Home / Sources / Domestic Homicide Reviews / Bath and North East Somerset · Apr 2023
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

Bath and North East Somerset review

CSP: Bath and North East Somerset Published: April 2023 Year of death: 2015 Extracted: 21 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The report identifies issues with inter-agency information sharing, particularly regarding the victim's mental health and domestic abuse risks. Delays in safeguarding referrals and inconsistent risk assessments for vulnerable adults and children were also identified.

Home Office classifications

38 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - died by suicide
  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - depression
  • Victim - psychosis
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (between victims)
  • Children - living with victim (including adult children)
  • Child - primary address same as victim
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

21 recommendations pulled from the report · 3 matched to organisations in the index

Recommendation R1

Addressed to Avon and Somerset Constabulary

Avon and Somerset Constabulary to ensure that all operational staff-members are reminded of the importance of intelligence submissions for any relevant incident they attend.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R2

Addressed to Avon and Somerset Constabulary

All operational staff to be reminded of the importance of recognising the risk to children living within a parent declining mental health. To be measured by an increase in referrals from the Safeguarding Coordination Units to Children’s social care.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R3

Addressed to AWP

AWP to organise training to increase awareness of how vulnerability to domestic abuse can be linked to history of trauma and agencies available to support

Verified wording from the published review · Original review (PDF) ↗

Recommendation R4

Addressed to AWP and Bath and North East Somerset Council Safeguarding Team

The Operating Protocol in relation to Safeguarding decisions between AWP and Bath and North East Somerset Council needs to be reviewed particularly in relation to alerts having to be made by Team Managers or Senior Practitioners

Verified wording from the published review · Original review (PDF) ↗

Recommendation R5

Addressed to AWP and Avon and Somerset Constabulary

Awareness raising to be undertaken amongst AWP on CAADA DASH/Safe Lives tool and MARAC referrals, particularly the availability of option to refer to MARAC on professional judgement basis.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R6

Addressed to BANES Local Authority and AWP

Explore IT solutions to reduce potential admin delays in reporting Safeguarding concerns

Verified wording from the published review · Original review (PDF) ↗

Recommendation R7

Addressed to B&NES Responsible Authorities Group(Community Safety Partnership)

During the Review it was identified that B&NES does not appear to have a clear multi-agency policy / procedure on Domestic Abuse and Violence or a multi-agency training programme.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R9

Addressed to Citizens advice B&NES

Continue to implement the“ASK RE” information policy which highlights the need not just to signpost to services but t where appropriate to directly refer.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R10

Addressed to Bath & NES Council Children’s Social Care

Referrals to Children's Social Care to ensure clarity on what constitutes a referral to CSC

Verified wording from the published review · Original review (PDF) ↗

Recommendation R11

Addressed to Bath & NES Council Children’s Social Care

Case notes Reminders to be given to Duty Team to ensure clarity and consistency in record keeping

Verified wording from the published review · Original review (PDF) ↗

Recommendation R12

Addressed to BANES Safeguarding Adults Board

That the Local Safeguarding Adults Board reviews the quality of referrals being made into safeguarding, particularly those made by statutory partners.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R14

Addressed to DHI

Relevant DHI policies and procedures to be reviewed to consider appropriateness of current thresholds for action

Verified wording from the published review · Original review (PDF) ↗

Recommendation R15

Addressed to Knightstone Housing

Lettings procedures to be clear about specifically asking about DV and what support is or could be in place.

Verified wording from the published review · Original review (PDF) ↗

Recommendation R17

Addressed to GP Practice

Baseline assessment of documentation of consideration of child and adult safeguarding issues for all patients on mental register

Verified wording from the published review · Original review (PDF) ↗

Recommendation R18

Addressed to GP Practice

All patients on mental health register to have documentation of consideration of safeguarding issues

Verified wording from the published review · Original review (PDF) ↗