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

Torbay review

CSP: Torbay Published: April 2023 Year of death: 2011 Extracted: 13 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 fragmented agency engagement with the perpetrator, who had complex needs including mental health issues, substance abuse, and a history of domestic abuse as both victim and perpetrator. Agencies primarily focused on her as a victim, missing a holistic view of her chronic situation and potential risks, which was exacerbated by limitations in risk assessment processes at the time.

Extracted recommendations

13 recommendations pulled from the report

#	Recommendation	Addressed to
1	The constituent agencies of Safer Communities Torbay should each have explicit domestic abuse policies that include how and when to report incidents of domestic abuse, whether linked to that agencies service provision or not. Agencies within Safer Communities Torbay should promote these policies and procedures to their staff who may receive disclosures of domestic or sexual abuse in the course of their other duties.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
10	The Adults & Children’s Safeguarding Boards have many different information sharing protocols. There is a particularly effective mental health data sharing protocol, allowing for the sharing of risk data when working with patients with mental health problems. These processes appear well known to small groups of professional leads, but not more widely known. There are different protocols for different professional areas. The Adults & Children’s Safeguarding Boards should require an audit to be carried out and if possible devise a generic information sharing protocol.	Torbay Safeguarding Adults Board \| Torbay Safeguarding Children Board
11	The importance of notifying partners of the risk to children seen in homes where domestic abuse is occurring should be included in any Domestic Abuse policies that are developed and should be promoted to staff.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
12	Torbay is developing a Multi-Agency Safeguarding Hub (MASH) process, this should be developed as the basis for multi-agency safeguarding for both children and adults.	Torbay Council \| Safer Communities Torbay
13	The panel recommend that the Community Safety Partnership make arrangements to enable the learning from this review (DHR01) to be disseminated to the local MARAC and the Torbay Adult Safeguarding Board and Torbay Children’s Safeguarding Board; And that the Community Safety Partnership monitors the recommendations and associated actions from the DHR via appropriate means; And that DHRs feature as a standing item on the Community Safety Partnership’s meeting agendas.	Safer Communities Torbay
2	The TSAB and TSCB should develop a process for the referral and management of disclosure of historical cases of sexual or domestic abuse.	Torbay Safeguarding Adults Board \| Torbay Safeguarding Children Board
3	That SCT continue to raise public awareness of domestic abuse (specifically controlling behaviours and the complexities of abusive relationship) and attempt to signpost victims to help and support at an early stage.	Safer Communities Torbay
4	When healthcare staff receive information that could indicate that a patient is a victim or potential perpetrator of domestic abuse they should seek specialist advice about the most appropriate action to take. Evidence of this consultation and decision making must be recorded on the appropriate patient record and with consideration of NICE PH50 guidelines.	Torbay and Southern Devon Clinical Commissioning Group \| Devon Partnership NHS Trust \| South Devon Healthcare NHS Foundation Trust \| Torbay and Southern Devon Health and Care NHS Trust \| General Practitioners
5	Domestic abuse training should be provided for all front line staff within the SCT constituent agencies. This should include front line A&E department staff. All training on domestic abuse should include the complete 2013 domestic abuse definition and with consideration of NICE PH50 guidelines.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
6	With consideration of NICE PH50 guidelines service providers should review their risk assessment processes to ensure they are robust, with dip sampling to ensure quality control.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
7	Patients with complex needs are liable to exhibit a high rate of “Did Not Attends”, this should be seen as evidence of complexity rather than evidence of lack of willingness to engage.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
8	Clinicians should follow up referrals made to other services if a reply has not been received within three weeks of the referral.	Torbay and Southern Devon Clinical Commissioning Group \| Devon Partnership NHS Trust \| South Devon Healthcare NHS Foundation Trust \| Torbay and Southern Devon Health and Care NHS Trust \| Torbay Council (Children’s Services, Housing Options)
9	The SCT constituent agencies should review, amend and make robust use of their domestic abuse risk assessment frameworks.	Torbay Council \| Devon and Cornwall Police \| Dorset Devon and Cornwall Community Rehabilitation Company \| National Probation Service \| Devon and Somerset Fire and Rescue Service \| Torbay and Southern Devon Clinical Commissioning Group
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗