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

Hartlepool review

CSP: Hartlepool Published: December 2022 Year of death: 2018 Extracted: 20 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 missed opportunities by agencies to recognise and respond to the victim's domestic abuse and coercive control. Key concerns include inadequate multi-agency information sharing, a lack of understanding of risk assessment processes like the Potentially Dangerous Person (PDP) framework, and the victim's fear of child removal as a barrier to disclosure.

Home Office classifications

37 tags

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

  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • 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 mental 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 perpetrator programme
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation services 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 - multi agency working recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

20 recommendations pulled from the report · 13 matched to organisations in the index

Recommendation 1

Addressed to Cleveland Police

Cleveland Police review their domestic abuse training for officers and staff to satisfy themselves and the Safer Hartlepool Partnership that it effectively encompasses and addresses the hidden signs of domestic abuse.

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

Recommendation 2

Addressed to Cleveland Police

Cleveland Police ensure that the decision-making rationale for prioritisation of investigations is clearly recorded.

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

Recommendation 3

Addressed to Cleveland Police

Cleveland Police review the governance and oversight of investigations with regard to timeliness and ensuring all available evidence is captured.

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

Recommendation 4

Addressed to TEWV

TEWV to ensure all frontline staff attend Domestic Abuse training focussing on staff always considering potential vulnerabilities of other members of the household when undertaking assessments of a patient’s mental health and associated risks encouraging the adoption of a think family approach..

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

Recommendation 5

Addressed to TEWV

TEWV to provide guidance to staff when working with the perpetrator of domestic violence and including this within the Domestic Abuse policy.

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

Recommendation 6

Addressed to TEWV

TEWV to ensure effective supervision processes are in place so that when a carers assessment is offered that it is completed.

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

Recommendation 7

Addressed to TEWV

When there is multi-agency involvement in a patient’s case, TEWV to ensure open channels of communication should be maintained with all agencies involved.

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

Recommendation 8

Addressed to TEWV

When there is multi-agency involvement in a patient’s case, TEWV to ensure any alerts pertaining to potential risks should be shared across all agencies.

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

Recommendation 9

Addressed to TEWV

All safeguarding concerns should be recorded in line with TEWV processes, policies and procedures.

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

Recommendation 10

Addressed to TEWV

TEWV to review their risk assessment arrangements to ensure it captures new information and intelligence.

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

Recommendation 11

Addressed to NHS England (North)

NHS England (North) share the MHHR report when finalised with the Safer Hartlepool Partnership to ensure co-ordination between relevant recommendations.

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

Recommendation 12

Addressed to Safer Hartlepool Partnership

The Safer Hartlepool Partnership to seek assurance that the 11 recommendations from the Cleveland Police internal review are implemented.

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

Recommendation 13

Addressed to Cleveland Police

Cleveland Police should engage with partner agencies, particularly the National Probation Service, in reviewing multi-agency knowledge and where appropriate involvement in the identification and management of a PDP.

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

Recommendation 14

Addressed to All relevant agencies

Once the above has been achieved all agencies to ensure that their staff are aware of the PDP policy and process.

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

Recommendation 15

Addressed to All relevant agencies

All agencies to review their policy on encouraging professional challenge and ensure staff are confident to do so including encouraging and listening to challenge from third sector organisations.

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

Recommendation 16

Addressed to Safer Hartlepool Partnership

The Safer Hartlepool Partnership to review the effectiveness of Prevent training and that multi-agency staff recognise when and how to make a referral.

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

Recommendation 17

Addressed to All relevant agencies

All agencies to ensure that staff recognise the increased vulnerability of carers who have a child(ren) taken into a care and how they may not seek help or disclose risks to themselves when in the process of seeking to get the child(ren) back.

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

Recommendation 19

Addressed to Safer Hartlepool Partnership

The Safer Hartlepool Partnership to share this DHR report with the Commission on Domestic & Sexual Violence and Multiple Disadvantage.

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

Recommendation National Recommendat

Addressed to Home Office

The Home Office to consider placing the guidance for the identification and management of PDP’s on a statutory footing to mirror MAPPA to prevent differing practices across England and Wales

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