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
Somerset review
CSP: Somerset
Published: April 2023
Year of death: 2015
Extracted: 44 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
Key concerns include missed opportunities for multi-agency intervention, inconsistent information sharing, and a lack of robust action against the perpetrator. Conflicting advice and an inadequate understanding of domestic abuse dynamics also contributed to the victim's escalating risk.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The police should seek to take opportunities to engage with domestic abuse victims when contact occurs and opportunities arise outside the usual response to domestic incidents themselves. A culture of approach, rather than waiting to be approached, might bring about improved contact between police and domestic abuse victims. | Avon and Somerset Police |
| 1 | Ensure that all comprehensive case audits address the following: a. Clarity of recording b. Rationale for decision making c. Management oversight of progress on actions d. The voice and experience of the child | Somerset County Council Children's Social Care |
| 1 | Review and refine the multi-agency domestic abuse policy and procedures under the LSCB to incorporate a multi-agency risk identification tool (i.e. the Domestic Violence Risk Indicator Checklist). | Somerset Safeguarding Children Board |
| 1 | With ASC case recording the AIS functionality to copy case notes from one family member to another should be used to facilitate full record keeping where relevant. | Somerset County Council Adult Social Care |
| 1 | Somerset Partnership CAAS to record electronic risk alerts, screening and information following assessment of all patients. | Somerset Partnership NHS Foundation Trust |
| 1 | Feedback and debrief to be offered to the General Practice prior to final publication. | Somerset Clinical Commissioning Group |
| 1 | Case intake policy and process to meet ‘Safe Lives Leading Lights’ required standard by ensuring that clients are contacted within 24-48 hours from referral date, and engagement to take place within 5 days of the initial contact if it is safe to do so. (Contact and engagement should be “meaningful” as described in the SCC Domestic Abuse Service Intake Process) | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 1 | Housing staff should have a clear procedure for dealing with domestic abuse cases which should include that such cases are raised as prevention cases at the earliest opportunity. | Mendip District Council Housing Department |
| 1 | To gain representation on Somerset MARACs by signing up to the Somerset MARAC Operating Protocol. | Curo Group |
| 1 | MARAC to review actions agreed for cases with specific focus on actions which are not complete due to a barrier. MARAC attendees to seek resolution as multi-agency group and agree alternative actions to reduce the risk. | Safer Somerset Partnership |
| 1 | Ward staff need to be reminded to ensure clear direction for GP in respect of follow-up appointments especially when these relate to psychiatry. | Yeovil District Hospital NHS Foundation Trust |
| 2 | Where DASH assessments are changed by police staff or police officers after the event, the rationale for that change should always be recorded. The recording of decision making rationale would allow for more effective ongoing case review. | Avon and Somerset Police |
| 2 | Ensure that Domestic Abuse training is compulsory for all CSC staff proportionate to their role. | Somerset County Council Children's Social Care |
| 2 | The domestic abuse policy and procedure ‘Children Affected by Domestic Abuse – last updated in October 2014’ needs to develop guidance on safety planning, emergency planning including procedures for closing a case file, and good practice guidance. | Somerset Safeguarding Children Board |
| 2 | Where a vulnerable adult is the victim of control and coercion, information on their wishes needs to be collated in a timely and speedy way. SCC ASC Safeguarding Adults processes should be reviewed and amended to ensure this. | Somerset County Council Adult Social Care |
| 2 | Somerset Partnership Safeguarding Service to produce an internal Domestic Abuse and MARAC protocol/procedure. | Somerset Partnership NHS Foundation Trust |
| 2 | For the practice to consider a review of consultations to include social questions. | Somerset Clinical Commissioning Group |
| 2 | Where an IDVA service is being transferred from one provider to another a standard procedure is recommended that all active cases 6 weeks prior to the transfer date remain active throughout the transition to a new provider. The new provider should not close cases until a full review has been undertaken by the allocated worker to ensure all actions have been completed and risks managed and reduced. This recognises the challenges a service transfer can bring to a team of staff. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 2 | Procedures should reflect that options such as homelessness applications, access to private sector options, staying with friends, injunctions etc. should always be discussed in parallel with any refuge offer, with these options confirmed in writing. | Mendip District Council Housing Department |
| 2 | In circumstances where a tenant is identified as a victim of domestic abuse, and is already known to be in receipt of DA specialist support, a discussion will be had with that specialist DA agency to determine who is the lead professional co-ordinating support to the individual/family. | Curo Group |
| 3 | The police should use elements of this DHR as a case study in training to raise awareness of the importance and effectiveness of the paramountcy principle. The police often faced high tension situations with difficult adults, but they did not allow their focus on the safety and welfare of the children to be compromised. This may be achieved in a number of ways in training settings. | Avon and Somerset Police |
| 3 | For Child In Need cases - expectations of visiting frequency, and regularity of review are set out in the practice framework and highlighted to all teams as the agreed standard. | Somerset County Council Children's Social Care |
| 3 | Where a vulnerable adult is the victim of control and coercion, SCC ASC should ensure that Social Workers have access to prompt legal advice on the processes to ensure the protection of individual rights under the Human Rights and Mental Capacity Acts, and also now, the Care Act. This should include information on referrals to the Court of Protection in urgent cases. SCC ASC Safeguarding Adults processes should be reviewed and amended to ensure this. | Somerset County Council Adult Social Care |
| 3 | Somerset Partnership Safeguarding Service to review and update Trust Domestic Abuse Policy and flowchart. | Somerset Partnership NHS Foundation Trust |
| 3 | Specific training in domestic abuse and knowledge of the GP champion approach. | Somerset Clinical Commissioning Group |
| 3 | The outgoing provider should provide the incoming provider with client case files as soon as practicable and no less than 3 weeks prior to transfer date, enabling the outgoing provider to organise consent forms from clients and organise files ready for transfer. This will be subject to obtaining client consent. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 3 | Housing staff who are working with Domestic abuse victims need to be aware of the national and local organisations that offer emergency injunction services and the costs of such services (especially where the client is working). | Mendip District Council Housing Department |
| 4 | To ensure officers are aware of all tactical options for progressing positive outcomes for Domestic Abuse. Training and awareness in relation to DVPN/DVPO and Stalking and Harassment (including coercion and control) to be included within training and refresher packages. | Avon and Somerset Police |
| 4 | Ensure that Core Groups are held in a timely manner in accordance with Government guidelines for the prompt identification and actions to address risks to children on Child Protection Plans. | Somerset County Council Children's Social Care |
| 4 | Where MASH and MARAC meetings are held in respect of domestic abuse within families, if there is a family member who is also a vulnerable adult, contact should be made with the allocated worker, where relevant, or to the SCC Adult Safeguarding Team, in all cases to ensure the effective sharing of information and invitation to subsequent meetings. This is to ensure that the risk of domestic abuse to the vulnerable adult is also considered within the MARAC. It is particularly important where a person may lack capacity and needs others to act in their best interests, under the Mental Capacity Act. | Somerset County Council Adult Social Care |
| 4 | Somerset Partnership Safeguarding Service to review protocols to share information and risk management of safeguarding cases which involve both adults and children. | Somerset Partnership NHS Foundation Trust |
| 4 | Adoption once ratified the CCG domestic abuse policy for primary care for all practices. | Somerset Clinical Commissioning Group |
| 4 | Clearer communication between IDVA and Outreach services with particular focus on transfer of referrals and hand over process for the client. Ideally this would be a team meeting with written records which can be audited. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 4 | Housing staff who are working with Domestic abuse victims need to be able to advise on affordability issues relating to existing accommodation commitments and refuge placements. | Mendip District Council Housing Department |
| 5 | To support the availability and information to victims and perpetrators there is a need to ensure that pathways to identified support networks are available. | Avon and Somerset Police |
| 5 | In cases involving domestic abuse and personal safety ASC should review their Safeguarding Adults processes to ensure that referrals to the Police Public Protection Unit are pursued, so that teams are provided with advice on available actions and police support in all cases. | Somerset County Council Adult Social Care |
| 5 | The Trust will utilise the Multi-Agency Safeguarding Hub (MASH) to work with partner agencies ensuring timely response and co-working when appropriate. | Somerset Partnership NHS Foundation Trust |
| 5 | Circulate lessons learnt from DHRs regarding the need to clearly document social history during consultations. | Somerset Clinical Commissioning Group |
| 5 | All cases should be closed as per the required standards of ‘Safe Lives Leading Lights’ whereby a recorded case management meeting is held and exit actions are completed with a client to include a final assessment of risk as part of that procedure. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 6 | In Safeguarding Adults and Domestic Abuse cases, SCC ASC needs to improve the clear recording of all: • Safeguarding Adults meeting minutes • Adult Protection Plans • Managers’ decisions • Risk Assessments. | Somerset County Council Adult Social Care |
| 6 | The Trust will utilise more fully the existing safeguarding information pathways (e.g. staff newsletter, safeguarding intranet pages and staff training) to raise awareness of domestic abuse and the protocols for managing these cases. | Somerset Partnership NHS Foundation Trust |
| 6 | All agencies need to take into consideration the client’s wishes and risk concerns around recommended safety plans offered by professionals, with particular understanding that the client will understand the perpetrators patterns of behaviour the most. Where possible, these wishes should be accommodated in options provided. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| 7 | The lessons from this Domestic Homicide Review should be reviewed and disseminated within the training commissioned for SCC ASC staff. | Somerset County Council Adult Social Care |
| 7 | Promotion of escalation processes within all agencies for all professionals working with high risk victims of domestic abuse. Promoting the benefit of escalation to find a resolution and removing any negativity from the escalation process. | Bournemouth Churches Housing Association | Knightstone Housing (SIDAS) |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||