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

Leeds review

CSP: Leeds Published: April 2023 Extracted: 2 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 review identified a lack of apparent domestic abuse history or significant agency involvement prior to the victim's death, yet several MARAC risk factors were present. This led to recommendations for GP practices to enhance understanding and identification of domestic abuse, including controlling behaviour, and to review related policies and training.

Home Office classifications

16 tags

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

  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - economic abuse
  • DHR process - family received draft report
  • DHR process - health services 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 - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

2 recommendations pulled from the report

Recommendation 1

Addressed to Surgery 1

Surgery 1 to assess and respond to identified training and resource needs for GPs and practice staff, relating to domestic violence and abuse
Surgery 1 to adopt a practice specific protocol for domestic violence and abuse
- to include a checklist of relevant interventions to offer, and current role and contact information for external specialist support agencies
- practice response to disclosure of domestic abuse and understanding of the referral route and role of GPs in MARAC
Surgery 1 to ensure practitioners are aware of potential risks and links between misuse of alcohol and domestic abuse
- Information relating to external sources of support for those people misusing alcohol should be available to practitioners to make informed referrals, and accessible in public areas for patients
Practice booklet, newsletter and public areas in Surgery 1 to reflect practice responses to disclosures of domestic violence and abuse; and highlight internal and external support available
Measure
The practice should review their compliance with Safe Lives/IRIS (Early Intervention in Psychosis) and NICE (National Institute for Health and Care Excellence) Guidance (2014) for general practices and submit a short report to NHSE on these findings and an action plan for service improvements to be made.

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

Recommendation 2

Addressed to Surgery 1

Safeguarding lead in Surgery 1 to review the significant event process to ensure all significant events are reviewed. This will include unexpected death or serious injury of a patient, or where wider learning and improvements to safeguarding practice can be obtained to ensure multi-disciplinary discussions of the learning identified in the IMR are undertaken, and learning is effectively disseminated to all practice staff
Measure
Surgery 1 has relevant protocols and pathways for domestic violence and abuse which identifies the process for undertaking a significant event review, and practice responses to any identified safeguarding risk or risk of serious harm
Systems are in place to effectively disseminate learning from significant event reviews to practice staff and to monitor identified actions
Whilst Alison did not present as an adult at risk, the panel thought that practice staff need to be conversant with the domestic abuse resources and material available from www.leedsdomesticviolenceandabuse.co.uk; which include the West Yorkshire Adult policy and procedure, practice guidance and joint working protocols. Other useful sites for local information are the following and these again should be sites with which the staff should ensure they are familiar:-
Women as Victims
• http://www.lhp.leedsth.nhs.uk/referral_info/detail.aspx?ID=186
Men as Victims
• http://www.lhp.leedsth.nhs.uk/referral_info/detail.aspx?ID=185
Guidance for GPs
• http://www.rcgp.org.uk/clinical-and-research/clinical-resources/domestic-violence.aspx

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