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

Lancaster review

CSP: Lancaster Published: April 2023 Year of death: 2017 Extracted: 22 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 that agencies lacked knowledge of the domestic abuse due to non-disclosure by the victim and missed opportunities for routine enquiry, particularly during pregnancy and mental health consultations. Family, friends, and the employer did not recognise the perpetrator's coercive control or physical abuse, nor the increased risk during separation.

Extracted recommendations

22 recommendations pulled from the report

#	Recommendation	Addressed to
1	Pennine Lancashire Community Safety Partnership review the ways in which they use social and other forms of media to increase the understanding and knowledge of family, friends and colleagues about the type of behaviour that comprises domestic abuse, including coercive and controlling behaviour.	Pennine Lancashire Community Safety Partnership
1.	Update Post Natal Care planning standards [SOP] to include transfer of care information and requirement to document family/household members and social support and who is present at visits.	Bolton NHS Foundation Trust
10.	The practice should implement a policy for following up mental health DNAs	East Lancashire Clinical Commissioning Group
11.	Clinicians should be aware of the increased risk of DA following separation particularly in the initial post-separation period	East Lancashire Clinical Commissioning Group
12.	Clinicians‘ practice of routine enquiry needs to be evidenced and incorporated into the standard EMIS templates	East Lancashire Clinical Commissioning Group
13.	All women receiving maternity care from ELHT are asked routine enquiry at least once during their maternity care episode	East Lancashire NHS Hospital Trust
14.	Implementation of NICE recommendation 5	East Lancashire NHS Hospital Trust
15	Have chronology sheets on hand to record any concerns that maybe disclosed by anyone.	Nursery Two
2	Pennine Lancashire Community Safety Partnership explore ways in which it can increase the understanding and knowledge of family, friends and colleagues about the importance of sharing information and concerns about domestic abuse with agencies. This should include ensuring information is provided to them on what steps they can take to safely support victims of domestic abuse.	Pennine Lancashire Community Safety Partnership
2.	Consider the value of routine enquiry in post- natal contacts and consider implications for midwifery practice	Bolton NHS Foundation Trust
3	Pennine Lancashire Community Safety Partnership work with the Lancashire Safeguarding Children‘s Board to assist this and other nurseries in their area to review their policies, systems and training so the risk pupils, employees and their children face from domestic abuse is recorded and, when appropriate, referred through safeguarding processes.	Pennine Lancashire Community Safety Partnership \| Lancashire Safeguarding Children‘s Board
3.	Enquiry about family/relationships /social circumstances should be made in mental health consultations as there may be a ―child behind the adult‖. [Keep Me Safe RCGP 2005]. This would enable any risk to children or vulnerable adults to be identified.	East Lancashire Clinical Commissioning Group
4	Pennine Lancashire Community Safety Partnership work with the Lancashire Safeguarding Children‘s Board to assist this and other nurseries in raising awareness and increasing their understanding of domestic abuse as well as in training them about the need to recognise and report the risks presented by perpetrators of domestic abuse who are in a position of trust and therefore might present a risk to vulnerable people in their care.	Pennine Lancashire Community Safety Partnership \| Lancashire Safeguarding Children‘s Board
4.	There should be an awareness of possible increased risk of DA in inter-racial relationships.	East Lancashire Clinical Commissioning Group
5	Pennine Lancashire Community Safety Partnership work with the Lancashire Criminal Justice Board who should use this case as an example to their partners about the importance of identifying non-compliance with safeguarding practice when undertaking investigations or considering the results of investigations.	Pennine Lancashire Community Safety Partnership \| Lancashire Criminal Justice Board
5.	All practice staff should receive domestic abuse training.	East Lancashire Clinical Commissioning Group
6	East Lancashire Clinical Commissioning Group consider ways in which they can raise GP‘s understanding of the heightened risk factors of pregnancy and improve the use of direct questions and signposting or follow up in appropriate cases. For example by highlighting good practice or making use of the Identification and Referral to Improve Safety [IRIS] programme.	East Lancashire Clinical Commissioning Group
6.	NICE guideline PH50 recommends that enquiry about Domestic Abuse should be made in mental health consultations, including when a patient presents with stress, even where there is no indication that such abuse is taking place. Clinicians should incorporate this into their practice. This recommendation is also in accordance with findings from the 2016 Domestic Homicide Review Case Analysis.	East Lancashire Clinical Commissioning Group
7	Home Office to consider a national campaign aimed at families and friends who have knowledge of domestic abuse on how they can report those concerns to safeguarding professionals.	Home Office
7.	NICE guideline PH50 recommends screening for DA both ante and postnatally as several studies have shown there is increased risk of domestic abuse at those times. The practice should incorporate DA screening questions into any ante or postnatal protocols.	East Lancashire Clinical Commissioning Group
8.	All records of consultations involving a child should include details of any accompanying adult. Where this is another family member, the clinician should confirm that this person has consent for examination and treatment of the child from someone with parental responsibility.	East Lancashire Clinical Commissioning Group
9.	The practice should incorporate routine screening questions for domestic abuse into its new patient checks.	East Lancashire Clinical Commissioning Group
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗