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

Southampton review

CSP: Southampton Published: April 2023 Year of death: 2011 Extracted: 28 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
Agencies failed to identify and respond to domestic abuse indicators, compounded by the victim's mental health and substance misuse vulnerabilities and the perpetrator's manipulative behaviour. This led to missed opportunities for intervention and a lack of coordinated risk assessment.

Home Office classifications

34 tags

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

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - depression
  • Victim - psychosis
  • Victim - suicide attempts
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies 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
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - housing 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
  • DHR process - other recommendation themes

Extracted recommendations

28 recommendations pulled from the report · 16 matched to organisations in the index

Recommendation 1

Addressed to Southampton Safe City Partnership

All services involved in this review should ensure relevant staff are fully trained in identifying, assessing and responding to domestic abuse.

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

Recommendation 2

Addressed to Southampton Safe City Partnership

Southampton Safe City Partnership should ensure that the Pippa (Prevention, Intervention and Public Protection Alliance) project is implemented. This will provide a clear point of contact for workers seeking advice and information about domestic abuse cases and will provide a place to make referrals of domestic abuse cases that require specialist support.

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

Recommendation 3

Addressed to NHS Southampton

NHS Southampton should ensure that the IRIS (Identification and Referral to Improve Safety) project is implemented and sustained in the City to work closely with GP practices to improve identification and referral of domestic abuse cases. The project should involve both Practice 1 and 2 as involved in this case within its first set of practices involved in the project.

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

Recommendation 4

Addressed to Southampton Safe City Partnership | NHS Southampton

Key services including Health and the Local Authority should require specific standards in training for providers so that all professionals and practitioners are able to ensure domestic abuse identification, assessment and appropriate referral.

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

Recommendation 5

Addressed to Vulnerable Victims Group

The Vulnerable Victims group should consider how agencies can respond more effectively to the cumulative impact of standard and medium risk cases for adults with compounding issues such as mental health and substance misuse as well as domestic abuse. To include consideration of developing a triage system similar to Multi Agency Safeguarding Hubs used in other parts of the UK, or the triage used for children and young people cases in Southampton.

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

Recommendation 6

Addressed to Hampshire Constabulary

Force policies and procedures are amended to provide police officers with more guidance when dealing with suspects who have mental health issues.

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

Recommendation 7

Addressed to Hampshire Constabulary

Force control room standard operating procedures are amended to provide clear risk based guidance on how to respond to calls from people with mental health issues.

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

Recommendation 8

Addressed to NHS Southampton

Increase GP and practice staff awareness and identification of domestic violence, the potential effects on relationships / families and the service provision available for support and intervention. Develop close working relationships between DV team, IDVA (Independent Domestic Violence Advisors) and health services.

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

Recommendation 9

Addressed to NHS Southampton

Increase awareness of GP role and responsibility in Safeguarding Adults with the development and implementation of individual practice Safeguarding Adult Policy. This policy should include recognising and managing domestic violence.

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

Recommendation 10

Addressed to NHS Southampton

New patient registration forms to have a detailed section requesting information on the consumption of alcohol, over the counter medications, alternative medication and illicit drugs to facilitate lifestyle assessment and opportunistic signposting to appropriate drug and alcohol services.

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

Recommendation 11

Addressed to NHS Southampton

A greater correlation between the data available in the form of easily identifiable read codes and the information contained in individual patient records. Increase performance management of Primary Care services to ensure practices are complying with this mandatory process in line with guidance using uniform read codes.

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

Recommendation 12

Addressed to Southampton University Hospitals Trust

Validate the 2011 update of management of domestic abuse guideline

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

Recommendation 13

Addressed to Southampton University Hospitals Trust

Ensure training re: management of domestic abuse is always included on the orientation for Emergency Department nurses and doctors.

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

Recommendation 14

Addressed to Southampton University Hospitals Trust

Include training re: management of domestic abuse on forthcoming Vulnerable Adult Champions Programme

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

Recommendation 15

Addressed to Southampton University Hospitals Trust

Ensure that the record of referral from Emergency Department re: mental health problems is included on the patient’s electronic mental health records by the mental health team receiving the referral, regardless of whether the patient is seen in Emergency Department, the Mental Health Team refuse to see or patient self discharges/absconds.

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

Recommendation 17

Addressed to Southampton University Hospitals Trust

Ensure clinical and non clinical staffs have easy access to information and resources on all vulnerable adults issues.

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

Recommendation 18

Addressed to Southampton University Hospitals Trust

Facilitate access to specialist services for victims of domestic abuse when they attend the acute hospital site.

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

Recommendation 19

Addressed to Southern Health Foundation Trust

Provide awareness for all staff groups of the recently developed domestic abuse policy including the availability of domestic abuse training throughout the trust.

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

Recommendation 20

Addressed to The Society of St James

Each service within the Society to ensure that at least one member of staff attends specialist domestic violence training each year, if this is appropriate to the role of the service. This is in order to keep teams up to date with the issues, and to maintain awareness of the issues over the longer term. This needs to be in line with the role of the service, so may not be considered relevant within the Registered Care Home, for example.

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

Recommendation 21

Addressed to Sovereign Kingfisher

Refresher Domestic Violence training for all Customer Service Advisors and Housing Officers

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

Recommendation 24

Addressed to Sovereign Kingfisher

Have a specific module within the Sovereign training framework covering domestic abuse

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

Recommendation 26

Addressed to Options Drug & Alcohol Service

Supervisors to attend DASH (risk assessment) and MARAC (Multi Agency Risk Assessment Conferences) training course.

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