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 Extracted: 18 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 highlights the unrecognised risk of fatal violence between non-intimate family members, exacerbated by a history of childhood domestic abuse, substance misuse, and mental health issues for both individuals. It also notes gaps in inter-agency information sharing and risk assessment regarding complex family dynamics.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
1	That Sefton Safer Communities Partnership (SSCP) raise with Merseyside Local Criminal Justice Board (LCJB) the issue of the disclosure of expert health reports and request the LCJB consider whether, when such reports are commissioned by the court, the defence or the prosecution, steps can be taken to ensure they are also provided to the subjects GP;	Sefton Safer Communities Partnership (SSCP)
1	When it is identified that a person involved in a ‘domestic incident’, is suspected of suffering with mental health issues, then that person must be referred to Adult Social Services.	Merseyside Police
1	Increase awareness of routine enquiry into domestic abuse across the service and Network in line with NICE Guidance February 2014	Lancashire Care NHS Foundation Trust
1	Alerts for domestic violence victims	Southport and Ormskirk NHS Trust
1	Ensure appropriate recording is in place.	Sefton Women’s and Children’s Aid
1	That a briefing is completed in relation to the learning from this IMR which is shared with all Team and Practice Managers within Lancashire Children’s Social Care for inclusion on team briefings with front-line practitioners. In particular this will highlight:  The need for accurate and clear recording in relation to the action taken when following up any safeguarding concerns.  That risk assessments must clearly identify the risk posed by an adult to a child and how this will be managed, in order to ensure children are appropriately safeguarded.  The requirement that Social Workers regularly see both parents as part of their ongoing assessment of the safety and well-being of children subject to home placement arrangements.  The need to undertake an assessment of siblings of the same household where a child is subject to home placement regulations.  The requirement to hold Child in Need Reviews in accordance with procedural requirements and to hold a Child in Need Review where consideration is being given to stepping down the case to universal services.	Lancashire Children’s Social Care
1 (NEW)	GPs and practice nurses to embed routine questioning about domestic abuse into consultations – particularly in ante natal and post-natal situations and in mental health presentations.	GPs
2	Work with partner agencies, and request them to review their own services in respect of domestic abuse and ensure they meet the needs of persons with similar issues to the victim. In particular as a child who had himself survived abuse and as someone who suffered with drugs, alcohol and mental health problems through his adolescent and adult years.	Sefton Safer Communities Partnership (SSCP)
2	When dealing with repeated low key ‘domestic incidents’ that involve alcohol abuse as a continued factor, then interventions and referrals to other agencies must be considered.	Merseyside Police
2	Share information from post incident review across Children and Family Network via governance arrangements.	Lancashire Care NHS Foundation Trust
2	Effective recording of management oversight and case discussion arrangements	Sefton Women’s and Children’s Aid
2	The learning from this IMR will be shared with IROs at a team learning and development event. Specific consideration to be given to decision making in child protection conferences and the criteria for making a child subject to a Child Protection Plan.	Lancashire Children’s Social Care
2 REVIEW	Practice to ensure that safeguarding concerns are routinely considered for the “child behind the adult”, particularly when toxic trio risk factors are present in the adult they are seeing (or reading correspondence about)	GPs
3	Share the findings of this review as a case study with other agencies so as to ensure they recognise the long term impact of domestic abuse on children and understand the impact it can have upon them and their behaviours as they reach maturity.	Sefton Safer Communities Partnership (SSCP)
3	Consider changes to the manner in which the Force records the part played by individual parties involved in ‘domestic incidents’ to encompass the situation when there is no clear victim or perpetrator.	Merseyside Police
3	Share learning from agency and Homicide Review.	Sefton Women’s and Children’s Aid
3 REVIEW	The practice to ensure that when coding child protection issues that the other family’s records are also coded.	GPs
4	Ask the Home Office whether they are able to identify the profile of offenders that have committed a domestic homicide (i.e. age, sex, relationship) and whether there are any emerging patterns such as an increase in the number of siblings who commit such offences.	Sefton Safer Communities Partnership (SSCP)
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗