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: 40 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 concerns regarding the victim's increased vulnerability due to disability and the perpetrator's controlling behaviour, alongside a misdiagnosis of the perpetrator's deteriorating mental health. Key issues include fragmented care, inadequate information sharing between agencies, and insufficient safeguarding and domestic abuse awareness among professionals, exacerbated by organisational capacity strains in mental health services.
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. | Local mental health crisis services | Local commissioners |
| 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. Specific proposal: to deliver GP Support Referral Service (previously known as IRIS) training package to all 11 practices in the CCG, and to strengthen the link between the Domestic Abuse Reduction Co-ordinator and the practices. Measure of success: that all 11 practices complete GP Support Referral Service training package before the 31st March 2016, delivered by the Co-ordinator to develop professional relationships with practices. An audit of GP practices will be undertaken to demonstrate that the GP Support Referral Service training has been implemented and that refresher training is undertaken annually. | Newbury & District Clinical Commissioning Group | General practices | West Berkshire Council |
| 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. Measure of success: All staff will be aware of the IMR, its findings and recommendations. Evidence that the report findings have been shared with staff. Accountable individual: CPE – Urgent Care manager CRHTT - Head of Crisis Resolution & Home Treatment Service | Berkshire Healthcare NHS Foundation Trust |
| 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. Measure of success: An appropriately approved, reviewed and updated Sovereign Anti-Social Behaviour, Domestic Abuse and Hate Behaviour Procedure in place by March 2015 and a documented publication date to all relevant Sovereign staff, also by March 2015. Thereafter, bi-annual documented reviews and publications of the procedure. | Sovereign Housing Association |
| 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 |
| 1 | The senior management team must clarify and differentiate the purpose of the CHRTT and CPE service models and ensure both services are reviewed and remodelled, to match capability with meeting capacity. | Berkshire Healthcare NHS Foundation Trust |
| 10 | Staff should receive and be able to access consistent and high quality clinical group and 1-1 supervision. | Berkshire Healthcare NHS Foundation Trust |
| 11 | Staff should have access to motivational interviewing skills to better improve their telephone relationships with those in crisis or hard to engage clients. | Berkshire Healthcare NHS Foundation Trust |
| 12 | An escalation criterion tool should be implemented, which helps staff consistently identify current and past risk behaviours and triangulate them with other information such as concerns expressed by other professionals. This tool should be regularly audited. | Berkshire Healthcare NHS Foundation Trust |
| 13 | Risk assessments should include gathering a holistic patient history based on past mental health history, family and employment factors as well as the presenting symptoms. | Berkshire Healthcare NHS Foundation Trust |
| 14 | A greater recognition should be given to family involvement in developing treatment plans especially when the service focus is inpatient avoidance, families views and history must be included in planning effective community based care. | 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. | GPs | Berkshire Healthcare NHS Foundation Trust |
| 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.) This could take the form of Clinical Case Review discussions in house and during regular mental health meetings conducted with the local consultant psychiatrist and/or a local community psychiatric nurse, in order to tap into their expertise and clinical advice. Specific Proposal: To promote secondary care mental health consultant visits to practices (already underway) and to include the remit to discuss difficult clinical cases during those meetings Measure of Success: GPs report clinical learning on mental health cases in those meetings, using them for appraisals and continuing professional development recorded learning, as identified by self-reporting. Minutes of these meetings should be recorded and audited annually as part of overall Safeguarding procedures overseen by the named professional for Safeguarding in the CCG. | Newbury & District Clinical Commissioning Group | GP Practices |
| 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. Measure of success: Training will have been provided to mental health staff about involving families and carers in drawing conclusions about a patient’s mental health particularly where they are indicating a different view to that of the patient. Safeguarding training will also be provided to staff regarding all risk factors including disability. Training records will show compliance with training requirements. A quarterly documentation audit will demonstrate that families and carers have been involved in care planning. Accountable individual: Head of Clinical Training | Berkshire Healthcare NHS Foundation Trust |
| 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. Measures of success: All current housing / supported housing staff trained in domestic violence and individuals training records reflect this training has taken place within the last 2 years by 31 March 2015. On-line e-learning domestic violence module completed in induction periods for all new housing staff from March 2015 and Sovereign’s Safeguarding Steering Group audits confirm this. The accountable individual within Sovereign for implementation is the Housing Services Director. | Sovereign Housing Association |
| 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 |
| 2 | Another level of triage should be considered to ensure that not all calls are processed and passed through to CHRTT; some should be diverted to either social care or non-health services. | 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. | Health and social care professionals | Agencies |
| 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. Specific proposal: promote the usage of email and telephone discussion between primary care & secondary care mental health consultants, underpinned by the improved professional relationships created in recommendation two. Measure of Success: clinicians report better interface and communication with secondary care, and vice versa as identified in the annual Berkshire Healthcare Foundation Trust commissioned survey of GPs regarding their service provision | Newbury & District Clinical Commissioning Group | Primary care clinicians | Secondary care mental health consultants |
| 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. Measure of success: An audit will show that GP requests for a psychiatrist opinion are followed or the reason why this has not happened clearly documented in the patient records. A baseline measure will be taken in January and quarterly audit of 50 records will be completed to monitor compliance. Accountable individual: CPE – Urgent Care manager | Berkshire Healthcare NHS Foundation Trust |
| 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 |
| 3 | Activity levels for both of the services should be set in line with capacity, and a staff skill mix set that is appropriate against the acuity and activity presented. | Berkshire Healthcare 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 | Social services |
| 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. Measure of success: All patients upon entry to the service, including self-referrals, are now checked to see if they have a Rio history. If they do have a Rio history a summary is transferred to IAPTus - all IAPT team leads and supervisors now have access to read only Rio. A monthly random audit of cases will demonstrate this is now a robust service process –success will be measured that all RiO history has been checked where the patient is known to services in 100% of cases. Accountable individual: Clinical Director for IAPT | Berkshire Healthcare NHS Foundation Trust |
| 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 |
| 4 | Staff to be supported to develop skills in effectively responding to and managing users of the crisis service presenting with personality disorders. Working with senior staff to develop effective responses that work towards reducing high levels of phone contact. | Berkshire Healthcare NHS Foundation Trust |
| 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. | GPs |
| 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. Measure of success: A quarterly audit will show that times of contact with patient are clearly documented in the patient records. Accountable individual: Head of Crisis Resolution & Home Treatment Services | Berkshire Healthcare NHS Foundation Trust |
| 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 |
| 5 | Permanent staff should be recruited and supported to manage caseloads based upon evidence-based guidelines and ensuring patient safety at all times. | Berkshire Healthcare NHS Foundation Trust |
| 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. | Health and social care professionals |
| 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. Measure of success: Staff will be aware of the need to complete the RiO Risk Assessment as soon as possible after an assessment. A quarterly audit will demonstrate compliance with this standard. Accountable individual: Head of Crisis Resolution & Home Treatment Services | Berkshire Healthcare NHS Foundation Trust |
| 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. In order to take forward the recommendations, SCAS will issue a Clinical Memorandum. A Clinical Memorandum requires SCAS staff to adhere to specific requirements / actions / practise or guidelines as would be explained in the memorandum itself. The Clinical Memorandum is sent to each SCAS employee’s email address, and is placed onto the SCAS intranet to allow access to the document there as well. SCAS staff have an obligation to ensure that they are up to date with any Clinical or Operational Memorandums / Directives. These are also displayed on station Notice Boards to ensure maximum expose and compliance. The failure to comply with a Clinical Memorandum can result in the professional registration of that person (if s/he is a Paramedic), being placed at risk (Paramedic are registered with the Health Care Professions Council and follow a Code of Conduct). If required disciplinary action will be taken should a full internal investigation deem those actions necessary. Measures of success: The number of flagged incidents to SCAS by the Mental Health Crisis Teams / Safeguarding bodies will provide one measure of success, dependent upon the number reported to SCAS. SCAS raise between 60 and 110 safeguarding referrals a day and to so physically filtering them is not an option at this time. SCAS will of course monitor where it can and this includes external monitoring from the likes the CQC and the 36 safeguarding boards SCAS as an organisation attends. The more likely route that a breech will be identified is through the SCAS DATIX system reporting system / a complaint or concern reported by our own staff, other Health Care Professionals or the public (Patient Experience Team) with reference to Safeguarding issues, which will then be investigated accordingly. There will be an expectation that SCAS staff have/ will have read the Clinical Memorandum. It would have been sent to their work email address, which they can access at work and at home. The staff have an obligation to ensure that they update themselves and are expected to check notice boards for any new notices, memorandums and directives upon return from any length of time off / sickness etc. The memorandums, directives etc. are also retained on the SCAS intranet which even if they had deleted (by mistake) their emails, the original is always available in the respective folders. SCAS has developed an audit tool with local authority colleagues to audit safeguarding referrals. This has been adapted to undertake single agency audits so SCAS can now internally audit our referrals. This will cover specific elements of the actions/ recommendations from the DHR. With respect to other actions/ recommendation of a corporate nature SCAS expect these will take longer to address and as they complete these they will update and share the action plan. Accountable individuals: The Executive Director with responsibility for safeguarding, the Head of Safeguarding and the Assistant Director for Patient Safety and Quality. | South Central Ambulance Service NHS Foundation Trust |
| 6 | Staff welfare should receive a greater priority from senior management and a renewed focus on staff retention and health should be increased in areas with repeated high turnover with risks of staff burnout. | Berkshire Healthcare 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 |
| 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. Measure of success: Family members of the victim and the perpetrator will have received a copy of the report. Accountable individual: Director of Nursing and Governance | Berkshire Healthcare NHS Foundation Trust |
| 7 | The admission system should more fully support allocating of contacts to a team or group of individuals, versus contact with a new staff member for each service contact, to promote consistency in the response and to ensure that a trusting relationship may be developed. | Berkshire Healthcare NHS Foundation Trust |
| 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 |
| 8 | Bespoke advanced mental health telephone counselling skills must be provided for all staff and refreshed biannually. Staff should not work in these services without undertaking a competency-based training. | Berkshire Healthcare NHS Foundation Trust |
| 9 | Staff should receive training in identifying suicidal ideation that is based on an evidence-based model and includes covert signs and managing ambivalence within telephone contact. | Berkshire Healthcare NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||