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
Sefton review
CSP: Sefton
Published: April 2023
Year of death: 2015
Extracted: 28 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 review identified systemic failures in risk assessment and management by police and probation, alongside inadequate responses to domestic abuse disclosures by police and hospital staff. Gaps in safeguarding procedures and inter-agency information sharing contributed to missed opportunities to protect the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Ensure that Patrols attending at the scene of ‘domestic abuse’ incidents are fully aware of the dangers of speaking with a potential victim in the presence of the alleged perpetrator. | Merseyside Police |
| 1 | A more investigative approach to be taken (by offender managers) in terms of Offenders with Domestic violence backgrounds. Regular FCIU checks to be undertaken regardless of whether an offender reports to being in a current relationship. | National Probation Service |
| 1 | Lifeline Sefton workers should always use the same file when an individual starts a new treatment episode, rather than closing one file and re-opening another, to ensure continuity and a full treatment history within a single file. | Lifeline |
| 1 | The adults at risk team will provide concise training to all areas on the subject of domestic abuse. The E Reader will be given to all 11B staff and followed up with face to face training Training Log will be provided Training materials will also be provided Upload the training onto DATIX | Southport and Ormskirk Hospitals NHS Trust |
| 1 | That the Ministry of Justice considers how the courts can avoid issuing electronic surveillance orders in support of bail curfews for known domestic abuse offenders, to addresses where victims of domestic abuse live. | Ministry of Justice |
| 10 | Lead to be highlighted during Safeguarding Training Electronic Communication to staff The profile of the AAR team will be raised through a media campaign across the trust | Southport and Ormskirk Hospitals NHS Trust |
| 11 | To include when capacity and consent is not relevant on the Flow Chart – e.g. when a crime has been committed Policy due for review August 2016- this incident to inform the review | Southport and Ormskirk Hospitals NHS Trust |
| 12 | Clinical Record Keeping must be adhered too – clinical records must reflect the episode of care Upload the discussions with staff onto DATIX | Southport and Ormskirk Hospitals NHS Trust |
| 13 | Letters must reflect the risks and the actions taken to mitigate the risk/ highlight further actions needed The Associate Medical Director Urgent Care | Southport and Ormskirk Hospitals NHS Trust |
| 14 | Clinical Record Keeping must be adhered too – clinical records must reflect the episode of care- RM 06 Policy for the Reporting and Management of Incidents- | Southport and Ormskirk Hospitals NHS Trust |
| 15 | The Trust has no Policy/ Pathway for Alcohol Use Disorders – Patient Safety Quality standards need to be adopted Upload the pathway | Southport and Ormskirk Hospitals NHS Trust |
| 2 | Ensure that Patrols attending at the scene of ‘domestic abuse’ incidents are aware of the content of the Storm log, in particular the comments of the informant. There should be evidence that such comments have been considered during the closure of a log. | Merseyside Police |
| 2 | Checks to be made to Prison establishment regarding visits/contact with unknown females when those with a DV history are in custody. | National Probation Service |
| 2 | The service should lead a reflective practice session with the team, focussing on working with couples when both are known to the service. Key questions for practitioners to consider should include: In what circumstances is it appropriate to follow-up independently something that one partner has told the service about the other? How should we best record risks relating to the clients in each other’s files when both are known to us? – How do we manage this for newly established couples? | Lifeline |
| 2 | Policy will be fit for purpose – to include MARAC processes/ staffs duties/ Threats to kill/ knife crime Protocol circulated devised to key areas –MARAC to be included within Safeguarding Training A protocol will be devised for the AAR team and A&E as to what steps should be taken following a patient being discussed at MARAC. This will include actions by the AAR team and the emergency care staff, both medics and nurses Upload the training and policy onto DATIX | Southport and Ormskirk Hospitals NHS Trust |
| 3 | When family members report concerns for the safety of a close relative that involve alleged ‘domestic abuse’, then positive action must be taken. This should include a full de brief of the evidence / information held by the relative and effective evidence gathering while at the scene, including house to house enquiries. | Merseyside Police |
| 3 | Increased Management oversight and discussion of Level 1 MAPPA cases with a view to increasing the level of MAPPA management if required. | National Probation Service |
| 3 | MARAC alerts amended so they are clear to staff Safeguarding Team Screenshot to be uploaded | Southport and Ormskirk Hospitals NHS Trust |
| 4 | When a ‘domestic abuse’ incident is reported, control room supervision must ensure that the communication officer handling the call has made all necessary checks of the relevant IT systems, not just the PROtect history, and informed the attending patrol of the full history of all parties concerned. | Merseyside Police |
| 4 | Domestic Violence training to be delivered via the Safeguarding Training; When Domestic Violence is reported Staff must always believe what the woman is telling them patient most risk when they leaving their partners Staff must interview the woman on her own in a quite private and safe area Inform the Domestic Violence lead The adults at risk team will provide concise training to all areas on the subject of domestic abuse. The E Reader will be given to all staff and followed up with face to face training | Southport and Ormskirk Hospitals NHS Trust |
| 5 | When a ‘domestic abuse’ incident is reported which is the first recorded between particular parties, this alone should not be judged as a factor to consider the incident as low risk. Cognisance must be taken of the ‘domestic abuse’ history of the parties with previous partners, particularly when they may have been risk assessed as ‘Gold’ or been a perpetrator of a ‘Gold’ victim and subject of the MARAC process. | Merseyside Police |
| 5 | Safeguarding Adults Policy CORP 77 staff awareness and education Safeguarding Training to include referrals process | Southport and Ormskirk Hospitals NHS Trust |
| 6 | All calls for service that initiate as domestic incidents, should be monitored and subject to scrutiny by control room supervision. The relevant Storm log must be endorsed by the supervisor to ensure compliance. | Merseyside Police |
| 6 | Safeguarding Training to include responsibilities / capacity/ consent / body mapping of injuries The Associate Medical Director Urgent Care | Southport and Ormskirk Hospitals NHS Trust |
| 7 | A patrol supervisor should be informed when a ‘domestic abuse’ incident is reported and his or her details recorded on the Storm log. The supervisor should ensure that a VPRF 1 is submitted prior to the end of the tour of duty, having quality assured it and having appended his or her name and signature. | Merseyside Police |
| 7 | Trust supports patients; we try and reduce the need for patients to go off the Ward for Cigarettes. To be discussed in meetings/ huddles – upload actions onto DATIX | Southport and Ormskirk Hospitals NHS Trust |
| 8 | Flow Chart to be reviewed so it is fit for purpose – include capacity / consent when a crime had been committed / how to send: check receipt of referrals/ referral document to be included within the Policy. Safeguarding Training to include the appropriateness of capacity / consent when a crime has been committed / hoe to make a referral and the audit trail | Southport and Ormskirk Hospitals NHS Trust |
| 9 | Staff must follow and implement the Protocol for the Missing Patient (CLIN CORP 76) and Risk Assessments must be completed The Protocol for the Missing Patient (CLIN CORP 76) is implemented and followed / reviewed and includes the suggested Contract and Risk Assessments Upload contract onto DATIX Upload the staff discussions regarding adherence to the protocol | Southport and Ormskirk Hospitals NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||