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
Lincoln review
CSP: Lincoln
Published: December 2022
Year of death: 2015
Extracted: 14 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 systemic failures in recognising and responding to domestic abuse, inadequate adult safeguarding, and insufficient application of the Mental Capacity Act for the victim. There were also concerns regarding unaddressed carer stress, poor communication support for the victim, and a lack of effective multi-agency information sharing and risk analysis.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | All professionals should be equipped to identify Domestic Abuse and have the appropriate tools and guidance to do so. This SAR/DHR highlights the need for the Safer Lincolnshire Partnership to work with the Domestic Abuse sub-group and partner agencies to assure itself that all practitioners are equipped to: • Have sensitive conversations and are able to engage and manage victims who are complex, and hostile including those who are older and have caring responsibilities; • Understand and address the effects of Domestic Abuse on all members of the household particularly those who are vulnerable including children and adults with care and support needs, and those who communicate non-verbally; • To have an understanding of the typologies of Domestic Abuse to enable an effective analysis and the appropriate response; • Are provided with appropriate supervision to undertake the complexities of the task. | Safer Lincolnshire Partnership | Domestic Abuse sub-group | partner agencies |
| 10 | • The LSAB should assure itself that all partner agencies ensure that adults who are described as lacking communication should have an advocate in line with their Human Rights and the Care Act 2014. | LSAB | all partner agencies |
| 11 | The LSAB should ensure that: • All partner agencies have enabled professionals to be equipped to work with adults/families who are hard to engage, and that this is always challenged in the best interest of an adult with care and support needs. | LSAB | All partner agencies |
| 12 | The carer assessment of the complex circumstances of Judith and Ron was not sufficiently robust and did not address the contradiction between the carer stress they experienced and their reluctance to accept services. It was not updated or reviewed. • Carers assessments are now subject to quality assurance audits and the LSAB will need to seek assurance that this is making a difference. | LSAB |
| 13 | The LSAB will need to seek assurance from ASC that: • Carer assessments are included in the annual review of an adult with care and support and that these have future planning embedded within them and a risk assessment regarding the sustainability of the caring role using existing frameworks. • The LSAB will need to be reassured that this is being addressed through audit and the best interest work referred to in Theme 3. | LSAB | ASC |
| 14 | LSAB should invite agencies to consider: • The importance of developing a formal multi-agency approach around “think family” to take a more holistic approach to the identification and management of risk, ensuring patterns of behaviour can be identified and incidents are not dealt with in isolation and that complex family needs are addressed. | LSAB | agencies |
| 2 | The LSAB should assure itself that multi-agency safeguarding arrangements are effective and in particular that: • Information is shared appropriately and in a timely manner between agencies to inform decision-making in accordance with LSAB Safeguarding Adults Policy, Procedure and Process 2017; • LSAB Policies and Procedures are reviewed to provide clear guidance about Strategy Meetings to ensure clarity of purpose and agency responsibilities; • LSAB should seek assurance that partner agencies have in place processes whereby those responsible for making safeguarding referrals have good quality and reflective supervision to enable professionals to undertake the complexities of responding to safeguarding concerns. | LSAB | partner agencies |
| 3 | This SAR/DHR has highlighted the need for clarity about the thresholds for acceptance of a safeguarding referral and the importance of feedback about next steps and proposals for other action if the referral is not accepted. There is now a process in place where feedback is provided to a referrer when a referral to Adult Safeguarding does not meet the criteria for a S.42 enquiry including the rationale for decision making, feedback about the quality of the referrals, and whether any further information was needed to make a decision and recommended for follow-up. There is now a process in place to ensure that feedback is provided and openness for challenge. • The LSAB will need to seek an update from relevant partner agencies regarding the progress of this and seek assurance that it is making a difference to adults with care and support needs. | LSAB | relevant partner agencies |
| 4 | Where Adult Safeguarding action is being considered for an adult with care and support needs, and that individual is assessed at that moment as lacking capacity to take part or provide a view about their circumstances and wishes, there needs to be some reflection about who represents those needs and the possibility of advocacy. • The LSAB will need to understand what is currently in place to address this and what further action is required from partners. | LSAB | partners |
| 5 | Professionals should always consider whether decisions about safeguarding responses in complex cases, such as this, need to be carried out in a multi-disciplinary way. This did not happen for Peter and there is currently no formal process to allow this to happen. • The LSAB will need to consider what process needs to be in place to ensure that where necessary adult safeguarding concerns are considered in a multi-agency context. | LSAB |
| 6 | LSAB should seek assurance from Adult Social Care: • The MCA is being applied appropriately and that the view that some adults lack capacity overall is challenged; • That the process supporting best interest decision making is clearly understood and effective. | LSAB | Adult Social Care |
| 7 | LSAB should seek assurance from partner agencies that: • The needs of those adults who would have made the transition from children to adults' services before the implementation of the MCA 2005 have appropriate MCA assessments which inform effective future planning. | LSAB | partner agencies |
| 8 | The LSAB will need to seek assurance about: • The progress of the CCG’s work around the use of Learning Disability Health Reviews, the extent to which these reviews address mental capacity and they are making a difference to adults with care and support needs. | LSAB | CCG |
| 9 | The LSAB should assure itself that: • All partner agencies promote the rights of adults with care and support needs and all those covered by the Care Act 2014, to have their communication skills enhanced ensuring a person-centred approach; And, • Partner agencies enable all practitioners to feel confident to challenge parents/carers around the rights of adults with care and support needs to have their communication enhanced. | LSAB | All partner agencies |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||