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

Oxford review

CSP: Oxford Published: April 2023 Year of death: 2012 Extracted: 11 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 identified inadequate mental health assessment and care planning for the perpetrator, poor inter-agency communication and information sharing, and misunderstandings of legal frameworks between police and mental health services. Missed opportunities to address safeguarding concerns for the victim were also noted.

Extracted recommendations

11 recommendations pulled from the report

#	Recommendation	Addressed to
1	We recommend that TVP, OHFT and Oxfordshire County Council Social & Community Services work together, through the adult safeguarding board to ensure a co-ordinated and mutually agreed approach to the identification and appropriate referral of vulnerable adults.	Thames Valley Police \| Oxford Health NHS Foundation Trust \| Oxfordshire County Council Social & Community Services
10	We recommend that OHFT, TVP and Oxfordshire County Council Social & Community Services Directorate work together to develop an appropriate forum where practitioners and clinicians can meet to discuss issues of practice and develop solutions to local operational challenges.	Oxford Health NHS Foundation Trust \| Thames Valley Police \| Oxfordshire County Council Social & Community Services Directorate
11	We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given that the account of their childhood raises a number of potential child protection issues, which may necessitate further investigation but fall outside the scope and Terms of Reference of the DHR.	Children’s social care \| local mental health services
2	We recommend that OHFT put in place systems to ensure the appointment of a care co-ordinator in the community as early as possible after a person is admitted to hospital. The failure to do so in this case has been highlighted as an omission in the care planning process. The Trust should also put in place a process to monitor and assure senior management that this is taking place and that their current policy is being applied.	Oxford Health NHS Foundation Trust
3	We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include a clear process for determining the responsible clinician and for making any necessary changes to that responsible clinician.	Oxford Health NHS Foundation Trust
4	We recommend that a robust and clear process for communicating with GPs should be devised, in consultation with primary care colleagues and implemented as swiftly as possible so that the management of patients who are temporarily registered with a GP or do not have a GP can be improved.	Oxford Health NHS Foundation Trust
5	We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG review their current recording processes and practices and put in place measures to assure themselves that recording is of a sufficient standard and takes place in a timely manner. This should focus in particular on recording of safeguarding and risk assessment, whether this is through established case management systems, file notes or other databases.	Thames Valley Police \| Oxford Health NHS Foundation Trust \| Oxfordshire County Council Social and Community Services \| Oxfordshire Clinical Commissioning Group
6	We recommend that the OHFT and Oxfordshire County Council Social & Community Services Directorate work together to put in place information technology systems that are accessible to the staff of both organisations.	Oxford Health NHS Foundation Trust \| Oxfordshire County Council Social & Community Services Directorate
7	We recommend that OHFT review its policy and guidance in respect of patients who are AWOL or missing from hospital. We further recommend that this policy and guidance be developed with partner agencies including TVP. OHFT and TVP should agree how expert advice should be sought and how concerns should be escalated from the front line.	Oxford Health NHS Foundation Trust \| Thames Valley Police
8	We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG work together with the adult safeguarding board to identify and address training needs and necessary organisational culture change in respect of mental health legislation and its application. In doing so the organisations should develop a mechanism for better networking and relationship building of frontline police, Trust and other health and social care staff.	Thames Valley Police \| Oxford Health NHS Foundation Trust \| Oxfordshire County Council Social and Community Services \| Oxfordshire Clinical Commissioning Group
9	We recommend that the content of mandatory safeguarding training for all health and social care staff should include material and information about domestic abuse/violence. It should highlight examples of incidents that might trigger a safeguarding alert. More specialist training should be available in relation to domestic abuse	Oxford Health NHS Foundation Trust \| Oxfordshire County Council Social & Community Services \| Oxfordshire Clinical Commissioning Group
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗