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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review highlights the long-term impact of childhood domestic abuse, substance misuse, and mental health issues on both the victim and perpetrator. It identifies gaps in routine domestic abuse enquiry by some agencies, inconsistent information sharing, and challenges in safeguarding children exposed to complex family dynamics.

Home Office classifications

46 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - physical disability
  • Victim - mental ill health
  • Victim - depression
  • Victim - panic attacks
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to others 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 - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working 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 · 8 matched to organisations in the index

Recommendation 1

Addressed to Sefton Safer Communities Partnership

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;

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

Recommendation 1

Addressed to Merseyside Police

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.

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

Recommendation 1

Addressed to GPs

(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.

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

Recommendation 1

Addressed to Lancashire Care NHS Foundation Trust

Increase awareness of routine enquiry into domestic abuse across the service and Network in line with NICE Guidance February 2014

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

Recommendation 1

Addressed to Sefton Women’s and Children’s Aid

Ensure appropriate recording is in place. A particular emphasis on accurate recording of professionals involved in the case, response to risk, sharing information in a timely manner, evidence of information shared, and achieved outcomes. To ensure consistent input of information.

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

Recommendation 1

Addressed to Lancashire Children’s Social Care

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.

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

Recommendation 2

Addressed to Sefton Safer Communities Partnership

SSCP 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.

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

Recommendation 2

Addressed to Merseyside Police

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.

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

Recommendation 2

Addressed to GPs

REVIEW Practice to consider in-house meeting to discuss – with facilitation from safeguarding team if the practice wish. 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)

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

Recommendation 2

Addressed to Lancashire Care NHS Foundation Trust

Share information from post incident review across Children and Family Network via governance arrangements.

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

Recommendation 2

Addressed to Sefton Women’s and Children’s Aid

Effective recording of management oversight and case discussion arrangements

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

Recommendation 2

Addressed to Lancashire Children’s Social Care

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.

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

Recommendation 3

Addressed to Sefton Safer Communities Partnership

SSCP to 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.

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

Recommendation 3

Addressed to Merseyside Police

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.

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

Recommendation 3

Addressed to GPs

REVIEW The practice to ensure that when coding child protection issues that the other family’s records are also coded.

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

Recommendation 4

Addressed to Sefton Safer Communities Partnership

SSCP 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.

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