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
West Berkshire review
CSP: West Berkshire
Published: April 2023
Year of death: 2014
Extracted: 26 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 highlights systemic failures in identifying the victim's increased vulnerability due to disability and the perpetrator's controlling behaviour amidst his deteriorating mental health. Concerns include inadequate inter-agency information sharing, mental health service capacity issues, and variable staff awareness of domestic abuse risks.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | We recommend that local mental health crisis services be strengthened, not only in terms of capacity to ensure swift response, but that they maintain evidence based methods for interview, assessment and response to mental health crisis. The matter of investment in these services will rest with local commissioners, but it is clear that these services must be responsive. | Newbury & District Clinical Commissioning Group | Berkshire Healthcare NHS Foundation Trust |
| 2 | We recommend that updated information and advice be provided to GPs in the recognition and treatment of mental health needs. Furthermore we recommend that BHT put in place processes for regular updating of GPs about how and in what circumstances to refer to their services. | Newbury & District Clinical Commissioning Group | Berkshire Healthcare NHS Foundation Trust |
| 3 | We recommend that the requirement to conduct Carers Assessments be re-emphasised in both health and social care and that the outcomes of such assessments be appropriately shared between professionals and agencies. | Newbury & District Clinical Commissioning Group | West Berkshire District Council | Berkshire Healthcare NHS Foundation Trust | South Central Ambulance Service NHS Foundation Trust |
| 4 | We recommend that protocols for sharing risk/safeguarding information between SCAS and social services be reviewed and strengthened in light of the deficits highlighted in the DHR. | South Central Ambulance Service NHS Foundation Trust | West Berkshire District Council |
| 5 | We recommend that GPs be advised to give consideration to services available through occupational health and employee assistance schemes provided by employers. This action would be assisted by the compilation of a list of employers in the county who provide occupational health and occupational health psychology services. | Newbury & District Clinical Commissioning Group | West Berkshire District Council |
| 6 | We recommend that health and social care professionals must wherever possible seek the views of an appropriate individual, for example spouse, carer, other relative and that this principle should be incorporated into health and social care professionals ongoing training and development. | Newbury & District Clinical Commissioning Group | West Berkshire District Council | Berkshire Healthcare NHS Foundation Trust | South Central Ambulance Service NHS Foundation Trust |
| 7 | We recommend that NHS England and the Home Office undertake work to examine the impact of the conflicting requirements of confidentiality and the Duty of Candour in the context of the conducting of Domestic Homicide Reviews and Mental Health Homicide Reviews. This case has demonstrated how these duties conflict and this places particular distress on families. The co-chairs will write to NHS England and the Home Office about this separately. | NHS England | Home Office |
| 8 | We recommend that the Home Office revise the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, to make clear the criteria that need to be met for a DHR Panel Chair to be considered fully independent. | Home Office |
| BHT 1 | It is recommended that comments about practice identified in the IMR should be considered by the relevant managers with a view to providing feedback to the staff concerned. | Berkshire Healthcare NHS Foundation Trust |
| BHT 2 | It is recommended that consideration be given to promoting awareness generally amongst practitioners, of the need to give particular attention to the identification of potential safeguarding issues where there is a combination of: (a) severity of symptoms which are persistent and not improving; (b) family members expressing distress as a result; (c) where disability may be a factor which adds to vulnerability. | Berkshire Healthcare NHS Foundation Trust |
| BHT 3 | It is recommended that policy and practice within CPE is reviewed in relation to ensuring that GPs’ specific requests for a psychiatrist’s opinion are routinely referred to a CPE psychiatrist for consideration, particularly where there is evidence of failure to respond to treatment. | Berkshire Healthcare NHS Foundation Trust |
| BHT 4 | It is suggested that processes in IAPT might be reviewed in order to ensure that any post-referral information recorded on RiO is evaluated and appropriately communicated to allocated practitioners. | Berkshire Healthcare NHS Foundation Trust |
| BHT 5 | It is recommended that policy and practice be reviewed in all teams with a view to ensuring that times of contacts are routinely entered on RiO progress notes. | Berkshire Healthcare NHS Foundation Trust |
| BHT 6 | It is recommended that staff be reminded of the need to complete the RiO Risk Assessment tool as soon as possible after an assessment and before the end of a shift. | Berkshire Healthcare NHS Foundation Trust |
| BHT 7 | The family members of the perpetrator and the victim who provided information and comments for the investigation, asked to receive a copy of the investigation report. It is suggested that consideration is given to this request and to an appropriate level of feedback. | Berkshire Healthcare NHS Foundation Trust |
| NDCCG 1 | It is recommended that in view of this tragic event, the profile and awareness of domestic abuse should be raised in general practices in Newbury & District CCG area, with training and linking in to the Safer Communities Partnership at West Berkshire Council. | Newbury & District Clinical Commissioning Group | West Berkshire District Council |
| NDCCG 2 | It is recommended that across the CCG GP Practices to hold clinical meetings to share patients with vulnerabilities (defined as patients in whom symptoms are not resolving despite usual treatment) amongst colleagues so that any GP who might consult this group of patients is fully briefed (in addition to the detailed information in the electronic record.) | Newbury & District Clinical Commissioning Group |
| NDCCG 3 | It is recommended that through this enhanced interface between clinicians in primary and secondary care, closer working on more challenging cases can take place both for the direct benefit in that case, and for wider learning. | Newbury & District Clinical Commissioning Group | Berkshire Healthcare NHS Foundation Trust |
| SCAS 1 | The current “Action Plan” template utilised in the Serious Incident Requiring Investigation (SIRI or SIs) forms part of all investigation packs within SCAS. | South Central Ambulance Service NHS Foundation Trust |
| SCAS 2 | A review of the number of staff employed within the Safeguarding department to establish if there are sufficient numbers to effectively manage current work-load from across the SCAS region. | South Central Ambulance Service NHS Foundation Trust |
| SCAS 3 | To look at the feasibility of having Vulnerable Adult / Children Safeguarding forms that SCAS staff have faxed into Safeguarding, forwarding these onto the respective Social Services agencies within the required 48 hour time frame. | South Central Ambulance Service NHS Foundation Trust |
| SCAS 4 | Staff employed within the Safeguarding Department who undertake investigations, attend an IMR Investigations and writer’s course. | South Central Ambulance Service NHS Foundation Trust |
| SCAS 5 | As a Quality Assurance process, all IMRs be reviewed by the SIRI Review Group or a specifically named sub group of the SIRI Review Group Panel, to ensure that investigations provided by any SCAS member of staff, meet the required standards as set out in the Home Office Multi-Agency Statutory Guidance for the review of Domestic Homicides. | South Central Ambulance Service NHS Foundation Trust |
| SCAS 6 | The Emergency Services Manager will discuss the complaint incident the perpetrator's ex-wife submitted with the Paramedic, with a view to obtaining a personal reflection on her personality and how that may impact upon patients. | South Central Ambulance Service NHS Foundation Trust |
| Sovereign 1 | Operating procedures are up to date and reflect good practice i. By March 2015 undertake a review of SHA’s anti-Social Behavior, Domestic Abuse and Hate Behaviour Procedure and publish a revised/updated procedure. | Sovereign Housing Association |
| Sovereign 2 | Front line housing/support staff are trained in domestic violence so they can recognise the signs and know how to respond i. By 31 March 2015 review training records for all front line housing/support staff to confirm domestic violence training has been completed in the last two years ii. From March 2015 all new SHA front line staff to complete an e-learning package ‘Understanding Domestic Abuse” within their six month probation period. iii. By June 2014 all staff delivering SHA’s new older person’s service from April 2015 to be trained on understanding domestic abuse. | Sovereign Housing Association |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||