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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

52 tags

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

  • Victim - substance misuse
  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - present at homicide (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • 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 - probation services 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

77 recommendations pulled from the report · 32 matched to organisations in the index

Recommendation 1

Addressed to Oxfordshire Safeguarding Children Board

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.

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

Recommendation 1

Addressed to Bournemouth Church Housing Association

Educate front line staff on the risk factors around domestic abuse and how to refer concerns to appropriate agencies within Oxford

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

Recommendation 1

Addressed to National Probation Service

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.

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

Recommendation 1

Addressed to Oxford Health NHS Foundation Trust

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.

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

Recommendation 1

Addressed to Oxfordshire Clinical Commissioning Group

A new protocol to govern the transfer of at risk records from one Practice to another must be devised.

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

Recommendation 1

Addressed to Oxford University Hospitals NHS Foundation Trust

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.

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

Recommendation 1

Addressed to Reducing the Risk of Domestic Violence

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.

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

Recommendation 1

Addressed to Thames Valley Police

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.

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

Recommendation 1

Addressed to Young Addaction Oxfordshire

Addaction to implement a training session in relation to recording the time of intervention within case notes with worker in Young Addaction Oxfordshire.

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

Recommendation 1a

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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.

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

Recommendation 1a

Addressed to Schools and Special Educational Needs

To improve the monitoring of reduced timetables both at local authority and school levels.

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

Recommendation 1b

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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.

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

Recommendation 1b

Addressed to Schools and Special Educational Needs

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.

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

Recommendation 1c

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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.

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

Recommendation 2

Addressed to Oxfordshire Safeguarding Children Board

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.

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

Recommendation 2

Addressed to Bournemouth Church Housing Association

Educate front line staff on the risk factors and signs of domestic abuse

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

Recommendation 2

Addressed to National Probation Service

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

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

Recommendation 2

Addressed to Oxford Health NHS Foundation Trust

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.

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

Recommendation 2

Addressed to Oxfordshire Clinical Commissioning Group

A review of the way at risk information is held in the patient record so that it fully complies with the latest guidance.

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

Recommendation 2

Addressed to Oxford University Hospitals NHS Foundation Trust

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.

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

Recommendation 2

Addressed to Reducing the Risk of Domestic Violence

Reducing the Risk should ensure that staff have appropriate specialised training in work with young people in an abusive relationship once training is available.

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

Recommendation 2

Addressed to Schools and Special Educational Needs

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.

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

Recommendation 2

Addressed to Thames Valley Police

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.

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

Recommendation 2

Addressed to Young Addaction Oxfordshire

Addaction will explore creative options for re-engaging young people who don’t want to engage or who drop.

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

Recommendation 2a

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

CSC should develop practice guidance for social workers and personal advisors on managing their responsibility to provide services to dangerous/offensive young people.

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

Recommendation 3

Addressed to Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board

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.

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

Recommendation 3

Addressed to Bournemouth Church Housing Association

Refresher training / briefing to front line staff regarding internal safe guarding procedures

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

Recommendation 3

Addressed to National Probation Service

To continue to review learning from SFOs and SCRs within the quarterly Public Protection Development Group.

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

Recommendation 3

Addressed to Oxford Health NHS Foundation Trust

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.

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

Recommendation 3

Addressed to Oxfordshire Clinical Commissioning Group

A review of the way registration questionaires are processed to try and act on certain significant unexpected data contained there.

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

Recommendation 3

Addressed to Oxford University Hospitals NHS Foundation Trust

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.

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

Recommendation 3

Addressed to Reducing the Risk of Domestic Violence

Reducing the Risk should ensure improved record keeping in particular of work prior to MARAC referral and associated activation of the IDVA casework software.

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

Recommendation 3

Addressed to Schools and Special Educational Needs

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.

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

Recommendation 3

Addressed to Thames Valley Police

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.

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

Recommendation 3a

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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

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

Recommendation 3b

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

Staff and managers are aware of Viva, the CEF advocacy service and how to access it.

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

Recommendation 4

Addressed to Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board

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.

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

Recommendation 4

Addressed to Bournemouth Church Housing Association

Reflect the Government’s guidance which extends the definition that domestic abuse can apply to 16 and 17 year olds.

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

Recommendation 4

Addressed to National Probation Service

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

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

Recommendation 4

Addressed to Oxford Health NHS Foundation Trust

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.

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

Recommendation 4

Addressed to Oxfordshire Clinical Commissioning Group

Advice to appraisers to discuss safeguarding specifically at appraisal

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

Recommendation 4

Addressed to Oxford University Hospitals NHS Foundation Trust

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.

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

Recommendation 4

Addressed to Reducing the Risk of Domestic Violence

Reducing the Risk should work proactively in partnership with child social care and ensure immediate liaison following a referral.

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

Recommendation 4

Addressed to Schools and Special Educational Needs

To remind schools about LA guidance relating to sharing personal information and the use of social networks.

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

Recommendation 4

Addressed to Thames Valley Police

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.

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

Recommendation 5

Addressed to Oxfordshire Safeguarding Children Board

The OSCB to seek assurance that the programme provided by schools in Oxfordshire covers healthy relationships in the context of domestic abuse.

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

Recommendation 5

Addressed to Reducing the Risk of Domestic Violence

Reducing the Risk should remind all designated MARAC officers of processes for simultaneous referral to IDVA and MARAC.

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

Recommendation 5

Addressed to Thames Valley Police

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.

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

Recommendation 6

Addressed to Oxfordshire Safer Communities Partnership | Community Safety Partnerships | Oxfordshire Safeguarding Children Board

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.

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

Recommendation 6

Addressed to Bournemouth Church Housing Association

Where there are concerns about an external agency workers conduct or profession working relationship, this should be escalated formally

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

Recommendation 6

Addressed to Reducing the Risk of Domestic Violence

Reducing the risk should continue to develop a partnership model of support in line with CAADA MARAC recommendations and ensure clear communication with partners.

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

Recommendation 6

Addressed to Thames Valley Police

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

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

Recommendation 7

Addressed to South and Vale Community Safety Partnership | Oxfordshire Safeguarding Children Board

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.

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

Recommendation 7

Addressed to Reducing the Risk of Domestic Violence

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.

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

Recommendation 7

Addressed to Thames Valley Police

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.

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

Recommendation 8

Addressed to Bournemouth Church Housing Association

Implement a more robust Multi agency approach to managing risk

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

Recommendation 8

Addressed to Reducing the Risk of Domestic Violence

Reducing the risk staff and trustees will contribute to the OSCB children’s domestic abuse strategy group young people’s pathway work.

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

Recommendation 8

Addressed to Thames Valley Police

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

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

Recommendation 9

Addressed to Bournemouth Church Housing Association

All BCHA managers working within Young People’s Services to include outside of Oxford Area) to attend domestic Abuse Training

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

Recommendation 9

Addressed to Thames Valley Police

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.

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

Recommendation 10

Addressed to Thames Valley Police

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’.

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

Recommendation 11

Addressed to Thames Valley Police

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.

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

Recommendation 12

Addressed to Thames Valley Police

Thames Valley Police to review how the local Daily Management Meetings are recorded and retained.

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

Recommendation 13

Addressed to Thames Valley Police

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.

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

Recommendation 14

Addressed to Thames Valley Police

Thames Valley Police to put in place an archive system for storage of handover documents between shift supervisors.

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

Recommendation 15

Addressed to Thames Valley Police

Thames Valley Police to put in place an archive system for storage of minutes from daily management meetings.

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

Recommendation 16

Addressed to Thames Valley Police

Thames Valley Police to carry out dip sampling of missing person records to ensure that adequate reporting standards are being met.

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

Recommendation 17

Addressed to Thames Valley Police

Thames Valley Police to carry out a review of property currently stored at Abingdon Police Station and a review of local management practices.

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

Recommendation 18

Addressed to Thames Valley Police

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.

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

Recommendation 19

Addressed to Thames Valley Police

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

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

Recommendation 20

Addressed to Thames Valley Police

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.

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

Recommendation CEF 1

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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.

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

Recommendation CEF 2

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

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.

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

Recommendation CEF 3

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

Detailed consideration needs to be given by CEF to creating a multi-agency, co-located Leaving Care service for 18-25 year olds.

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

Recommendation EIS 1

Addressed to Oxfordshire County Council Children’s Social Care and Early Intervention Services

Undertake an audit of practice and safeguarding focussing on quality of referral, assessment, planning, review and impact on outcomes.

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