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
Stoke-on-Trent review
CSP: Stoke-on-Trent
Published: April 2023
Year of death: 2016
Extracted: 19 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 challenges in multi-agency responses to domestic abuse, parental mental health issues, and substance misuse, particularly regarding consistent risk assessment, MARAC referrals, and victim engagement. Concerns were raised about the robustness of Child in Need processes, premature case closures, and ensuring the child's voice was adequately considered.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Stoke-on-Trent Local Safeguarding Children Board should seek assurance that appropriate support services are in place for children at risk of significant harm as a result of being exposed to domestic abuse, parental mental health difficulties or parental substance misuse. That the pathways to those services are clear and that professionals are aware of the support available and equipped to advise how to access it. | Stoke-on-Trent Local Safeguarding Children Board |
| 2 | Stoke-on-Trent Responsible Authorities Group should seek assurances that appropriate systems are in place to ensure that organisations (e.g. GP surgeries and schools) receive relevant information about domestic abuse incidents. This should include, but not be restricted to, consideration of Operation Encompass. | Stoke-on-Trent Responsible Authorities Group |
| 3 | Stoke-on-Trent Local Safeguarding Children Board should seek assurance that Child In Need meetings are properly recorded, communicated and professionals have a shared understanding of agreed actions. | Stoke-on-Trent Local Safeguarding Children Board |
| 4 | Stoke-on-Trent City Council Learning Services (education) department should seek assurance that when children subject to child protection plans move between schools that there are appropriate mechanisms to ensure effective transfer of information and engagement in multi-agency work by the new school. This should include effective two-way communications between schools and children’s social care. | Stoke-on-Trent City Council Learning Services (education) department |
| 5 | Stoke-on-Trent Responsible Authorities Group should seek assurance that appropriate cases are being referred to the MARAC and in particular professional judgement in conjunction with risk scores is used to identify the high-risk cases. | Stoke-on-Trent Responsible Authorities Group |
| BCHFT.a | For the School Health Service to receive level 3 domestic abuse training delivered by the Safeguarding Children Team, including the use of the DASH risk assessment tool and referral to MARAC. | Birmingham Community Healthcare NHS Foundation Trust |
| BCHFT.b | To ensure that the School Health Service document the journey of the child clearly within the Child Health records. | Birmingham Community Healthcare NHS Foundation Trust |
| BCHFT.c | For all children that require paediatric liaison/MASH feedback to have a standardised and clear approach to sharing and managing information. | Birmingham Community Healthcare NHS Foundation Trust |
| NHEM.a | The author identified that if Children’s Social Care is involved with children and the children have an alert in place on their records, this does not mean that an alert is automatically put on to the parental records. This is not part of the GP contractual obligations however it would be considered good practice for GPs to put an alert on the parental records at the same time an alert is added to the children’s records. An example of an alert on parental records may read ‘Children known to Children’s Social Care’. | NHS England North Midlands |
| NSCHT.1 | Early Intervention Team to ensure when staff are discussing early signs of relapse with service users this is recorded in detail in the staying well plan, and that carers are involved in staying well and relapse plans. | North Staffs Combined Healthcare NHS Trust |
| S1.a | Ensure all members of the nurture team and safeguarding leads have undertaken appropriate training in all three areas of the toxic trio so that they can more readily recognise the indicators and appropriate actions. G may have benefitted from a more structured programme to help him deal with the impact of domestic abuse in the home. | School 1 |
| S1.b | Ensure all records are clearly dated with the year so that the chronology of events can be more easily followed, cross referenced and patterns identified to influence actions and support. | School 1 |
| S1.c | Ensure there is a clear protocol for the archiving of informal notes and diaries from members of staff working with children being safeguarded and that this is clearly understood by all staff. | School 1 |
| SOTCSC.1 | Ensure that risk related to domestic abuse is clearly articulated and addressed by proven, evidence-based practice frameworks in use across all services in Stoke-on-Trent creating a consistent approach by professionals to working with children and their families. The danger statement will be clear about the actual risk and not use shorthand e.g. ‘domestic abuse’. | Stoke-on-Trent City Council – Children’s Social Care |
| SP.1 | Staffordshire Police should initiate a review of incidents of domestic abuse with the aim of ascertaining if all the measures introduced are achieving the positive outcomes available. | Staffordshire Police |
| SSOTP.a | The in house domestic abuse training includes the emotional impact and is mandatory for qualified school nurses. The organisation needs to ensure that this mandatory training is being received by all school nurses. | Staffordshire and Stoke-On-Trent Partnership NHS Trust |
| SSOTP.b | Unqualified Our Health 5-19 staff who have direct contact with children should receive training on domestic abuse and the impact of this on children. The Partnership Trust currently offers a half day in house training which would appropriately meet this need. | Staffordshire and Stoke-On-Trent Partnership NHS Trust |
| SSOTP.c | Through discrete direct enquiry all children of appropriate age and understanding will be given the opportunity, when seen by a member of the Our Health 5-19 team, to express what life is like for them and to raise anything that gives them concern. The child needs to be seen alone for this to take place. This information should be recorded within the school health record and shared with other agencies as appropriate. | Staffordshire and Stoke-On-Trent Partnership NHS Trust |
| SSOTP.d | As far as is possible a child who is the subject of a child protection plan should have a named member of staff who deals with the health input of the child protection plan. Where this is not possible there must be clear, documented liaison between staff who have had involvement. | Staffordshire and Stoke-On-Trent Partnership NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||