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
Flintshire review
CSP: Flintshire
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 found no agency could have prevented the victim's death given the brief relationship and lack of reported abuse. However, it identified systemic issues including inadequate public awareness of silent 999 calls, risks of internet dating, and missed opportunities for agencies to share information and support past victims of the perpetrator.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 11.23a | All spoken advice and leaflets nationally and locally should reflect the above. | Public services nationally | Public services locally |
| 11.23b | The advice and guidance given, on how to seek help in an emergency situation and the pitfalls of relying on silent calls, needs to form part of any training or publicity. | Public services |
| 11.23c | The Silent Solutions method needs wide ranging and frequent publicity and needs to feature in advice leaflets, procedures and training for all agencies who give advice, or assist victims of Domestic Abuse both locally and nationally (Recommendation for Regional Domestic Abuse Advisor and National Recommendation for Welsh Assembly and Home Office, to be monitored and progressed locally by the Safer Communities Board) | Regional Domestic Abuse Advisor | Welsh Assembly | Home Office | Safer Communities Board |
| 11.24 | We would recommend that there is a national information advert about the risks inherent in using internet dating sites and personal disclosure online. This should include information on how to meet safely, and how to recognise the first signs of coercive control and abuse and what to do about that. (National Recommendation) | Government |
| 11.25 | We recommend that advice on safeguarding whilst using internet dating sites and other social media should be included in those areas to which we already have ready access and can make changes, this includes; council safeguarding web sites, domestic abuse advice web sites and leaflets and police advice pages. (Safer Communities Board) | Safer Communities Board |
| 11.26 | The Panel will approach Welsh Government about the proposed new series of campaigns about Domestic Abuse and ask that the campaigns include the issues with the use of Mobile Phones for calling help and also include keeping safe on line and when using internet dating sites. (Welsh Government) | Welsh Government |
| 11.27 | We recommend that training is provided nationally to GPs and Health Workers about how to recognise and deal with Domestic Abuse issues that may arise in discussion with their patients, including how to deal with disclosure from patients about abuse that they indicate they may be perpetrating against their partner. (Local BCUHB and National Recommendation) | Betsi Cadwaladr University Health Board | National Health Service |
| 11.28 | We recommend to the Home Office that discussion take place with the Royal College of Physicians and the Royal College of Nursing to ensure that the legal and ethical limits on patient confidentiality are re-considered in terms of Health Professionals being given clear guidance about how to recognise and manage when Domestic Abuse issues arise in discussion with their patients or are indicated by their patient’s presentation. This should include how to deal with disclosure from patients about significant anger control issues, which may indicate to a GP or other Health Worker that the patient may be a danger to others, including the patient’s partner or children. (Home Office) | Home Office |
| 13.35 | The Panel recommend that training programmes ensure that practitioners and their managers are careful to consider all the children and young people who may be in regular contact with a violent person and not only those who are permanently resident. (Recommendation to the North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 13.36 | The training of frontline staff, who attend multi-agency meetings and make assessments in regard to victim safety across the age ranges, should include a section which covers the grooming and control of workers and of the multi-agency network. This is in recognition that abusers attempt to control environments, including professionals as well as their victims. (Recommendation to the North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 14.26 | We recommend that a protocol for managing incidents of Domestic Abuse is developed between North Wales Police and RAF Valley. (North Wales Police and RAF Valley) | North Wales Police | RAF Valley |
| 14.27 | We recommend that nationally, consideration is given to developing protocols between police and military police services across the British Isles where they do not already exist. (National Recommendation to the Home Office) | Home Office |
| 14.28 | Panel recommends that supervision and training of staff across the multi-agency network, including training of reception and ancillary staff, emphasises the importance of a listening and empathic approach. This training should ensure that all workers keep at the forefront of their minds the courage that it takes to ask for help or report abuse. (North Wales Regional Safeguarding Board) | North Wales Regional Safeguarding Board |
| 14.29 | We recommend that all staff are trained to recognise that when a person is reporting domestic abuse or planning to leave an abuser that the victim of abuse is likely to be at increased danger, if the perpetrator becomes aware of their action or intention. (North Wales Regional Safeguarding Board) | North Wales Regional Safeguarding Board |
| 14.30 | We recommend that all agencies concerned with safeguarding check that their procedures give sufficient guidance to staff, to ensure that workers disclose adequate information to parents and caregivers of children and vulnerable adults, in order that parents and carers are able to are able to protect those for whom they care. This guidance should include reference to schemes that are already in place such as the Domestic Violence Disclosure Scheme (DVDS) or Claire’s Law as it is also known, and the Child Sex Offender Disclosure Scheme (CSODS). CSODS was introduced in order to raise public confidence and increase the protection of children. This disclosure scheme includes routes for managed access to information regarding not only those individuals who are convicted child sex offenders but also those individuals who pose a risk of harm to children. These may include persons who are convicted of other offences such as serious domestic violence. (North Wales Regional Safeguarding Board) | North Wales Regional Safeguarding Board |
| 14.31 | We recommend that training of staff responsible for safeguarding should always include a reminder of their duty to give sufficient information to parents and carers so that vulnerable children and adults are protected. (North Wales Regional Safeguarding Board) | North Wales Regional Safeguarding Board |
| 15.80 | Flintshire Social Services should ensure that during the supervision of fieldwork social workers supervisors carefully record the instructions given to worker. Supervisors should then check that the instructions have been carried out. Supervisors should note that these tasks have been completed and if not should make sure that they are promptly followed through. (FCC) | Flintshire County Council |
| 15.81 | We recommend that agencies should review their recording policies to ensure that all decisions and recommendations from Panels, case conferences and other decision making forums are clearly recorded and that the reasons for those decisions are clear in the notes of the meeting. (North Wales Regional Safeguarding Boards for Children and Adults) | North Wales Regional Safeguarding Boards for Children and Adults |
| 15.82 | Whilst we recognise the independence of the courts and that sentencing guidelines exist, we make a national recommendation that Courts consider carefully the opportunities that may be missed to moderate an offenders behaviour if they do not follow the recommendations of the National Probation Service in those cases where it has been identified that it would be appropriate and beneficial for the offender to attend a treatment programme. If the court decides not to follow such a recommendation the reason should be documented. (Home Office) | Home Office |
| 15.83 | We recommend that nationally court records should be retained for a sufficient period so that any review such as a serious case review or DHR can benefit from access to those records. Ten years would be a reasonable timescale. (Home Office) | Home Office |
| 15.84 | We recommend that training and supervision focuses upon quality assessments which emphasise the use of professional curiosity and judgement and avoids over reliance on tools. (North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 15.85 | Professionals should be trained to recognise that tools are frameworks for the collection of information and to assist in assessment but they are not the complete assessment of risk; which should be a dynamic process involving the collection and evaluation of all the relevant information available, including the voices of victims and families. ‘Safe Lives’ (previously CADDA DASH) is part of that assessment and not the whole of it. The outcome of the use of the Safe Lives tool should be measured together with all other information available. (North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 15.86 | When making an assessment in cases of domestic abuse the focus on the victim should not detract from also gaining sufficient information about the perpetrator to protect those with whom he/she is, or is likely, to come into contact. So agencies need to note that Safe Lives, which has replaced the CAADA DASH tool, does not cover this area of an assessment currently. Therefore, assessors must ensure they gain sufficient information about a perpetrator’s circle of contacts to ensure the safety of all other vulnerable contacts is taken into account. (North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 15.87 | Panel notes that it is already a requirement that all front line staff and managers in Wales will be trained on national minimum standards for implementation of the Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015. A Regional Training Consortium will be set up in North Wales for the purpose of rolling out the delivery of Welsh Government National Training Framework and will run for five years. The Panel recommends that the findings of the DHR are fed to the organisers and trainers in order to ensure that training emphasises that assessments must be robust and dynamic and not over reliant on single tools. (DHR Panel to North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 15.88 | Panel notes that the police are not included in the requirement for training regarding the implementation of the Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015 and so we recommend that Domestic Abuse and PVPU officers in Wales do receive training that is commensurate to their specific role (North Wales Police on behalf of the Safer Communities Board) | North Wales Police | Safer Communities Board |
| 15.89 | Training on risk assessment in Domestic Abuse should include reference to the phenomena of hiding offences in plain sight, as this is similar to ‘Disguised Compliance’ in child protection work and can mislead and falsely comfort practitioners. (North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 15.90 | Training needs to help practitioners explore the complexity of working in the area of personal relationships and to raise awareness of the conflicts of loyalty which exist for the victim when reporting abuse or considering ending relationships. (North Wales Regional Training Consortium) | North Wales Regional Training Consortium |
| 16.54 | We recommend that The Royal British Legion has a mission statement in its safeguarding policies, which makes it clear that TRBL has a zero tolerance approach towards Domestic Abuse. (TRBL, to be monitored by Flintshire Community Safety Partnership FCSP) | The Royal British Legion | Flintshire Community Safety Partnership |
| 16.55 | We recommend that TRBL develops a specific policy on managing incidents of Domestic/Partner based violence that occur either on their premises or at events that are organised by or specifically on behalf of TRBL. (TRBL, FCSP) | The Royal British Legion | Flintshire Community Safety Partnership |
| 16.56 | We recommend that TRBL ensure that all its officials and organisers think very carefully about placing anyone in any position within the organisation, however lowly the role, after they have committed an act of Domestic Abuse at a TRBL event. We say this because doing so not only gives the message that tolerance of such abuse exists within the organisation but it may further assist the ability of the perpetrator to coerce and control others. (TRBL FCSP) | The Royal British Legion | Flintshire Community Safety Partnership |
| 16.57 | We recommend that WCVA and NCVO provide guidance for all Voluntary Organisations, which ensures a robust standard for Child and Adult protection procedures within Voluntary Organisations and provides for procedures for dealing with and reporting Domestic Abuse. The guidance should include a nil tolerance stance to Domestic Abuse. Such guidance should also refer to the various serious case reviews, which may take place for instance Child Practice Reviews, Adult Protection Reviews and Domestic Homicide Reviews and the importance of full participation in these reviews when requested. | Wales Council for Voluntary Action | National Council for Voluntary Organisations |
| 17.26 | We recommend that supervision and training across the multi-agency network, including training of ancillary and reception staff, emphasises the importance of a listening approach and aims at ensuring that staff keep in the forefront of their minds the courage it takes to ask for help and to report abuse. (Community Safety Partnership) | Community Safety Partnership |
| 17.27 | We recommend that staff are trained to recognise that when reporting domestic abuse or planning to leave an abuser, a victim is likely to be in increased danger if the perpetrator becomes aware of this. (Community Safety Partnership) | Community Safety Partnership |
| 17.28 | The Panel will request that the new Welsh Government publicity campaign regarding Domestic Abuse includes reference to supporting family, friends, neighbours and the general public to report abuse and how they can report. (DHR Panel to Welsh Government) | Welsh Government |
| 17.29 | We recommend that national discussions about further developments aimed at the prevention of Domestic Abuse includes how family, neighbours, friends and the general public can be encouraged and supported to report abuse. (Welsh Government and Home Office) | Welsh Government | Home Office |
| 17.9 | We recommend that advice to victims given directly or via leaflets, on line etc. includes advice to switch off phones and devices to avoid being contacted when made vulnerable by tiredness or being awoken from sleep. (Safer Communities Board) | Safer Communities Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||