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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

21 recommendations pulled from the report

#	Recommendation	Addressed to
R1	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.	Avon and Somerset Constabulary
R10	Referrals to Children's Social Care to ensure clarity on what constitutes a referral to CSC	Bath & NES Council Children’s Social Care
R11	Case notes Reminders to be given to Duty Team to ensure clarity and consistency in record keeping	Bath & NES Council Children’s Social Care
R12	That the Local Safeguarding Adults Board reviews the quality of referrals being made into safeguarding, particularly those made by statutory partners.	BANES Safeguarding Adults Board
R13	DHI risk assessment for clients entering casework services to be reviewed and re-issued to all staff	DHI
R14	Relevant DHI policies and procedures to be reviewed to consider appropriateness of current thresholds for action	DHI
R15	Lettings procedures to be clear about specifically asking about DV and what support is or could be in place.	Knightstone Housing
R16	Audit of thyroid function test management as proxy for management of blood results	GP Practice
R17	Baseline assessment of documentation of consideration of child and adult safeguarding issues for all patients on mental register	GP Practice
R18	All patients on mental health register to have documentation of consideration of safeguarding issues	GP Practice
R19	Staff are up to date with mandatory child and adult safeguarding training	GP Practice
R2	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.	Avon and Somerset Constabulary
R20	IRIS training and advocacy package completed	GP Practice
R21	Specific DVA policy developed	GP Practice
R3	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	AWP
R4	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	AWP and Bath and North East Somerset Council Safeguarding Team
R5	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.	AWP and Avon and Somerset Constabulary
R6	Explore IT solutions to reduce potential admin delays in reporting Safeguarding concerns	BANES Local Authority and AWP
R7	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.	B&NES Responsible Authorities Group(Community Safety Partnership)
R8	Review procedure on passing messages to advisers	Citizens advice B&NES
R9	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.	Citizens advice B&NES
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗