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

Herefordshire review

CSP: Herefordshire Published: April 2023 Year of death: 2014 Extracted: 21 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 challenges in coordinating multi-agency support for a devoted carer struggling with the victim's deteriorating health, compounded by the carer's reluctance to accept help and fragmented information sharing among services. It notes the absence of a coordinated care plan and documented risk assessments.

Extracted recommendations

21 recommendations pulled from the report

#	Recommendation	Addressed to
1	Trust to look at ways of ensuring that information leaflets for carers of patients with a diagnosis of dementia is given to all carers, in order that they are aware of how to access help if required.	Wye Valley NHS Trust
1	Deliver a learning event to the teams involved in this episode of care delivery. This will provide staff with the learning from this review and give education on the actions.	2gether NHS Foundation Trust
1	Map of Medicine needs to include the car pathway for domestic abuse	Herefordshire Clinical Commissioning Group
1	All cross boundary Nursing cases to be discussed at Clinical supervision to ensure that there is a plan to try and gain access to information.	Admiral Nursing Service
10	Provide clear guidance on the process for ascertaining that a carers assessment has been requested, and undertaken or refused, should be reviewed, including its documentation and reference to actions in RIO.	2gether NHS Foundation Trust
11	Provide additional training and guidance for the Herefordshire Memory Assessment Service and Older Persons Services regarding safeguarding information on older persons abuse issues.	2gether NHS Foundation Trust
12	Meet with Wye Valley Trust nursing lead to discuss methods for improving communication between services in light of the learning from this IMR.	2gether NHS Foundation Trust
2	Trust to look at developing a carer’s self-assessment tool that could be completed by carers of patients with dementia, in order to identify those carers who are finding it difficult to cope.	Wye Valley NHS Trust
2	Provide a Trust wide briefing on this case, detailing the observations, learning and recommendations from this individual management report. This will be communicated and Team managers will be directed to discuss in Team meetings.	2gether NHS Foundation Trust
2	The care pathway needs to be reviewed to assess whether it is fit for purpose for all age groups, amended as necessary and published on adult focused web	Herefordshire Clinical Commissioning Group
2	When Care Notes Electronic records are introduced, separate records should be created for carers who are in receipt if direct interventions from Trust services with links to the patient’s records so that other services within the Trust can have access to carer records. Separate interventions for a carer would be visible and in the case of Admiral Nurses, the involvement of the service would be clear to all who view the record.(the Admiral Nurse would still need to maintain their WANDA records)	Admiral Nursing Service
3	SBARD training will be delivered to the teams involved in this case and will also be made available to other Trust services in Herefordshire.	2gether NHS Foundation Trust
3	The CCG to include a link to the document managing pain in dementia in their next GP newsletter	Herefordshire Clinical Commissioning Group
3	Where Admiral Nursing Service are seeing carers, key points of information and concern should be actively shared with other members of the care team e.g. GP and Psychiatrist etc via telephone, email or letter as appropriate with professionals and agencies involved in the care and support of the family.	Admiral Nursing Service
4	Conduct an audit of carers assessments completion and review dates will be completed for the Herefordshire Memory Assessment Service and Older Person Services.	2gether NHS Foundation Trust
5	Conduct an audit of completion of care plans, risk assessments and crisis contingency plans for the Herefordshire Memory Assessment Service and Older Person Services.	2gether NHS Foundation Trust
6	Development work on better liaison and promotion of careers support services linked with wider Trust work in this area. This will include the development and communication of strategies to be used when reasonable support is being refused.	2gether NHS Foundation Trust
7	Review the interface between the Memory Services, Primary Mental Health Teams and Older Adults Community Mental Health Teams utilising the learning from this review.	2gether NHS Foundation Trust
8	Review the Herefordshire Memory Assessment and Older Person Services sharing of information with clinicians, patients and carers, including the practice of copying or addressing letters to patients. This will also consider the sharing of information regarding medication and care planning.	2gether NHS Foundation Trust
9	Provide clear guidance to ensure that patients and carers are offered and consistently reminded of a clear single point of contact at whatever level they are engaged, and that appropriate supporting information is given regarding planned interventions and indications for contacting services before crisis.	2gether NHS Foundation Trust
P1	West Mercia Police to amend the post grant letter to reinforce that the consent of the certificate holder for the sharing of medical information throughout the life of the certificate has been given.	West Mercia Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗