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
Oxford review
CSP: Oxford
Published: April 2023
Year of death: 2013
Extracted: 77 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 inadequate multi-agency assessment and response to the victim's needs as an adolescent, particularly regarding domestic abuse in peer relationships. Concerns include underestimation of risks posed by the perpetrator, poor engagement with the victim, and a flawed police response to her disappearance, alongside a lack of coordinated risk management for the perpetrator.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The OSCB to request that the importance of young people’s relationships with professionals is built into the multi-agency work currently being undertaken on vulnerable adolescents. The learning should be used to identify how best practice can be developed more widely across the multi-agency partnership. | Oxfordshire Safeguarding Children Board |
| 1 | Educate front line staff on the risk factors around domestic abuse and how to refer concerns to appropriate agencies within Oxford | Bournemouth Church Housing Association |
| 1 | To ensure that Court Induction processes clearly inform Courts staff of the routes and contacts for obtaining information pertaining to risk assessments for Oral Reports. | National Probation Service |
| 1 | A Strategic and operational review of domestic violence pathways within all Oxford Health NHS Foundation Trust services is completed. To include information sharing systems; a consistent documentation strategy and training strategy for staff. | Oxford Health NHS Foundation Trust |
| 1 | A new protocol to govern the transfer of at risk records from one Practice to another must be devised. | Oxfordshire Clinical Commissioning Group |
| 1 | To have routine access to the list of LAC to enable the Trust to enter a flag on Trust hospital electronic patient records. This is being discussed with colleagues in children’s social care to ascertain the feasibility of sharing this information. | Oxford University Hospitals NHS Foundation Trust |
| 1 | Reducing the Risk trustees and staff should draw on national and CAADA guidelines and good practice research in work with young people in abusive relationships, as and when available, and incorporate these within their practice and procedures. | Reducing the Risk of Domestic Violence |
| 1 | Thames Valley Police to revise their Domestic Abuse Standard Operating Procedure to ensure that referrals as opposed to notifications are made to Children’s Social care following domestic abuse incidents were either party is a child. The referral should then prompt a strategy discussion between police and CSC to consider the requirement for a joint investigation. | Thames Valley Police |
| 1 | Addaction to implement a training session in relation to recording the time of intervention within case notes with worker in Young Addaction Oxfordshire. | Young Addaction Oxfordshire |
| 10 | Thames Valley Police to issue guidance to all staff in relation to the investigation of incidents involving the exchange of indecent images between children (under 18) via mobile phones and other such devices; referred to as ‘sexting’. | Thames Valley Police |
| 11 | Thames Valley Police to task Local Police Areas with considering local partnership working groups as somewhere to refer offenders who fall below the threshold for MAPPA but whose offending behaviour and level of risk nonetheless are of concern. | Thames Valley Police |
| 12 | Thames Valley Police to review how the local Daily Management Meetings are recorded and retained. | Thames Valley Police |
| 13 | Thames Valley Police’s Crime Strategy Unit to review and determine how rolling arrest attempts should be recorded, including any specific instructions such as searching for evidence, rationale for arrest resourcing decisions and results of any arrests attempts. These are decisions relating to an investigation and must be recorded in the Niche Occurrence or a related Command and Control log, and not solely within handovers between supervisors. | Thames Valley Police |
| 14 | Thames Valley Police to put in place an archive system for storage of handover documents between shift supervisors. | Thames Valley Police |
| 15 | Thames Valley Police to put in place an archive system for storage of minutes from daily management meetings. | Thames Valley Police |
| 16 | Thames Valley Police to carry out dip sampling of missing person records to ensure that adequate reporting standards are being met. | Thames Valley Police |
| 17 | Thames Valley Police to carry out a review of property currently stored at Abingdon Police Station and a review of local management practices. | Thames Valley Police |
| 18 | Thames Valley Police to issue further practical guidance to clarify the use of ‘investigator summaries’ and the frequency of reviews (to include Detective Inspector reviews) in NICHE RMS when managing missing person investigations. | Thames Valley Police |
| 19 | Thames Valley Police Protecting Vulnerable Strategy Unit to conduct research into other police force areas’ approaches in relation to the role of Missing Person Co-ordinator and/or a dedicated Missing Persons Investigation Unit. This could be used as a basis for Thames Valley Police to review their own approach to this role | Thames Valley Police |
| 1a | Undertake a countywide audit of safeguarding practice focussing on s37 reports, thresholds for child in need, child protection and entry into care, threshold for case closures, ensuring these are consistently applied within all teams in respect of vulnerable adolescents. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 1a | To improve the monitoring of reduced timetables both at local authority and school levels. | Schools and Special Educational Needs |
| 1b | Countywide training for staff on domestic abuse: understanding the issues for 16 and 17yr olds and using MARAC and CP procedures appropriately; understanding the dynamics of violent and controlling relationships. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 1b | To ensure that any use of a reduced timetable is part of a holistic plan to re-engage a young person into full-time education. | Schools and Special Educational Needs |
| 1c | Undertake a management review of the roles and locations of specialist housing workers (Southwark) to ensure young people's safeguarding needs are addressed as well as their need for accommodation. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 2 | The OSCB to seek assurance from the relevant health and children’s services commissioning agencies that suitable services are available for young people with complex emotional and behavioural problems who do not meet current CAMHS thresholds. | Oxfordshire Safeguarding Children Board |
| 2 | Educate front line staff on the risk factors and signs of domestic abuse | Bournemouth Church Housing Association |
| 2 | To monitor any issues in respect of any delays or difficulties in obtaining checks and feed these back immediately to the Head Of Public Protection/Safeguarding for the South West South Central Division | National Probation Service |
| 2 | Review of Oxford Health NHS Foundation Trust MARAC guidance for Named Nurse and information sharing protocols for MARAC cases- in line with the strategic and operational review of domestic violence pathway. | Oxford Health NHS Foundation Trust |
| 2 | A review of the way at risk information is held in the patient record so that it fully complies with the latest guidance. | Oxfordshire Clinical Commissioning Group |
| 2 | To discuss with legal services whether it is possible for hospital staff to automatically inform police of any incidences of young people under the age of 18 being victims of assault. | Oxford University Hospitals NHS Foundation Trust |
| 2 | Reducing the Risk should ensure that staff have appropriate specialised training in work with young people in an abusive relationship once training is available. | Reducing the Risk of Domestic Violence |
| 2 | To ensure that the critical information schools hold about the most vulnerable children and young people, particular where they are living with domestic violence, substance misuse and mental health issues, is used for planning. | Schools and Special Educational Needs |
| 2 | Thames Valley Police MARAC Coordinators to update the Record Management System (Niche) in relation to MARAC referrals from other agencies. This will include the reasons for referral into MARAC and an indication as to risk level. | Thames Valley Police |
| 2 | Addaction will explore creative options for re-engaging young people who don’t want to engage or who drop. | Young Addaction Oxfordshire |
| 20 | Thames Valley Police to issue guidance to CR&ED staff asking them to actively consider whether any early contact with a victim would put them at risk from the perpetrator and to refer any concerns to a supervisor before making contact. | Thames Valley Police |
| 2a | CSC should develop practice guidance for social workers and personal advisors on managing their responsibility to provide services to dangerous/offensive young people. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 3 | The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB to work with the strategic lead on domestic abuse to ensure an effective unified approach to working with young people who are victims and/or perpetrators of domestic abuse. | Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board |
| 3 | Refresher training / briefing to front line staff regarding internal safe guarding procedures | Bournemouth Church Housing Association |
| 3 | To continue to review learning from SFOs and SCRs within the quarterly Public Protection Development Group. | National Probation Service |
| 3 | There needs to be further clarity about the service provision for young people who are excluded or not attending school, to ensure the school nursing service has the capacity to outreach to these vulnerable young people in partnership with other services. | Oxford Health NHS Foundation Trust |
| 3 | A review of the way registration questionaires are processed to try and act on certain significant unexpected data contained there. | Oxfordshire Clinical Commissioning Group |
| 3 | To assure that the process of recording whether any 16 or 17 year old attending ED is unaccompanied or, if accompanied to identify the person accompanying by name and relationship, is robust. | Oxford University Hospitals NHS Foundation Trust |
| 3 | Reducing the Risk should ensure improved record keeping in particular of work prior to MARAC referral and associated activation of the IDVA casework software. | Reducing the Risk of Domestic Violence |
| 3 | To disseminate guidance for settings/schools, colleges and professionals and parents on identifying and supporting children and young people with social, emotional and mental health difficulties as a graduated response to special educational needs, in line with the Children and Families Act 2014. | Schools and Special Educational Needs |
| 3 | Thames Valley Police to devise an innovative and effective way of delivering the message to front line officers of the importance of identifying and responding to offences, vulnerability and safeguarding issues when dealing with potentially vulnerable people. This is to include the vital role of supervision. | Thames Valley Police |
| 3a | Children and young people who request to become LAC and who are refused should be offered an advocate so their views can be represented in decision-making | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 3b | Staff and managers are aware of Viva, the CEF advocacy service and how to access it. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| 4 | The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB seek assurance that all agencies have in place systems for ensuring information regarding referral to MARAC is shared with all relevant frontline professionals. | Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board |
| 4 | Reflect the Government’s guidance which extends the definition that domestic abuse can apply to 16 and 17 year olds. | Bournemouth Church Housing Association |
| 4 | To maintain links with sentencers to keep the tensions noted above on the agenda and raise with the SWSC Leads for Courts and Public Protection | National Probation Service |
| 4 | There needs to be communication with adult mental health services to ensure that the assessment questions and documents whether there is contact with children or young people both in and out of the home environment. | Oxford Health NHS Foundation Trust |
| 4 | Advice to appraisers to discuss safeguarding specifically at appraisal | Oxfordshire Clinical Commissioning Group |
| 4 | To develop a formal policy for assessment and actions when a young person aged 16 or 17 years absconds from ED prior to full assessment/treatment. | Oxford University Hospitals NHS Foundation Trust |
| 4 | Reducing the Risk should work proactively in partnership with child social care and ensure immediate liaison following a referral. | Reducing the Risk of Domestic Violence |
| 4 | To remind schools about LA guidance relating to sharing personal information and the use of social networks. | Schools and Special Educational Needs |
| 4 | Thames Valley Police to carry out an audit in six months’ time to assess whether the new Niche RMS system is correctly creating a record for every missing person report. The quarterly held performance meeting (chaired by the Deputy Chief Constable) in relation to Child Sexual Exploitation and Missing People will monitor this. | Thames Valley Police |
| 5 | The OSCB to seek assurance that the programme provided by schools in Oxfordshire covers healthy relationships in the context of domestic abuse. | Oxfordshire Safeguarding Children Board |
| 5 | Implement a Missing Young Person protocol | Bournemouth Church Housing Association |
| 5 | Reducing the Risk should remind all designated MARAC officers of processes for simultaneous referral to IDVA and MARAC. | Reducing the Risk of Domestic Violence |
| 5 | Thames Valley Police to ensure that all front line staff abide by their duty to record and investigate any disclosures of serious crime, e.g. rape, serious assault, made by a victim in any circumstance. This should include an input to Supervisors. | Thames Valley Police |
| 6 | The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB to review current multi-agency approaches for young people who present serious risks in the community, but do not meet the criteria for MAPPA and are not subject to court orders. Consideration to be given to: i) Clarifying and promoting the most appropriate structures for managing both the risks and needs of the young person concerned. ii) Maximising good interagency communication. ii) Ensuring that staff are properly supported and that adequate management oversight and supervision arrangements are in place. | Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board |
| 6 | Where there are concerns about an external agency workers conduct or profession working relationship, this should be escalated formally | Bournemouth Church Housing Association |
| 6 | Reducing the risk should continue to develop a partnership model of support in line with CAADA MARAC recommendations and ensure clear communication with partners. | Reducing the Risk of Domestic Violence |
| 6 | Thames Valley Police to consider and implement options in relation to who should conduct research (secondary investigation) for Missing Person Investigations. An options paper should be completed addressing the viability of the following: Responsibility remaining with the attending officer Missing Person Co-ordinator Information Research Bureau | Thames Valley Police |
| 7 | That South and Vale Community Safety Partnership and the OSCB recommend to the Home Office and the Department for Education that a Memorandum of Understanding is agreed with the IPCC regarding the production of DHRs, SCRs and IPCC investigations. | South and Vale Community Safety Partnership | Oxfordshire Safeguarding Children Board |
| 7 | Raise awareness on online child exploitation | Bournemouth Church Housing Association |
| 7 | In circumstances where there may be reason not to follow Reducing the Risk practice guidelines Reducing the Risk will ensure a robust process of decision making. | Reducing the Risk of Domestic Violence |
| 7 | Thames Valley Police to provide anonymised DOM5 forms from this review to domestic abuse risk assessors throughout Thames Valley Police and ask them to complete risk assessments and grade the victims. The results will indicate whether staff are competent risk assessors. | Thames Valley Police |
| 8 | Implement a more robust Multi agency approach to managing risk | Bournemouth Church Housing Association |
| 8 | Reducing the risk staff and trustees will contribute to the OSCB children’s domestic abuse strategy group young people’s pathway work. | Reducing the Risk of Domestic Violence |
| 8 | Thames Valley Police to provide role/rank based training and reference materials to Sergeants and Inspectors providing guidance on how best to use Niche Record Management System (whiteboard) to carry out their reviewing responsibilities for Missing Person Investigations in relation to: Risk assessment approval/amendment Action management Closure Inspector reviews | Thames Valley Police |
| 9 | All BCHA managers working within Young People’s Services to include outside of Oxford Area) to attend domestic Abuse Training | Bournemouth Church Housing Association |
| 9 | Thames Valley Police to raise awareness amongst front line staff in relation to the potential serious impact of emotional blackmail incidents involving the threat of publicly circulating intimate images of people. | Thames Valley Police |
| CEF 1 | Ensure practitioners have prompt access to updated risk information on dangerous young people and adults. Significant event chronologies and multi-agency risk assessment and management plans should be consistently updated in order to provide this. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| CEF 2 | Consider how practitioners in YOS can participate in plans for dangerous young people for whom CEF has a statutory responsibility e.g. they are LAC, care-leavers, subject to CP plans, even when they are not formally subject to criminal disposals. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| CEF 3 | Detailed consideration needs to be given by CEF to creating a multi-agency, co-located Leaving Care service for 18-25 year olds. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| EIS 1 | Undertake an audit of practice and safeguarding focussing on quality of referral, assessment, planning, review and impact on outcomes. | Oxfordshire County Council Children’s Social Care and Early Intervention Services |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||