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
Coventry review
CSP: Coventry
Published: December 2022
Year of death: 2017
Extracted: 21 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 report identifies systemic failures in recognising familial domestic abuse, often obscured by mental illness and substance misuse. It highlights inadequate risk assessments for older victims and carers, and a lack of coordinated multi-agency support for vulnerable individuals' housing and care.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The agencies of Coventry Police and Crime Board should provide evidence-based assurance that their services are capable of identifying the breadth and range of domestic abuse, including tactics of coercive control and economic abuse identifying and responding to indicators of risk including recognising the history of domestic abuse and the potential to use weapons holding perpetrators of domestic abuse to account differentiating between domestic abuse and mental ill-health behaviours, intentions and effects | Coventry Police and Crime Board |
| 2 | The agencies of Coventry Police and Crime Board should consider how they can increase take-up of substance misuse services for individuals with multiple needs | Coventry Police and Crime Board |
| 3 | Coventry Police and Crime Board should consider whether the barriers experienced by older women experiencing domestic abuse in accessing services, and the barriers experienced by agencies in providing services to older women, are sufficiently understood and being addressed. | Coventry Police and Crime Board |
| 4 | The Home Office should consider commissioning a review of the domestic abuse risk assessment, in its latest form, to ensure that it is capable of effectively assessing the risk indicators of domestic abuse for older victims. | Home Office |
| 5 | Coventry agencies to ensure that frontline staff have an understanding of, and are able to recognise, familial domestic abuse. This should include consideration of abuse to, and by, relatives who have a caring role. | Coventry agencies |
| 6 | Coventry Police and Crime Board should raise public awareness of familial domestic abuse including widely advertising sources of help and support; targeting families and friends | Coventry Police and Crime Board |
| 7 | Coventry Police and Crime Board to assess whether there is sufficient multi-agency support and co-ordination for the resettlement of homeless individuals with multiple and complex needs. | Coventry Police and Crime Board |
| 7.1.1 | Implementation of the IRIS project in GP Primary Care | Coventry and Rugby Clinical Commissioning Group |
| 7.1.2 | Circulate the lessons from this case to all GPs in Coventry and Rugby CCG with a summary of the case history and discuss at the Face-to-Face GP training. | Coventry and Rugby Clinical Commissioning Group |
| 7.1.3 | The CCG will review how the national strategy for supporting carers is being implemented locally by local GP primary care providers. This piece of work will review the activities of the finance, contracting, communications and clinical groups to ensure a joined up approach is being delivered to improve support to carers. | Coventry and Rugby Clinical Commissioning Group |
| 7.2.1 | Frontline staff to have an increased understanding of, and be able to recognise, familial domestic abuse and how it may present in the client groups served by CWPT. This should include consideration of abuse to, and by, relatives who have a caring role. | Coventry and Warwickshire Partnership NHS Trust |
| 7.2.2 | Team managers who provide supervision to staff to have the knowledge and skills necessary to identify domestic abuse, particularly in the context of familial abuse, even if the caseworker has not recognised the abuse and is not presenting the case in the context of domestic abuse | Coventry and Warwickshire Partnership NHS Trust |
| 7.2.3 | Staff to recognise the importance of considering known risk factors, including information provided by relatives/carers, when assessing risk | Coventry and Warwickshire Partnership NHS Trust |
| 7.3.1 | Comprehensive and ongoing review of all practitioner referrals to interventions | Staffordshire and West Midlands Community Rehabilitation Company |
| 7.3.2 | Dip sampling of Responsible Office’s case management/assessment records to ensure correct recording of factors linked to risk of harm | Staffordshire and West Midlands Community Rehabilitation Company |
| 7.3.3 | Quality assurance of the Responsible Officer’s enforcement action and decision making | Staffordshire and West Midlands Community Rehabilitation Company |
| 7.4.1 | A feasibility study into the use of a referral portal app to be added to the mobile device thus enabling officers to make referrals directly from the scene. At present, front line officers have to return to a police station to do this which can be time consuming; completing a referral directly from the scene, affords vulnerable individuals greater service and is a better use time, relevant when policing faces increasing demands | West Midlands Police |
| 7.5.1 | To promote the benefit of carers’ assessments amongst housing practitioners | Whitefriars Housing Group |
| 7.5.2 | To increase housing practitioner’s awareness of indicators that a person may be a perpetrator of domestic abuse | Whitefriars Housing Group |
| 8 | Coventry Safeguarding Adult Board seeks assurance from its agencies that they are delivering their responsibilities to carers under the Care Act 2014. | Coventry Safeguarding Adult Board |
| 9 | Coventry Safeguarding Adult Board should ensure that the multi-agency dual diagnosis policy (which is out of date) is refreshed between CGL, Coventry and Warwickshire Partnership NHS Trust and other mental health providers and overseen by commissioners of those services. | Coventry Safeguarding Adult Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||