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: 26 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 a failure to recognise familial domestic abuse, often masked by mental illness and substance misuse, leading to missed safeguarding opportunities. It highlights inadequate risk assessments, barriers for older victims/carers, and a lack of multi-agency coordination for vulnerable individuals with complex needs.
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 |
| 1.1 | Implementation of the IRIS project in GP Primary Care | Coventry and Rugby Clinical Commissioning Group |
| 1.1 | Email a summary of the case with all the lessons to all GPs in CRCCG and discuss the case at the GP training event | Coventry and Rugby Clinical Commissioning Group |
| 1.1 | The CCG will review how the national strategy for supporting carers is being implemented locally by local GP primary care providers and use the CCG to help improve this element of care. | Coventry and Rugby Clinical Commissioning Group |
| 1.1 | CWPT Level 3 Domestic Abuse Training to be revised to ensure increased emphasis on familial abuse. | Coventry and Warwickshire Partnership NHS Trust |
| 1.1 | CWPT Safeguarding Team to contact team managers to offer targeted training/support, specifically related to supporting staff in supervision. | Coventry and Warwickshire Partnership NHS Trust |
| 1.1 | ‘Signs of safety’ model of supervision to be rolled out across the Trust to enable staff to consider the importance of not relying on self-reported risk and on considering all risk factors, including historical factors, when assessing risk | Coventry and Warwickshire Partnership NHS Trust |
| 1.1 | Team Manager use of the PMF (Performance Management Framework) on a monthly basis to target low referring practitioners. | Staffordshire and West Midlands Community Rehabilitation Company |
| 1.1 | To review 3 cases per month during supervision with specific focus on changes in risk and recording of changes. | Staffordshire and West Midlands Community Rehabilitation Company |
| 1.1 | Team Manager to quality assure 3 cases with specific focus on enforcement action/management oversight. | Staffordshire and West Midlands Community Rehabilitation Company |
| 1.1 | Develop a referral app for inclusion on the mobility device used by frontline officers | West Midlands Police |
| 1.1 | Brief all front-line Managers of the principles of the Carers’ Assessments so that this can then be cascaded to their operational teams. It should be recognised that whilst this action is specific to Whitefriars it is relevant in other operating areas as the manager and teams involved cover all the West Midlands giving added value and spread of information. | Citizen Housing |
| 1.1 | Safeguarding awareness training has been delivered to over 600 front line staff and this focused on key areas like domestic violence partners and families and know how to respond, including taking action against perpetrators and supporting victims | Citizen Housing |
| 1.2 | ‘Standalone’ DASH Risk Indicator Checklist module, to include an exercise which requires staff to consider familial domestic abuse in families with complex needs, to be developed and delivered to teams in accordance with CWPT training needs analysis | Coventry and Warwickshire Partnership NHS Trust |
| 1.2 | CWPT Level 3 Domestic Abuse Training to be revised to emphasise the importance of considering known risk factors, including information provided by relatives/carers, when assessing risk. | Coventry and Warwickshire Partnership NHS Trust |
| 1.2 | Team Manager to review 1 OASys per month during supervision with specific focus on Responsible Officer’s analysis and defensible decision making in respect of sentence plan objective setting. | Staffordshire and West Midlands Community Rehabilitation Company |
| 1.2 | Ensure the principles of the carers’ assessment are shared as part of new staff induction programmes | Citizen Housing |
| 1.2 | Review underway to determine if we need to designate a Group wide domestic violence support role, engagement with key partners like Women’s Aid and The Haven and determine if a single Group wide point of contact as part of a wider tenancy sustainment team is required | Citizen Housing |
| 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 |
| 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 ↗ | ||