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

Lincoln review

CSP: Lincoln Published: April 2023 Year of death: 2014 Extracted: 18 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 highlights inadequate inter-agency information sharing, particularly police PND checks and health visitor handovers, leading to incomplete domestic abuse risk assessments. It also notes insufficient professional curiosity and cultural sensitivity in practitioner responses.

Home Office classifications

35 tags

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

  • Victim - mental ill health
  • Victim - anxiety
  • Victim - panic attacks
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - immigration involvement
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - school recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

18 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation 9.1

Addressed to Lincolnshire Police

SIOs should be reminded of the need to consider safeguarding policies and procedures during murder investigations and of the resources available to them in the Public Protection Unit Central Referral Unit for advice, guidance and co-ordination with partner agencies.

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

Recommendation 9.2

Addressed to Lincolnshire Police

Lincolnshire Police should take steps to raise the awareness of all officers and staff as to the value of the PND and ensure that policies, procedures and guidelines in respect of its use in DA cases are complied with.

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

Recommendation 9.3

Addressed to ULHT

To audit paediatric and A & E records to assess whether information relating to those who are accompanying a child into hospital is adequately recorded.

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

Recommendation 9.4

Addressed to CCGs

Lessons learned from this review will be taken forward through the newly formed contract management arrangements and assurance sought that the necessary protocols and controls are in place to ensure that practitioners have the requisite competence and skill to recognise and act upon DA.

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

Recommendation 9.5

Addressed to CCGs

Where DA within a family is recognised and entered into the child`s records through Children’s Services e.g. HV SN and maternity services or following a conviction a further entry should be recorded, flagged and linked to the parents records.

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

Recommendation 9.6

Addressed to LCHS

LCHS to audit whether the routine enquiry of DA and appropriate action is now embedded as part of all practitioners practice.

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

Recommendation 9.7

Addressed to Education

The school to provide evidence that it has an effective system in place for allocating cases to the Parent Support Advisor and for monitoring, recording and feeding back to senior management.

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

Recommendation 9.8

Addressed to Education

Schools will review their Safeguarding Policy in line with the recently amended model policy provided by the Local Authority and taking into consideration the guidance on the new Ofsted inspections.

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

Recommendation 9.10

Addressed to Education

Ensure all staff inviting both parents to joint meetings understand that where parents are estranged and there is potential for conflict or coercive control that the potential risk of that activity is recognised and merited and careful consideration is given to how such a meeting is managed

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

Recommendation 9.11

Addressed to Northern Lincolnshire and Goole NHS Foundation Trust Health Visiting Service

The Domestic Abuse Screening Tool now used in Health visiting in NLAG to be expanded to also be used for "movement in contacts" to assist in the early identification of DA.

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

Recommendation 9.12

Addressed to Northern Lincolnshire and Goole NHS Foundation Trust Health Visiting Service

All Health Visitors to receive DASH training to ensure that they are equipped in the identification and assessment of DA.

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

Recommendation 9.13

Addressed to Northern Lincolnshire and Goole NHS Foundation Trust Health Visiting Service

Health Visiting Managers to remind practitioners to utilise The Interpreting and Translation Services Policy for work with those for whom English is not their first language in accordance with North Lincolnshire and Goole NHS Foundation Trust Policy.

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

Recommendation 9.14

Addressed to Northern Lincolnshire and Goole NHS Foundation Trust Health Visiting Service

Review Health Visitor recording to confirm it is completed using the SBAR format following contact with Children and Young People`s Services

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

Recommendation 9.15

Addressed to Northern Lincolnshire and Goole NHS Foundation Trust Health Visiting Service

Review the North Lincolnshire and Goole NHS Foundation Trust guidance for the transfer of community health records for children with additional/safeguarding needs.

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

Recommendation 9.16

Addressed to Community Safety Partnership

The Community Safety Partnership through the DA protocol and training to ensure practitioners are aware of the need to consider the effect of cultural differences experienced by those suffering DA to improve service delivery and understanding.

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

Recommendation 9.17

Addressed to Community Safety Partnership

To offer training to Solicitors who work on divorce, custody and contact arrangements where DA is an issue. The purpose of the training would be to improve the awareness that parental separation is a known risk factor which increases risk in DA situations and to challenge the thinking that abusive behaviour can be separated from parenting ability in the assessment of risk.

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

Recommendation 9.18

Addressed to Nationally

Consider developing DA help lines in a range of languages for those for whom English is not a first language in order to facilitate the disclosure of DA and enable access to services that aim to support and work towards protection of the victim and family.

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