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
Preston review
CSP: Preston
Published: April 2023
Year of death: 2013
Extracted: 24 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 challenges in identifying and responding to the risks posed by a carer with an undisclosed alcohol problem to a vulnerable adult with dementia. It also points to issues with inter-agency communication, care coordination, and assumptions about family dynamics.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The organisation will insist that any referral made to Day Support must be supported by an overview assessment prior to commencement. The overview assessment will/should inform appropriate staff of an individual’s needs, wishes and concerns which will provide a baseline for an individual’s personal/support plan | Age Concern Central Lancashire (Withy Trees Day Centre) |
| 1 | Use of the “abuse” question | Cheshire and Wirral Partnership NHS Foundation Trust |
| 1 | Change in procedure around reporting of bruises, marks etc. Amend current policy and procedure surrounding the reporting of any concerns. | Home Care Mellor |
| 1 | A review of governance of personal data | Lady Elsie Finney House |
| 1 | The CMHT & MAS should include both ‘main carer’ and ‘other significant carers’ for signposting to local authority for carer’s assessments. | Lancashire Care NHS Foundation Trust |
| 2 | All contacts to the centre in relation to service user non-attendance must be recorded in the individuals Personal/Support Plan, with the named communicator. | Age Concern Central Lancashire (Withy Trees Day Centre) |
| 2 | Provide assurance of the use of Clinical Assessment of Risk to Self and Others in IAPT | Cheshire and Wirral Partnership NHS Foundation Trust |
| 2 | Develop short code/key words to alert office/staff member of an incident. Universal key words to be agreed upon. | Home Care Mellor |
| 2 | The podiatrists should ensure care plans are in their clinical records | Lancashire Care NHS Foundation Trust |
| 3 | Raise awareness of domestic abuse, recognition and signposting | Cheshire and Wirral Partnership NHS Foundation Trust |
| 3 | Further training on Domestic Violence. | Home Care Mellor |
| 3 | The MAS complete a risk assessment for patients during assessment. | Lancashire Care NHS Foundation Trust |
| 4 | Improved documentation. Introduce a new standard of working with regard to documentation. Best practice guidelines for documenting. | Home Care Mellor |
| 4 | The waiting times for MAS should decrease as a result of reviewed care pathways and efficient working practices. | Lancashire Care NHS Foundation Trust |
| 5 | The CMHT should be given clearer guidance about rating referral information and working to agreed timescales to action a referral to assessment completion. | Lancashire Care NHS Foundation Trust |
| 6 | The CMHT clinicians should be more aware of how and where to carry out the most accurate and informative assessments | Lancashire Care NHS Foundation Trust |
| 7 | Explore both the risk to the patient and the risk presented to others by the patient thoroughly. | Lancashire Care NHS Foundation Trust |
| 8 | The CMHT should be given clearer guidance about rating referral information and working to agreed timescales to action a referral to assessment completion. | Lancashire Care NHS Foundation Trust |
| 9 | If a case is discussed in supervision a note should be made in the patients clinical record to record the supervision outcomes and agreed action if any. | Lancashire Care NHS Foundation Trust |
| R1 | All home care workers are required to undertake basic training in recognition and referral of concerns. | Home Care Mellor |
| R2 | All home care workers are offered regular opportunities for reflective supervision | Home Care Mellor |
| R3 | The home care agency institutes a means of monitoring the effectiveness of training and supervision | Home Care Mellor |
| R4 | That the LASB be asked to assure itself that all organisations in Lancashire providing personal care to adults at risk have in place arrangements for training and supervision of workers. | Lancashire Adult Safeguarding Board (LASB) |
| R5 | That commissioners of health and home care services are asked to ensure that their contract monitoring arrangements include the monitoring of training, supervision and compliance with safeguarding procedures. | Commissioners of health and home care services |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||