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

Windsor and Maidenhead review

CSP: Windsor and Maidenhead Published: April 2023 Year of death: 2017 Extracted: 22 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 concerns regarding inconsistent multi-agency information sharing, insufficient professional curiosity, and inadequate risk assessments for domestic abuse and safeguarding. It highlights missed opportunities to assess the perpetrator's mental capacity and support the victim as a carer, alongside poor record-keeping.

Home Office classifications

41 tags

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

  • Victim - was a carer
  • Victim - carer for perpetrator
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - depression
  • Victim - psychosis
  • Victim - suicide attempts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - mental ill health
  • Perpetrator - neurodiverse condition diagnosis
  • Perpetrator - self harm
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - supervised by mental health services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • 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 - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

22 recommendations pulled from the report · 10 matched to organisations in the index

Recommendation 1

Addressed to Community Safety Partnership

The Community Safety Partnership should assess the process of ‘Carers Assessments’ within agencies providing such a service.

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

Recommendation 2

Addressed to Thames Valley Police

Front line practitioners completing DASH or DOM5 risk assessments should also provide an assessment based upon professional judgement alongside the visible high risk. TVP should complete a review of their DOM5 reports to ensure that suitable levels of professional curiosity are demonstrated when completing these records. Assurance should also be sought that staff are trained in providing such professional judgement.

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

Recommendation 3

Addressed to Community Safety Partnership

All Community Safety Partnership agencies should ensure that on-going training packages include the subjects of domestic abuse between parents and adult children and Professional Curiosity

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

Recommendation 4

Addressed to Community Safety Partnership

The Community Safety Partnership should reassure itself that suitable audit processes are in place to ensure that all staff from Review Panel agencies should receive training on relevant areas of legislation to support them when dealing with similar circumstances.

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

Recommendation 5

Addressed to Community Safety Partnership

Agencies to share all relevant information regarding anti-social behaviour and domestic abuse, on a case by case basis, through an information pathway agreed with the Community Safety Partnership.

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

Recommendation 6

Addressed to Community Safety Partnership

The Community Safety Partnership should seek to confirm that record keeping within Adult Social Care is accurate and relevant and reassure itself that standards of accuracy and detail are continually maintained.

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

Recommendation 7

Addressed to Community Safety Partnership

The Community Safety Partnership should seek reassurance that service users are receiving the necessary support and that front-line practitioners are suitably trained in two subject areas of sexualised behaviour: i) The need for parents and family members to understand their role in providing boundaries and guidance to support those with ASC in understanding what appropriate behaviour is and isn’t. ii) The processes to be followed when service users demonstrate acts of sexualised behaviour which involve breaches of criminal law, including the Human Rights Act.

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

Recommendation 8

Addressed to Strategic Adult Safeguarding Coordinator

The Strategic Adult Safeguarding Coordinator should be alerted each time an agency or service user enters the Multi-Agency Risk Management Framework process to ensure they can provide an active and reactive role.

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

Recommendation 8.1.1.2.1

Addressed to Adult Social Care

Assessment of both carer and service user must include consideration of the wellbeing of both people. Services are to ensure that part of the yearly carers assessment includes a discussion with the carer about their present situation and an assessment of risks posed to the carer from caring with someone known to have a history of challenging behaviours

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

Recommendation 8.1.1.2.2

Addressed to Adult Social Care

For services to recognise that a safeguarding concern for the carer can be raised, if reports are received that they are experiencing intentional or unintentional harm as a result of the support they provide to a person with support needs.

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

Recommendation 8.1.1.2.3

Addressed to Adult Social Care

Professional Curiosity Training to be offered to all Adult Social care staff. Professional Curiosity is a capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things on face value.

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

Recommendation 8.1.1.2.4

Addressed to Adult Social Care

Increase awareness of domestic abuse and coercive control amongst social care professionals outside of the usual male/female intimate relationship paradigm.

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

Recommendation 8.1.1.3.2

Addressed to Radian Housing

Anti-Social Behaviour Training to be provided to front-line staff to ensure all notes are recorded effectively and correspondence store appropriately.

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

Recommendation 8.1.1.4.1

Addressed to Berkshire Healthcare NHS Foundation Trust

Professionals need to be aware of their responsibility to dependants when working with an adult who is a carer. This pathway is to be developed.

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

Recommendation 8.1.1.4.2

Addressed to Berkshire Healthcare NHS Foundation Trust

Further support on identification of potential domestic abuse concerns for CRHTT and police triage to be explored such as reflective supervision sessions.

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

Recommendation 8.1.1.4.3

Addressed to Berkshire Healthcare NHS Foundation Trust

Improve compliance with the Mental Capacity Act 2005 and best interests’ assessment. Consent to or withdrawal of treatment for CTPLD

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

Recommendation 8.1.1.5.1

Addressed to Thames Valley Police

With the introduction of the new Domestic Abuse Risk Assessment online recording function the police strategic unit are to review: o How adults at risk are identified and risk assessed and o How their details are recorded and shared, when they live in households, where there has been domestic abuse.

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

Recommendation 9

Addressed to Domestic Abuse Executive Group

The Domestic Abuse Executive Group should work with MATAC to continue to raise awareness of its function amongst frontline practitioners, review panel membership and ensure that all relevant agencies are represented.

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

Recommendation 10

Addressed to All agencies

All agencies report progress on their single agency IMR recommendations to the Community Safety Partnership.

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