sustainable Communities Partnership to seek assurance from SHSC NHS Foundation Trust with regard to the following: future service redesign safeguards against any adverse impact upon service delivery timely and robust processes for referrals made to CMHT which incorporates the learning from this DHR | Sheffield Safer and Sustainable Communities Partnership | SHSC NHS Foundation Trust |
| e | Consideration should be given to selective domestic abuse enquires being made in cases of presenting acute mental illness within A&E, for the patient and for any partner accompanying them. | Sheffield Teaching Hospitals NHS Foundation Trust |
| f | For the use of routine domestic abuse enquiries to be rolled out within all GP practices within Sheffield. | Sheffield Clinical Commissioning Group |
| g | Ongoing priority is given to the need for a better understanding of carers, their needs and vulnerabilities and referral routes. Best practice would be for people who are identified as carers to be routinely offered signposting or referral for a carers assessment and to be seen alone. | Sheffield Safer and Sustainable Communities Partnership |
| h | For the Sheffield City Council Public Health ACE workstream to consider the learning from this DHR | Sheffield City Council Public Health ACE workstream |
| i | For the SSSCP to explore options for promoting local community awareness of domestic abuse and neighbourhood watch initiatives. | Sheffield Safer and Sustainable Communities Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||