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

North Lincolnshire review

CSP: North Lincolnshire Published: April 2023 Year of death: 2014 Extracted: 17 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review highlights missed opportunities to identify the victim's vulnerability and engage him with domestic violence services, as he was primarily seen as a perpetrator. It also notes inadequate risk assessments, particularly regarding alcohol use and separation, and the perpetrator's manipulation of services.

Home Office classifications

37 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • 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 - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - police recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes

Extracted recommendations

17 recommendations pulled from the report · 10 matched to organisations in the index

Recommendation 8.3

Addressed to Humberside Police

The learning from this case around the submission and detail of Domestic Violence Forms should be included in the Domestic Violence training currently being delivered to all front-line staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.5

Addressed to National Probation Service

Details of domestic abuse history obtained from Humberside Police are routinely recorded in the Non-Disclosure Section of OASys, as well as in the Case Management System in order to ensure that this information is flagged to any member of staff who may need to access the case record. It is a recommended action that this guidance should be issued within the next 3 months.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.6

Addressed to National Probation Service

Details of the purpose and requirements to complete Spousal Assault Risk Assessments (SARA) are reissued to all staff to ensure understanding of appropriate use and review of these assessments, to ultimately inform the OASys Risk Management Plan and Sentence Plan.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.7

Addressed to National Probation Service

Home Visit Guidance is reviewed and re-issued to all staff in order to reiterate the importance of home visits and the purpose of them in identifying and addressing risk factors, particularly in child and adult safeguarding cases.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.8

Addressed to National Probation Service

Guidance to be formally issued to staff to ensure that in all cases where there are concerns regarding arson, that contact is made with Humberside Fire and Rescue where there is a change of address. This is particularly important where such cases do not fall under the remit of MAPPA.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.9

Addressed to National Probation Service

Guidance to be issued to staff in relation to the importance of maintaining communications with Children’s Social Care in child safeguarding cases, particularly where the Offender Manager is undertaking a review of the risk assessment.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.10

Addressed to National Probation Service

Information to be provided to staff in relation to the importance of clear and accurate recording on the case record of all offenders in order to ensure that all contacts, and work undertaken are evident to any authorised individual accessing that record.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.11

Addressed to National Probation Service

OASys Risk Assessment Guidance to be reviewed and cascaded to all staff to enhance the quality of such assessments.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.13

Addressed to It’s My Right

Follow up screening for IDVAs when depression or suicidal thoughts are disclosed should be considered.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.15

Addressed to It’s My Right

Programmes should be made are available to enable perpetrators of domestic abuse to address their behaviours

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.16

Addressed to It’s My Right

A more flexible Freedom Programme for those that work shifts or can attend infrequently should be considered.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.19.1

Addressed to Rotherham, Doncaster and South Humber NHS foundation Trust (RDaSH)

Staff should clearly consider the policy regarding assessment and domestic abuse when assessing service users and relate this to practice. The policy relating to assessment clearly states to consider domestic abuse issues. Staff must record discussions about domestic abuse when there is a reported escalation in arguments in the home and offering advice and support regarding domestic abuse services. It should be noted that ‘low level’ abuse such as verbal abuse and arguments have been factors in other domestic homicide reviews with no other preceding factors of violence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.19.2

Addressed to Rotherham, Doncaster and South Humber NHS foundation Trust (RDaSH)

RDaSH will review this policy /practice issue via an internal audit of clinical records that is in place at the moment to ensure staff are considering the current policy and translating that into practice. This will be aligned with further guidance to staff regarding the recognition of male victims in domestic abuse and the recognition of low-level abuse signs such as an increase in arguments or verbal abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.20.1

Addressed to North Lincolnshire Council Housing Advice Team

Lack of a single IT system – even across council departments prevents effective sharing of data and intelligence on those at risk of DV or identified as being likely to offend. Access to the ‘Care first’ system for HAT would help break down some silo working and assistance in the sharing of intelligence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.21

Addressed to North Lincolnshire Council Housing Advice Team

HAT’s ability to assist the perpetrator was significantly hampered by her past convictions and rent arrears. There should be an agreed process across all departments for being able to specifically assist clients identified as being at risk from DV but with no chance of getting social housing.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8.23.1

Addressed to North Lincolnshire Safer Neighbourhoods Partnership

There is an issue of a single incorporated computer system to allow agencies to ascertain what information is available or where it can be identified and signposted. The recommendation is to examine the feasibility and determine if this is a strategic way forward for the partnership.

Verified wording from the published review · Original review (PDF) ↗