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
Chiltern review
CSP: Chiltern
Published: April 2023
Year of death: 2015
Extracted: 51 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 identifies systemic challenges in managing complex cases involving co-occurring domestic abuse, mental health issues, and substance misuse, particularly concerning risk assessment for male victims and inter-agency information sharing.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| BCC Recommendation 1 | Parenting assessments on adults resulting in significant findings should be recorded and accessible when relevant. | Head of Children Social Care |
| FH NHS Recommendatio | To include men as victims of domestic abuse in the content of the organisation’s domestic abuse training. | Frimley Health NHS Foundation Trust | Buckinghamshire Healthcare Trust |
| FH NHS Recommendatio | Update the Domestic Abuse Policy to reflect current legislation and guidance. | Frimley Health NHS Foundation Trust | Buckinghamshire Healthcare Trust. |
| FH NHS Recommendatio | To raise awareness of the Emergency Department domestic abuse flowchart. | Frimley Health NHS Foundation Trust | Buckinghamshire Healthcare Trust. |
| FH NHS Recommendatio | To complete a Trust Domestic Violence Training needs analysis | Frimley Health NHS Foundation Trust |
| FH NHS Recommendatio | Develop a Trust Domestic Violence training strategy identifying specific levels of training required for identified staff groups/ clinical areas. | Frimley Health NHS Foundation Trust |
| L&Q Recommendation 1 | L&Q Housing to maintain awareness of cases and contribute to MARAC where appropriate. | L&Q |
| Panel Recommendation | Any agency can arrange a professionals’ meeting when there is a need for a collaborative response. | Chair of the D&CV Strategy Group |
| Panel Recommendation | Department of Health to consider a central database for hospitals to access accurate and timely information about treatments and medications a patient has received when attending either their GP or another hospital. | Department of Health |
| Panel Recommendation | To undertake a review of information and advice available to men about Domestic Abuse locally and nationally. | Chair of the D&CV Strategy Group |
| Panel Recommendation | Thames Valley Police to review the TVP Safeguarding Policy which is currently dated 15/10/2009. | TVP |
| Panel Recommendation | SCAS to review the Service guidance on requesting Police attendance for 999 calls where there is a concern about safety of staff or violence is possible. | SCAS |
| Panel Recommendation | Individual agencies are responsible for submitting MARAC referrals regardless of whether other agencies have referred. | BCC Community Safety Team and MARAC Chair. |
| Panel Recommendation | To review guidance for risk assessment information for Information Research Bureau (IRB) staff. | Thames Valley Police |
| Panel Recommendation | Services which deal with clients who have complex needs are signposted towards the e-learning package for Complicated Matters – Domestic and Sexual Violence, Problematic Substance Misuse and Mental Ill-Health. | Countywide D&CV Strategy Group |
| Panel Recommendation | Review and improve the process of information sharing between CMHT (Community Mental Health Team) and inpatient services. | Oxford Health NHS Foundation Trust |
| Panel Recommendation | GP practices which receive correspondence about patients who are not registered with them should contact the sender to advise them of this. | GP Safeguarding Team - Clinical Commissioning Group. |
| Panel Recommendation | To ensure follow up letters to GP practices are sent and recorded. | Oxford Health NHS Foundation Trust |
| Panel Recommendation | BCC Children’s Services undertakes a review of the processes for recording and indexing information received and of referrals made, to ensure that key information is recorded and acted on appropriately. | BCC Childrens’ Services |
| Panel Recommendation | Review Chaperoning Policy to ensure that all domestic abuse victims, regardless of gender, have an opportunity to have a private consultation. | Buckinghamshire Healthcare Trust | Frimley Health NHS Foundation Trust |
| SCAS Recommendation | SCAS to implement a process to engage with MARAC. | SCAS |
| SCAS Recommendation | Ensure that all SCAS staff are trained to a level commensurate with their role in Adult Safeguarding. | SCAS |
| SCAS Recommendation | To provide assurance that the new Electronic Patient Records system is being followed appropriately. | SCAS |
| SCAS Recommendation | SCAS to review the provision of mental health expertise within the Emergency Call Centre | SCAS |
| SMART Recommendation | Provision of domestic abuse and MARAC training to all SMART teams. | SMART – Service Manager |
| SMART Recommendation | Training on risk assessment delivered to all SMART staff within the local team meeting schedule. | SMART– Service Manager |
| SMART Recommendation | All SMART staff to be aware of the local domestic abuse champions/ leads within their service and referral pathways where there are concerns or disclosure. | SMART– Service Manager |
| SMART Recommendation | Develop Information Sharing and recording processes from MARAC meetings involving service users. | SMART– Service Manager |
| SMART Recommendation | SMART & STARS to develop integrated working practices over recording and sharing information about MARAC cases. | SMART & STARS |
| SMART Recommendation | A review of record keeping practices should be undertaken across the organisation to ensure consistent quality of case notes and record storage. This is to be initially undertaken via local case notes file audits | SMART– Service Manager |
| SMART Recommendation | Targeted and proactive outreach work should be employed with service users identified as having multiple and complex needs. | SMART– Service Manager |
| STARS Recommendation | Audit and improvement plan to be carried out to ensure all reviews are carried out in line with agreed pathways of care. | South Staffordshire and Shropshire Healthcare Trust – STARS. Clinical Lead, Inclusion |
| STARS Recommendation | All staff to complete child protection training commensurate with their role. | South Staffordshire and Shropshire Healthcare Trust – STARS. Service Lead Inclusion Buckinghamshire |
| STARS Recommendation | Team leaders attending MARAC to record the MARAC discussions in the client record on ILLY and feedback information from keyworkers. | South Staffordshire and Shropshire Healthcare Trust – STARS. Service Lead Inclusion Buckinghamshire |
| STARS Recommendation | Inclusion services to develop processes to inform the client’s GP of involvement with services. | South Staffordshire and Shropshire Healthcare Trust – STARS. Service Lead Inclusion Buckinghamshire |
| TVP Recommendation 1 | Thames Valley Police to review its capacity to manage high risk domestic abuse victims. This should look at the recent increase in victims being assessed as high risk and the reasons behind this. | D/Supt – Crime and PVPSU (TVP) | D/Supt – PVP Operations |
| TVP Recommendation 1 | Thames Valley Police to clarify roles and responsibilities of custody officers when detaining a person pending a mental health assessment. | Criminal Justice Supt |
| TVP Recommendation 1 | All custody officers to complete the mental health training module ‘Safer detention’ which relates to detainees who are suspected of suffering from mental health issues. | Criminal Justice Supt |
| TVP Recommendation 1 | Neighbourhood Policing Teams to record any actions (multiagency or otherwise) taken as part of safety planning for a Domestic Abuse victim in the victim’s Risk Management Occurrence on NICHE. | D/Supt– C&PVPSU |
| TVP Recommendation 2 | Thames Valley Police to ensure compliance with the SOP requirement for DAIU DI’s to review high risk domestic abuse cases within 72 hours. | D/Supt – Crime and PVPSU (TVP) | D/Supt – PVP Operations |
| TVP Recommendation 3 | Thames Valley Police to provide guidance in relation to what a holistic supervisory review of a high risk domestic abuse victim should include. | D/ Supt – Crime and PVPSU |
| TVP Recommendation 4 | Thames Valley Police to ensure there is clarity for MARAC Co-ordinators and DAIU staff of the process and responsibilities for repeat referrals into MARAC. | D/Supt – Crime &PVPSU |
| TVP Recommendation 4 | Thames Valley Police to develop a system through NICHE/MINERVA (record management system) to alert the DAIU Detective Inspectors when a high risk domestic abuse victim’s review is required. | Performance Management Lead | D/Supt – C&PVPSU | D/Supt – Force Change |
| TVP Recommendation 5 | Thames Valley Police to ensure MARAC co-ordinators include a summary of MARAC discussions and actions in the Risk Management Occurrence. | D/Supt – Crime & PVPSU |
| TVP Recommendation 6 | Thames Valley Police MARAC co-ordinators to provide a list of allocated actions following MARACs within three working days. | D/Supt – Crime & PVPSU |
| TVP Recommendation 8 | Domestic Abuse Risk Assessors training to include the risks of gender bias and the risks associated with dual perpetrators. | D/Supt – Crime &PVPSU | D/Supt – PVP Operations |
| TVP Recommendation 9 | Thames Valley Police to support and develop consistent practice of Domestic Abuse Risk Assessors. | D/Supt Crime and PVPSU (TVP) | D/Supt – PVP Operations |
| WWA Recommendation 1 | To implement operating procedures for staff to follow when providing services. | Manager Wycombe Women’s Aid |
| WWA Recommendation 2 | The IDVA Manager to ensure that notes are taken and kept of all group case management meetings. | Manager Wycombe Women’s Aid |
| WWA Recommendation 3 | The IDVA Manager to regularly audit random case files to establish consistency and conformity of the service provided by the IDVA team. | Manager Wycombe Women’s Aid |
| WWA Recommendation 4 | Wycombe Women’s Aid Leadership Team to consider further ways of engaging with clients who are hard to reach. | Manager Wycombe Women’s Aid |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||