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 LincolnshirePublished: April 2023Year of death: 2014Extracted: 17 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.