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
Durham review
CSP: Durham
Published: April 2023
Year of death: 2012
Extracted: 46 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 report identifies systemic failures in inter-agency information sharing and communication, leading to missed opportunities for intervention in domestic abuse and child safeguarding. Concerns include inadequate firearms licensing procedures, lack of holistic risk assessment, and insufficient support for victims and children exposed to parental alcohol misuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Safe Durham Partnership Board (SDPB) through the Domestic Abuse Focus Executive Group (DAFEG) develops a protocol to deal with DHR’s including timescales and processes that all of the partners sign up to and adhere to. | Safe Durham Partnership Board |
| 10 | The Safe Durham partnership explore with other police forces and partnerships nationally including Co-ordinated Action Against Domestic Abuse (CAADA), for an innovative way to capture third party reporting in relation to DA. | Safe Durham Partnership |
| 10.1.1 | The NTHFT should ensure that relevant learning identified in this Domestic Homicide Review is shared with staff working in relevant areas within the Trust | North Tees and Hartlepool Foundation Trust |
| 10.1.2 | The NTHFT should ensure staff working in the A/E departments and Minor Injury Units within the Trust are aware of the importance gathering all relevant information from victims of domestic abuse and that they provide victims with appropriate information on how to access support services | North Tees and Hartlepool Foundation Trust |
| 10.1.3 | The NTHFT to seek confirmation/assurance from their training provider that considering the potential risks to children living in families where domestic abuse has been identified should continue to be an integral part of safeguarding children training | North Tees and Hartlepool Foundation Trust |
| 10.2.1 | To undertake a full review of all firearms’ certificate holders to ascertain if any are perpetrators of domestic abuse or have been previously identified as such. This action is currently underway. | Durham Constabulary |
| 10.2.10 | Police system checks- systems to recover all information about a certificate holder. | Durham Constabulary |
| 10.2.11 | Medical information- interpretation of medical conditions / medications and risk, consent Vs honest disclosure. | Durham Constabulary |
| 10.2.12 | Risk assessment of new firearms licence applications. | Durham Constabulary |
| 10.2.13 | Impact of Service level agreements. | Durham Constabulary |
| 10.2.14 | Public Confidence. | Durham Constabulary |
| 10.2.15 | Manage on going risks- police tactics going forward. | Durham Constabulary |
| 10.2.16 | Record keeping- consistent/ accurate record keeping. | Durham Constabulary |
| 10.2.17 | Training and development of licensing staff. | Durham Constabulary |
| 10.2.2 | Durham Constabulary to finalise a firearms review once the independent report is received from the IPCC. | Durham Constabulary |
| 10.2.3 | The Safe Durham Partnership to consider innovative ways of third part reporting. The DA executive Group is to oversee a working group. | Safe Durham Partnership |
| 10.2.4 | Durham Constabulary needs to complete the awareness campaign for front line officers of what services are available to victims of domestic abuse. | Durham Constabulary |
| 10.2.5 | Staffing-Licensing function to be part of constabulary’s operational core business, with long term investment of operationally capable staff. | Durham Constabulary |
| 10.2.6 | CRU- Ensure risk based approach through effective use of police/partner agency information. | Durham Constabulary |
| 10.2.7 | On-going risk assessment- Ability to identify policing activity involving firearms certificate holders. | Durham Constabulary |
| 10.2.8 | Domestic abuse-framework based on risk using constabulary’s experts and a robust response. | Durham Constabulary |
| 10.2.9 | Information technology- Force’s systems support firearms licensing. | Durham Constabulary |
| 10.3.1 | The Safeguarding lead(s) within each clinical commissioning group for each GP practice needs to be made aware of existing training and updated when new opportunities arise so that they are able to cascade this information to the practice team. | NHS County Durham and Darlington |
| 10.3.2 | A ‘Quick Reference Guide’ to be developed by the author of the IMR and disseminated to all local surgeries via their safeguarding lead(s) which will include the recommendation that practices identify at least one member of staff to take a lead on domestic abuse. | NHS County Durham and Darlington |
| 10.3.3 | A mechanism needs to be established by the author of the IMR report to ensure that key information such as this is brought to the attention of front line professionals via the Safeguarding lead(s) at the practice. | NHS County Durham and Darlington |
| 10.3.4 | The PCT and clinical commissioning groups needs to ensure that the future commissioner(s) of counselling services for Primary Care consider this issue and includes the requirement that counsellors contracted to provide this service attend formal Safeguarding Children Training in line with the intercollegiate Guidance (RCPCH 2010) | NHS County Durham and Darlington |
| 10.4.1 | To ensure appropriate literature and contact numbers are available for those affected by domestic abuse. | County Durham and Darlington Foundation Trust |
| 10.4.2 | To ensure Safeguarding Children’s training captures the importance of considering risks to children where domestic abuse is known. | County Durham and Darlington Foundation Trust |
| 10.4.3 | To identify a domestic abuse lead/champion within the Urgent Care Centre(s) | County Durham and Darlington Foundation Trust |
| 10.4.4 | Practitioners are to be trained to at least level 3 Safeguarding Children | County Durham and Darlington Foundation Trust |
| 10.4.5 | To ensure that lessons learnt are shared across the organisation. | County Durham and Darlington Foundation Trust |
| 11 | The Safe Durham Partnership Board should consider the opportunity to establish priority stakeholder workshops to examine this DHR as a case history from reporting to conclusion in a useful table-top exercise. | Safe Durham Partnership Board |
| 12 | The Housing Solutions Service should explore the development of a protocol which supports the effective information exchange with the Police Domestic Abuse Service. | Durham County Council Housing Solutions Service |
| 2 | The Safe Durham Partnership, through the Domestic Abuse Forum Executive Group has already considered the VAWG action plan; they should review the activity that they are taking to implement this action plan across County Durham. | Safe Durham Partnership |
| 3 | The Safe Durham Partnership Board should review its existing information sharing protocol and ensure it is fit for purpose in relation to domestic abuse and firearms licencing. Consideration should be given to the inclusion of specific addendums that include what information is to be shared by whom and under what circumstances and so that those expectations are clear to all staff. | Safe Durham Partnership Board |
| 4a | The Central Referral Unit defines for all partners what its role and function is. | Central Referral Unit |
| 4b | The CRU urgently considers incorporating primary and secondary health services into the CRU. | Central Referral Unit |
| 4c | Further consideration is given to the Central Referral Unit becoming a fully functioning Multi-Agency Safeguarding Hub (MASH) | Central Referral Unit |
| 5a | Although no illegally held weapon was used in this case; when an incident occurs which warrants the seizure of weapons from a licenced shotgun or firearms holder, all certificates are seized. | Durham Constabulary |
| 5b | Before the decision to return any weapons is made, full recorded checks are undertaken both internally and externally, to determine the fitness of the licence holder to return the weapons and certificates to. | Durham Constabulary |
| 6a | The police firearms licensing department explore the feasibility of carrying out checks both internally and externally, on the applicants relevant history with other agencies in particular primary health care i.e. GP's, to help them makes decisions in relation to the granting of either a shotgun or firearm license or a review of same. This will enable information to be shared relevant to domestic abuse, substance misuse, physical harm and mental health issues. During the course of their enquiries both at application stages and review or at any other time where intelligence indicates there may be issues of concern about a member of the same household checks will be undertaken in respect of that individual with their GP. | Durham Constabulary |
| 6b | Once a firearm or shotgun certificate has been awarded, the police firearms licencing department should notify the individual's GP so that they are proactive in their information sharing if they have concerns about the certificate holder and their appropriateness to continue to hold these certificates. | Durham Constabulary |
| 6c | During the course of those discussions the police representative should also seek permission for a 'flag' to be placed upon the individuals medical record which identifies that if granted a licence it is clearly visible to those accessing the record. | Durham Constabulary |
| 7 | The training of professionals is to include understanding the importance of not assuming that other professionals are aware, and taking appropriate action in light of each individual set of circumstances | Safe Durham Partnership Board |
| 8 | The Domestic Abuse Forum Executive group consider that each agency, where not already identified, appoints and trains at least one member of staff to be the operational lead for domestic abuse. | Domestic Abuse Forum Executive Group |
| 9 | An approved DAFEG ‘package’ of leaflets and information is made available to all health agencies that encompasses both domestic abuse support and guidance and also signposts other organisations and charities | Domestic Abuse Forum Executive Group |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||