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
South Tyneside review
CSP: South Tyneside
Published: April 2023
Extracted: 33 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 systemic failures across multiple agencies to conduct routine domestic abuse enquiries and robustly assess presenting concerns, including the victim's frequent health issues and Child 1's behavioural problems. It also highlighted issues with police incident recording and public awareness of mental health support.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 18.1.1 | All agencies to review how they ask people they come into contact with about possible domestic abuse (routine and selective enquiries). To consider the recommendations of a previous DHR and how the learning has been implemented. | All agencies |
| 18.1.2 | All agencies to review what training, policies and procedures they have in place to ensure that there is a robust approach to identifying potential domestic abuse situations. | All agencies |
| 18.2.1a | NHS South Tyneside CCG to ensure that key topics highlighted in the Review are included within Domestic Abuse Training. | NHS South Tyneside CCG |
| 18.2.1b | NHS South Tyneside CCG to monitor uptake of Domestic Abuse Awareness training in Practices. | NHS South Tyneside CCG |
| 18.2.1c | Northern Doctors Urgent Care to review their training requirements regarding Domestic Abuse. | Northern Doctors Urgent Care |
| 18.2.2 | The Quality Assurance processes need to be strengthened in relation to management oversight of Senior Practitioner ‘no further action’ decision-making. | South Tyneside Council: Children’s Service |
| 18.2.3a | Early Help and Advice Teams to review their systems for recording information and advice calls and referrals as appropriate. | South Tyneside Council: Early Years Service |
| 18.2.3b | Training should be provided for Managers on reflective supervision and analysis of cases to promote reflective practice and ensure more effective management oversight within the supervision process. | South Tyneside Council: Early Years Service |
| 18.2.3c | Case supervision should be held on file. Verbal discussions of cases and recommendations from management should be recorded within the contact notes of the file to evidence management oversight. | South Tyneside Council: Early Years Service |
| 18.2.3d | Dissemination of learning from the IMR across the Early Help Partnership with a view to: a) Strengthening communication between all professionals with the Early Help Plan; b) Ensuring the engagement with families as a whole unit (as appropriate) in the work being undertaken; and c) Providing effective challenge where family members are not engaging and participating in the support and interventions provided in line with agreed plans. | South Tyneside Council: Early Years Service |
| 18.2.4a | Delivery of Domestic Abuse Routine and Selective Enquiry will remain an integral part of safeguarding training, with managers and service leads asked to provide evidence of attendance by those staff working with families or who may come into contact with potential victims of domestic abuse during their work within the Trust A&E, Maternity, and Health Visiting Services. | South Tyneside NHS Foundation Trust |
| 18.2.4b | To evaluate the uptake and impact of previous Routine and Selective Enquiry training delivered to STNHSFT A&E staff. An audit of assessment documentation will be completed to understand the effectiveness of training and impact on practice. | South Tyneside NHS Foundation Trust |
| 18.2.5a | All Officers and staff responding to, and investigating, domestic abuse are to be reminded that ‘Proportionate Investigation does not apply to reports of domestic abuse. All reports of domestic abuse are to be thoroughly and robustly investigated as clearly stated in the current Force policy on crime investigation. This can be found on the Force intranet. | Northumbria Police |
| 18.2.5b | In relation to investigating domestic abuse, all Officers and staff responding to and investigating domestic abuse are to be reminded that the Northumbria Procedure for Investigating Domestic Abuse clearly states that enquiries should be intrusive and tenacious in establishing the facts. Both parties should be spoken to in a domestic abuse incident. | Northumbria Police |
| 18.2.5c | All supervisors for Officers and staff responding to and investigating domestic abuse are to be reminded that it is the duty of the front line supervisor to ensure that the DASH form and domestic abuse screens are fully completed before the Officer terminates their duty, this includes completion of the DT screen with details of the safeguarding carried out. The form should be referred to the Central Referral Unit. The duty supervisor should monitor the incomplete domestic queue for front line staff | Northumbria Police |
| 18.2.5d | This is a list of domestic abuse records which Officers have failed to complete. Incomplete records should be completed as soon as possible to avoid further delay in the risk assessment process. The Duty Supervisor is intrusive of reports of domestic violence and abuse to ensure ‘all reports of domestic violence are to be thoroughly and robustly investigated’. | Northumbria Police |
| 19.1a | To ensure Routine & Selective Enquiry are embedded in practice within STNHSFT (continued action from DHR#1) | STNHSFT |
| 19.1b | To ensure that staff who come into contact with potential victims of domestic abuse are effectively trained. | STNHSFT |
| 19.2a | To ensure that wider social factors are taken into consideration in Early Help assessments. | South Tyneside Council – Early Help |
| 19.3a | All incidents of Domestic Abuse to be recorded accurately with a DASH risk identification checklist. | Northumbria Police |
| 19.4a | Raise public awareness of how to identify and seek appropriate help for mental ill health issues in the community | NTW |
| 19.4b | Raise awareness across organisations and communities of the evidence-based actions that can be taken to promote and protect mental health and emotional wellbeing across the lifecourse. | South Tyneside Council - Public Health |
| 19.4c | To ensure changes in key crisis mental health service provision are made clear to out-of-hours contacts. | NTW |
| 19.AP.1 | To ensure that lessons learned from this DHR are included in domestic abuse training. | STCCG |
| 19.AP.10 | Dissemination of learning from the IMR to improve inter-agency working, engagement with families and professional challenge. | South Tyneside Council – Early Years’ Service |
| 19.AP.2 | To ensure each GP practice to monitor the uptake of Domestic Abuse training by GP staff. | STCCG |
| 19.AP.3 | To ensure the provision of Domestic Abuse training for out of hours GPs is current. | NDUC Out of Hours GP Safeguarding Lead |
| 19.AP.4 | To strengthen the management oversight quality assurance processes when decisions are made to take ‘no further action’ following referrals. | South Tyneside Council – Contact & Early Response |
| 19.AP.5 | Development of an early help system for all contact’s not reaching social care threshold’s to be offered a service. | South Tyneside Council – Contact & Early Response |
| 19.AP.6 | Development of a multi-agency safeguarding hub which will take over the CRT function. | South Tyneside Council – Contact & Early Response |
| 19.AP.7 | Review the systems for recording information, advice calls and referrals | South Tyneside Council – Early Years’ Service |
| 19.AP.8 | To provide training for Managers to promote reflective practice and ensure more effective management oversight within the supervision process. | South Tyneside Council – Early Years’ Service |
| 19.AP.9 | Case supervision to be held on file. Verbal discussions of cases and recommendations from management should be recorded within the contact notes of the file to evidence management oversight. | South Tyneside Council – Early Years’ Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||