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
Bolton review
CSP: BoltonPublished: April 2023Year of death: 2012Extracted: 9 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report identifies systemic failures in multi-agency information sharing, risk assessment, and coordination, particularly regarding the perpetrator's unsupervised release from prison and the victim's obscured status as a domestic violence victim. Opportunities for MARAC referrals were missed, and a narrow agency focus impeded safeguarding efforts.
Home Office classifications
46 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - alcohol misuse
Victim - substance misuse
Victim - housing issues
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - living with victim (including adult children)
Children - present at homicide (including adult children)
Children - subject to child protection or domestic abuse prior to homicide
Children - removed into care
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - housing issues
Perpetrator - mental ill health
Perpetrator - suicide attempts
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 probation services as a domestic abuse perpetrator
Perpetrator - known to housing services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - attended drug and alcohol services
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - sexual abuse
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - idva or other domestic abuse support service recommendations
DHR process - probation services recommendations
DHR process - community safety partnership recommendations
DHR process - technology systems recommendation themes
DHR process - identification of risk 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
That the narrow single agency focus which impeded efforts to safeguard Adult A is comprehensively challenged. When the Bolton Domestic Violence Strategy is revised it should set out in the clearest possible terms expectations that colleagues are expected to take a holistic approach, work effectively together and share information so that risks are accurately assessed and professionally managed.
That the range of single agency plans to improve information sharing are monitored by Bolton Community Safety Partnership to ensure that information sharing necessary to safeguard the victims and potential victims of domestic violence is as effective as possible. In order to fulfil this recommendation the Community Safety Partnership should consider focussed audit activity.
That Bolton Community Safety Partnership assures itself that the individual agency failings identified in this Domestic Homicide Review are remedied by monitoring of single agency action plans. Where system failings are apparent, the Partnership gains assurance that systems have been put in place or existing systems strengthened to prevent a recurrence of the failings identified by this Review.
That Bolton Community Safety Partnership write to the Home Office to propose an analysis of the Domestic Homicide Reviews completed so far in an effort to identify the reasons why a number of domestic homicide cases are unknown to the MARAC process. This analysis could then be used to further develop and enhance the MARAC process.
That the procedure by which cases are referred to the MARAC process is reviewed to ensure that cases are not overlooked because they do not obviously fit the criteria and that the scope for referring cases on the grounds of professional judgement is reinforced.
That Greater Manchester Probation Trust review its use of RAMA in cases where high risk offenders will be released at sentence expiry date, and to put a further stage in the process where a RAMA should take place a few weeks prior to release to ensure that a risk management plan is in place, agreed by all agencies.
That multi-agency and single agency domestic violence training is informed by this case. In particular, the issues raised in paragraphs 8.61(contrasting decisions in respect of Adult A and Adult F), 9.8 (“forensic curiosity”) and 9.9 (the obscuring of Adult A’s status as a victim) should be addressed in such training.
That Bolton Community Safety Partnership work with partners to improve the planning and co-ordination of work carried out across a range of agencies to challenge the behaviour of violent and aggressive offenders.
That Bolton Community Safety Partnership ensure that all staff who have roles in safeguarding the victim of domestic violence are able to readily access information about the range of refuge provision available.