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

Lancaster review

CSP: Lancaster Published: April 2023 Year of death: 2013 Extracted: 35 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 highlights concerns regarding the assessment and management of the perpetrator's emerging psychotic illness, including the prioritisation of face-to-face mental health assessments and communication between primary and secondary care. It also identifies gaps in routine screening for domestic abuse and social isolation, and the thoroughness of inquiry and documentation for injuries in emergency settings.

Extracted recommendations

35 recommendations pulled from the report

#	Recommendation	Addressed to
1	I would recommend that the practice considers incorporating these into its computer templates. This should be preceded by general training on identification and management of disclosures of domestic violence so that the questions would only be asked in the appropriate setting and manner. Such risk factors may be picked up if enquiries are made about wider social circumstances at routine checks and again I would recommend that consideration is given to the incorporation of this.	GP Practice
1	If bruising is noted that indicated a suspicion or potential domestic abuse, questioning of the adult victim should happen as soon as possible.	Blackpool Teaching Hospital NHS Foundation Trust
1	Continue to raise awareness of signs of domestic abuse via safeguarding training	Southport and Ormskirk Hospitals NHS Trust
1	The referral form is in need of review to ensure areas of identified risk are focussed and of an assured standard. This will include recording and training aspects.	Lancashire Care NHS Foundation Trust
1	Awareness raising session for staff on Domestic Abuse and the effects on children especially early years children and babies and the effects on women. (How to spot potential signs and gain support access for parents and children.)	Kindergarten
1	Third party reporting of Domestic Abuse to be written into the new DASH Policy and Supporting Procedures currently under review.	Lancashire Constabulary
1	To set up archive evidence index for safeguarding.	University Hospitals of Morecambe Bay NHS Foundation Trust
2	I would recommend that consideration is given to incorporating the two screening questions into all chronic disease reviews.	GP Practice
2	Domestic abuse training that will address the importance of providing contact details of Women's Aid when domestic abuse is suspected but denied.	Blackpool Teaching Hospital NHS Foundation Trust
2	Ensure information is available regarding domestic abuse for patients in the accident and emergency departments.	Southport and Ormskirk Hospitals NHS Trust
2	That triage information is recorded on the clinical record system (rather than added to referral form). Citing who has provided the information.	Lancashire Care NHS Foundation Trust
2	E learning CP training for all staff annually rather than the 3 yearly updates at present this would go above and the current recommendations within the EYFS guidance	Kindergarten
2	Specific training from Woman’s Aid on domestic abuse to continue to support A+E staff and Midwives and develop skills in the issue of Domestic Violence.	University Hospitals of Morecambe Bay NHS Foundation Trust
3	Currently the practice has neither a formal nor informal arrangement for regular information sharing with the attached Health Visitors. Consideration should be given to implementing regular two way communication	GP Practice
3	Ensure all health visitors and school nurses aware of the most recent guidance from DOH 2013 health visiting and school nursing programmes, no.5 Domestic Violence and Abuse Professional Guidance	Blackpool Teaching Hospital NHS Foundation Trust
3	Staff are aware of the importance of documentation and the need for a full history and details of attendance.	Southport and Ormskirk Hospitals NHS Trust
3	That consideration should be given to the use of multi-disciplinary working, increased access to clinical discussion.	Lancashire Care NHS Foundation Trust
3	UHMBFT A+E to work with Lancaster Women’s Aid to raise the awareness of the support available to victims of Domestic abuse.	University Hospitals of Morecambe Bay NHS Foundation Trust
4	I would recommend that consideration is given as to whether disclosures such as this should prompt any further enquiries.	GP Practice
4	Record keeping training - looking at basic entry details such as time of visits/contacts and also completion of the record regarding information about fathers/significant males living in a household.	Blackpool Teaching Hospital NHS Foundation Trust
4	To develop the Domestic Violence Link Nurse at Southport Accident and Emergency Department	Southport and Ormskirk Hospitals NHS Trust
4	To review the potential for isolation in the current environment of the Single Point of Access team in Lancaster and Morecambe – small office, lone working	Lancashire Care NHS Foundation Trust
4	UHMBFT clinical service team to work with the local MAPPA coordinator to strengthen information sharing of individuals who pose a risk to the others who may access care from UHMBFT.	University Hospitals of Morecambe Bay NHS Foundation Trust
5	I would recommend that practitioners when they receive an Emergency Department discharge for a child or adult ask themselves whether there may be safeguarding concerns. In the case of injury to an adult which arouses suspicion of domestic violence the "child behind the adult" should be considered and an appropriate risk assessment made.	GP Practice
5	Review the Accident and Emergency Domestic Violence protocol to include routine questioning	Southport and Ormskirk Hospitals NHS Trust
5	To review the interface with CRHT re referrals for urgent assessments.	Lancashire Care NHS Foundation Trust
6	I would recommend that risk to others is not only considered but specifically documented in Mental Health consultations as we already do for risk of self-harm.	GP Practice
6	To understand the capacity of urgent referrals and the use of telephone triage	Lancashire Care NHS Foundation Trust
7	Consider whether the Blue Light 71 needs to be revised to ensure risks and vulnerabilities are understood.	Lancashire Care NHS Foundation Trust
7a	In my opinion it would be good practice to make inquiries as to who lives in the household as this may raise safeguarding issues.	GP Practice
7b	All practice staff should have the relevant safeguarding training as recommended by the Intercollegiate Guidance for Safeguarding Competencies (2010). Staff should have training commensurate with their responsibilities - level 1 for all practice staff, level 2 for practice nurses and although GPs only require level 2 training for revalidation it is recommended that they undergo level 3 training as this includes multi-agency working relevant to their everyday practice.	GP Practice
8	To review stepped care model and the concept of resources influencing pathways.	Lancashire Care NHS Foundation Trust
8a	Where there is a change in the original care plan such as this, then that information should be communicated back to the referrer to ascertain whether this is acceptable as the referrer is the person who has actually seen the patient.	Mental Health service
8b	Communication in general between the practice and Mental Health team should be looked at to enable any other potential problems to be identified.	GP Practice \| Mental Health team
9	I would recommend that the responsible CCG considers implementing this as a matter of urgency.	CCG
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗