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
Southend-on-Sea review
CSP: Southend-on-Sea
Published: April 2023
Year of death: 2014
Extracted: 36 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 identifies systemic failures in multi-agency risk assessment and information sharing, especially concerning separation and child contact. It highlights insufficient professional training on perpetrator management, coercive control, and the intersection of domestic abuse with mental health and substance misuse, alongside issues with drug and alcohol intervention effectiveness.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | That the Community Safety Partnership note the learning from this Review and ensure that specific early intervention action is written into the Southend Domestic Abuse Strategy which will result in the development and provision of broader partnership initiatives in families with children where the risk of domestic abuse is high. The aim of this recommendation is to reduce the negative effects on children living with domestic abuse, and the barriers which impede them from reaching their full potential. These actions reflect the Health & Wellbeing Strategy Ambition 1 - 'A Positive Start in Life' | The Community Safety Partnership |
| 10 | The provision of services for drug and alcohol users needs to be driven by risk to others and themselves as much as their willingness to engage. A review should take place to establish whether drug and alcohol services meet the needs of those who are resistant to change or who need longer-term intensive support, and where their use of drugs or alcohol make them a risk to others particularly partners, former partners and their children. | Drug & Alcohol Commissioning |
| 11 | CRI to ensure that staff members are provided with a safe environment in which to disclose any personal issues or risks and colleagues are able signposted to appropriate support. | Crime Reduction Initiatives (CRI) |
| 12 | All staff to be sent a copy of the Staff Domestic Abuse and Sexual Assault Policy providing a framework and guidance for future similar incidents and reminded of their responsibilities. All staff who have supervisory responsibility for others will be specifically reminded of this policy and required to work within it. | Crime Reduction Initiatives (CRI) |
| 13 | CRI to review their policies to ensure they give clear guidance on what level of information can be shared, how this can safely be done, and to whom to disclose concerns about an individual’s vulnerability within the context of safeguarding. | Crime Reduction Initiatives (CRI) |
| 14 | Improve referral pathways for IYSS into adult services for substance misuse should be developed. | Integrated Youth Support Services |
| 15 | The number of different case management systems should be reviewed with a view to achieving joined up case management systems across IYSS. | Integrated Youth Support Services |
| 16 | Clinicians are to be reminded to check all flags and notifications prior to consultation. | G.P. Practice |
| 17 | Clinicians should be reminded that records should contain appropriate detail to highlight apparent risks. | G.P. Practice |
| 18 | The practice are recommended to adopt the Royal College of General Practitioner’s domestic abuse guidance to augment local procedures. | G.P. Practice |
| 19 | SEPT must develop a domestic abuse strategy based upon the NICE guidance for domestic abuse. | South Essex Partnership University NHS Foundation Trust (SEPT) |
| 2 | All agencies to have procedures in place to deliver domestic abuse training appropriate to the role and function of all staff, including refresher training at regular intervals. Specific consideration must be given to staff who assess risk in their day-to-day roles and/or who deliver staff supervision. This training should be audited and supported via annual training needs assessments. | All agencies |
| 20 | SEPT children’s services must audit the ‘strengths and needs’ assessment used during the ante natal period, which includes lines of enquiry relating to the use of alcohol and substances and domestic abuse and the impact on victims and their children. | South Essex Partnership University NHS Foundation Trust (SEPT) |
| 21 | South Essex Partnership Trust Community Drug and Alcohol Service must ensure that all service users’ case notes are recorded and saved securely to enable retrieval when required. Supervisors and practitioners should be informed of the Trust policy on adequate case note recording and storage. | South Essex Partnership University NHS Foundation Trust Community Drug & Alcohol Service |
| 22 | The Trust should implement NICE guidance Recommendations 6 and 9 in its current review of domestic abuse training and signposting resources for key staff including Emergency Department staff and Midwives. Training should address the dismissal of disclosures being judged to be ‘historical’ and not considered as irrelevant to risk assessment. Training should to be aligned to relevant internal policies. | Southend University Hospital NHS Foundation Trust |
| 23 | The Trust to review its internal coordination and working in its approach to safeguarding, particularly around Section 17 and Section 47 requests, and DHRs and ensure that flags or alerts concerning domestic abuse are uniform and understood across departments | Southend University Hospital NHS Foundation Trust |
| 24 | Essex Police to ensure that the DV1 section on the safe contact details for a victim is completed with telephone number and safe time to make contact. | Essex Police |
| 25 | Essex Police to ensure that when a domestic abuse suspect is released with bail conditions in place this information and the content of the conditions is forwarded to Children’s Services, Health and IDVA service, including the date of the court hearing where bail will be reviewed. | Essex Police |
| 26 | Where a HIGH Risk offender is bailed from court with previous bail conditions lifted or released from custody Witness Care should notify Essex Police CRU of any changes and a further risk assessment should be undertaken. This should be shared with Children’s Services, IDVA Services and any other agency working with the family (as identified via the JDATT/MASH) as soon as possible. | Essex Police |
| 27 | Ensure that all evidence, full past history including cautions, and information known about the perpetrator is given to the Crown Prosecution Service, this to include where a victim has been referred to MARAC and that consideration is given to the application of bail conditions or a restraining order to prevent risk of further offences in domestic abuse cases and to augment the MARAC safety plan. | Essex Police |
| 28 | The MARAC coordinator should review the distribution list for the circulation of the MARAC agenda a minimum of 6 monthly to ensure that agency representation at MARAC remains appropriate and takes into account changes in agency structures and re-commissioning of services. | MARAC coordinator |
| 29 | The Crown Prosecution Service should ensure that all available domestic abuse history is provided to the court to assist their decision making. Where a victim is referred to MARAC suitable bail conditions/or Restraining Order should be pressed for to augment the safety plan for the victim. | Crown Prosecution Service |
| 3 | The Domestic Homicide Review Overview Report should be disseminated to all participating agencies, and in particular briefings should include the importance of timely and continuous information sharing and risk assessment. | All participating agencies |
| 30 | The Crown Prosecution Service should ensure that where an offender’s legal representative produces a note or letter said to be from the victim in support of lifting bail conditions or countering a request for a restraining order, the CPS should insist that the authenticity of the written material and free will of the author is verified. | Crown Prosecution Service |
| 31 | The Southend Bench should ensure that all its magistrates are trained in all aspects of domestic abuse and coercive control and are fully informed of the MARAC and the significance of the risk faced by a victim who is referred to MARAC. Confirmation of training to be confirmed to the Community Safety Partnership Board. | Southend Magistrates Court |
| 32 | Safer Places should increase the staff capable of undertaking the DASH risk assessment and referral paperwork to ensure that those entering the refuge at weekends are promptly assessed. Refresher training should be provided for all staff to minimise the risk of omissions. | Safer Places |
| 33 | Line Managers should put in place quarterly reviews of casework and attached files to ensure completion meets with agency standards. | Safer Places |
| 34 | Ensure all staff receive training to sensitively probe and challenge the reasons for a victim declining the service and able to work towards achieving their engagement with support and to CAADA (SafeLives) Case management Guidelines. | Victim Support | Safer Places |
| 35 | Review the system of service delivery to victims to ensure a flexible IDVA Service which can respond to all victims and service users quickly after an incident, including those who can only be contacted outside working hours. | Victim Support | Safer Places |
| 36 | A system of regular clinical supervision for all IDVA staff who carry caseloads should be in place separate from their caseload and personal development supervision. | Victim Support | Safer Places |
| 4 | The Community Safety Partnership and their strategic partners should build on the work of the Joint Domestic Abuse Triage Team to improve coordination. | The Community Safety Partnership | strategic partners |
| 5 | The Community Safety Partnership and strategic partners should investigate & consider the provision of an appropriate community based programme for unconvicted high risk domestic abuse perpetrators whose victims are referred to MARAC, and/or where there are concerns for children. This would form part of the coordinated community response for the Borough and provide community interventions for local services. | The Community Safety Partnership | strategic partners |
| 6 | A domestic abuse communications strategy should be put in place which includes regular multi-media public information campaigns to alert victims, perpetrators, family, friends and colleagues to all aspects of domestic abuse and coercive control, and which includes a range of statutory and voluntary sector sources of help and support including for young people in schools. | Community Safety Partnership | strategic partners |
| 7 | The Group Manager, Fieldwork Services, Children’s Services to identify and implement the use of specific risk assessment tools in relation to assessing the risks to children and non-abusive partners where there is domestic abuse and also in assessing the risks in relation to contact between an abusive partner and their child. | Southend Borough Council Children’s Services |
| 8 | The Group Manager, Quality Assurance in partnership with the Workforce Development Manager to develop a programme of briefings, training and other development opportunities to inform Social Workers and Managers within Children’s Services of the role of MARAC within domestic abuse. | Southend Borough Council Children’s Services |
| 9 | The Probation Service and Community Rehabilitation Service to provide a presentation to Southend Children's and Adults Services and relevant allied services staff to explain the roles and responsibilities of the Service, the changes in structure which have taken place since June 2014, and in consideration of the findings of this DHR to clarify how the agencies might work better together. | National Probation Service | Community Rehabilitation Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||