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.

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

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

51 tags

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

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (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 - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - psychosis
  • Perpetrator - suicidal thoughts
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • 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 - community safety partnership recommendations
  • 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

36 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1

Addressed to The Community Safety Partnership

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'

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

Recommendation 2

Addressed to All agencies

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.

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

Recommendation 3

Addressed to All participating agencies

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.

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

Recommendation 4

Addressed to The Community Safety Partnership | strategic partners

The Community Safety Partnership and their strategic partners should build on the work of the Joint Domestic Abuse Triage Team to improve coordination.

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

Recommendation 5

Addressed to The Community Safety Partnership | strategic partners

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.

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

Recommendation 6

Addressed to Community Safety Partnership | strategic partners

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.

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

Recommendation 7

Addressed to Southend Borough Council Children’s Services

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.

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

Recommendation 8

Addressed to Southend Borough Council Children’s Services

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.

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

Recommendation 9

Addressed to National Probation Service | Community Rehabilitation Service

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.

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

Recommendation 10

Addressed to Drug & Alcohol Commissioning

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.

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

Recommendation 11

Addressed to Crime Reduction Initiatives (CRI)

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.

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

Recommendation 12

Addressed to Crime Reduction Initiatives (CRI)

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.

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

Recommendation 13

Addressed to Crime Reduction Initiatives (CRI)

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.

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

Recommendation 14

Addressed to Integrated Youth Support Services

Improve referral pathways for IYSS into adult services for substance misuse should be developed.

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

Recommendation 15

Addressed to Integrated Youth Support Services

The number of different case management systems should be reviewed with a view to achieving joined up case management systems across IYSS.

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

Recommendation 17

Addressed to G.P. Practice

Clinicians should be reminded that records should contain appropriate detail to highlight apparent risks.

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

Recommendation 18

Addressed to G.P. Practice

The practice are recommended to adopt the Royal College of General Practitioner’s domestic abuse guidance to augment local procedures.

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

Recommendation 19

Addressed to South Essex Partnership University NHS Foundation Trust (SEPT)

SEPT must develop a domestic abuse strategy based upon the NICE guidance for domestic abuse.

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

Recommendation 20

Addressed to South Essex Partnership University NHS Foundation Trust (SEPT)

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.

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

Recommendation 21

Addressed to South Essex Partnership University NHS Foundation Trust Community Drug & Alcohol Service

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.

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

Recommendation 22

Addressed to Southend University Hospital NHS Foundation Trust

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.

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

Recommendation 23

Addressed to Southend University Hospital NHS Foundation Trust

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

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

Recommendation 24

Addressed to Essex Police

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.

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

Recommendation 25

Addressed to Essex Police

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.

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

Recommendation 26

Addressed to Essex Police

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.

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

Recommendation 27

Addressed to Essex Police

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.

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

Recommendation 28

Addressed to MARAC coordinator

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.

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

Recommendation 29

Addressed to Crown Prosecution Service

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.

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

Recommendation 30

Addressed to Crown Prosecution Service

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.

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

Recommendation 31

Addressed to Southend Magistrates Court

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.

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

Recommendation 32

Addressed to Safer Places

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.

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

Recommendation 33

Addressed to Safer Places

Line Managers should put in place quarterly reviews of casework and attached files to ensure completion meets with agency standards.

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

Recommendation 34

Addressed to Victim Support | Safer Places

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.

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

Recommendation 35

Addressed to Victim Support | Safer Places

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.

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

Recommendation 36

Addressed to Victim Support | Safer Places

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.

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