Summary AI-generated
Verify against the full report at the source link
Agencies missed multiple opportunities to identify and respond to escalating domestic violence risks, particularly around separation. This included failures in risk assessment, inter-agency information sharing, and adherence to domestic violence policies by police, social care, and other services.
Extracted recommendations
21 recommendations pulled from the report · 15 matched to organisations in the index
Addressed to
Torbay and Southern Devon Health and Care NHS Trust
The Torbay and Southern Devon Health and Care NHS Trust must ensure that all staff follow fully its procedures in respect of routine screening for domestic violence issues through management review at key points, supervision and audit.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Community Safety Partnership agencies
CSP agencies should consider whether there is a need to review compliance with routine domestic violence procedures.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Agencies in contact with families
Agencies in contact with families arriving in the area should ensure that they are informed of supportive services in their area relevant to their circumstances and assisted to access them.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Domestic Abuse risk assessment to change from DIAL to DASH and better use of lateral research database checks.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Operational Communications Department managers to ensure that all staff, regardless of role have an understanding of how to receive and record emergency calls.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire County Council Families First
In Private Fostering arrangements which are unplanned or provided in an emergency the Child Protection team based in Headquarters must be asked to include in checks: i. The LADO (local authority designated officer) database ii. PPRC (persons posing a risk to children) database iii. Checks with Staffordshire Police PPU (public protection unit) relevant to the making of an emergency or unplanned placement
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Newcastle-under-Lyme Housing Advice Services
Changes will be made to make it clear whether domestic violence is or is not identified at the housing advice interview; the Newcastle Housing Advice procedures and paperwork will be updated to include a section to complete to show if there is any evidence of DV or any statements that led the officer to believe there was an issue of safety.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Aspire Housing Association
All internal and customer facing roles will be considered and included with regard to Domestic Violence awareness and training, including Officers with specific skills or roles, e.g. sign language.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Learning and Development to make the Threats to Life Training available for all staff who have contact with public, and to monitor completion of the training package.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Operational Communications Department managers should also ensure that there is a good and comprehensive understanding of the Threat to Life Policy and the National Decision Making Model by ACR staff.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire County Council Families First
In Private Fostering arrangements there should always be consideration of any risks the child being fostered may pose to existing children in the household including carrying out lateral and other checks as appropriate and this should be emphasised in the Local Authority Policy and Procedures in relation to Private Fostering Arrangements.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
For there to be a clear protocol between IMR authors and Professional Standards investigators for speaking to staff involved in IPCC enquiries where:- 1) It is known from the outset that the IPCC have an interest in the case; 2) Where an initial scope of the case indicates that identified staff involved in the case may be subject to a disciplinary investigation
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Operational Communications Department managers ensure that ACR positions are adequately staffed to ensure operator efficiency.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
There should be a clear process and guide lines to ensure that a Managed Crime Investigation (MCI) is used only when it is appropriate to do so. Where a report involves a threat to kill someone the default position should be that the MCI process is not to be used unless a supervisor has viewed the incident and given a rationale for MCI use.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Operational Communications Department managers review the failure rate of attendance at priority incidents to establish if this can be improved upon and also to ensure that the current gradings are appropriate given the outcome of this particular case.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
Operational Communications Department managers ensure that ACR operatives are aware of their duty of care in respect of domestic abuse and threat to life incidents. It is not merely good enough to close an incident if they have any concerns or realise that appropriate accountability is not present they should notify their supervision for advice.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
The role of the Real Time Intelligence (RTI) Officers based within the ACR are explored in relation to researching force and national police systems to assist and inform risk assessments for domestic violence and threats to life incidents.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
The Investigating Officer recommends that the Domestic Abuse Policy is reviewed to ensure clear lines of supervisory accountability and ownership and this should be linked to the Threat to Life policy.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
An allegation of a threat to life or incident where there may be a threat to life or personal safety is a heavy burden to rest on the shoulders of a constable or ACR operative. The Investigating Officer recommends that the importance of supervisory accountability is disseminated to members of Staffordshire Police so that there is no misunderstanding in the application of professional judgment, no matter how low a risk assessment may, on the face of it, appear and in such circumstance supervisory accountability is an absolute requirement.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
There is an NCALT training package now available for the threats to life policy. The Investigating Officer recommends that all staff in contact with the public, intelligence and ACR operatives complete the training package, to ensure that there is robust understanding in relation to threat and risk.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Staffordshire Police
The Investigating officer recommends that the Managed Crime Incident MCI process is not adopted where ownership and accountability is required in respect of personal safety and where there may be a current or future risk to a victim. This is to avoid a silo approach in dealing with risk unless there is an identified owner of the issue who has a holistic view.
Verified wording from the published review · Original review (PDF) ↗