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
Norfolk review
CSP: Norfolk
Published: April 2023
Year of death: 2017
Extracted: 31 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 identifies systemic failures across multiple agencies to protect the victim from a serial domestic abuser, including inadequate information sharing, underestimation of risk, and challenges in victim engagement, despite various safeguarding processes being in place.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | It is recommended that, alongside the awareness raising campaigns undertaken in Norfolk, there are two specific campaigns recommended. The first targeted at young people to stress the message about healthy relationships and the second at hairdressers, beauticians etc. as potentially confidants of victims. | Norfolk County Community Safety Partnership |
| 10 | The National Probation Service has identified a number of service specific recommendations which this review recommends are undertaken: • To plan and implement effective measures to reduce caseloads and workload pressure on staff working at the relevant office • To widen and improve the recruitment campaign/package to encourage new applicants and experienced probation staff to relocate to the relevant office • To clarify the boundaries of all local measures introduced to reduce offender manager workloads with high risk offenders in the community | National Probation Service |
| 11 | It is recommended that the existing programme of domestic abuse awareness raising across all GP practices in Norfolk is stepped up for adult safeguarding, to raise professional curiosity and knowledge of referral routes, signposting to specialist support agencies and triggers for and signs of abuse. | NHS Norfolk and Waveney ICB |
| 12 | It is recommended that the pack provided to locum GPs by a practice includes information on how they can make sure patients ‘of concern’ are followed up. For example, where to direct a ‘patient task’ to make sure a follow up in the case of a DNA (Did Not Attend) | NHS Norfolk and Waveney ICB |
| 13 | It is recommended that DNA (Did Not Attend) processes in GP surgeries are reviewed to ensure their effectiveness for safeguarding purposes | NHS Norfolk and Waveney ICB |
| 14 | It is recommended that A&E staff are trained in domestic abuse, including how to ask the abuse question and how to complete the DASH form | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 15 | It is recommended that consideration is given to a process that will allow A&E staff to check previous attendances for those attending with assault injuries. This will assist in a more holistic view of the patient presenting at A&E. | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 16 | It is recommended that a ‘safeguarding’ box is added to Symphony as a mandatory reporting field. This should include if there are any safeguarding concerns and identify whether the concerns relate to a child, adult or domestic abuse | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 17 | It is recommended that A&E staff are identified to train as Domestic Abuse Champions | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 18 | It is recommended that domestic abuse information is displayed in public areas in the hospital, specifically toilets which should have contact details for charities and support services | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 19 | It is recommended that, as suggested by a consultant in the Maxillo-Facial surgery department, a specific session on domestic abuse is included in the induction programme for all junior doctors joining the department | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 2 | It is recommended that the publicity within Norfolk surrounding the DVDS Right to Ask scheme is reviewed, with a view to ongoing and targeting awareness raising campaigns. Consideration should be given to adopting, and publishing on the police website, the explanatory leaflet used by a number of forces. | Norfolk Constabulary |
| 20 | It is recommended that the Hospital Trust considers Domestic Abuse Awareness becoming a mandatory training requirement for patient facing staff, acknowledging the pressures that exist for different mandatory training | Norfolk and Norwich University Hospital NHS Foundation Trust |
| 21 | It is recommended that non-abusive, absent parents are informed of any concerns and involved in any assessments that are undertaken | Norfolk County Council, Children’s Social Care |
| 22 | That children’s services review their process for sending out letters such as those sent to April to ensure that they are all case specific and written in light of the information available | Norfolk County Council, Children’s Social Care |
| 23 | That children’s social care holds a series of workshops and communications is implemented to share the learning identified | Norfolk County Council, Children’s Social Care |
| 24 | That procedures in the children’s social care department are reviewed to ensure the learning is captured in future practice | Norfolk County Council, Children’s Social Care |
| 25 | That a specific learning event is held for those in the children’s social care who were directly involved in the case | Norfolk County Council, Children’s Social Care |
| 26 | It is recommended that customer services and repairs staff/contractors are reminded of Circle 33’s Safeguarding and Domestic Abuse policies and ensure that requests for repair or concerns raised by third parties, linked to actual or potential domestic abuse, are also recorded as a Safeguarding Alert and/or ASB case and passed to the Neighbourhood Team for further action | Circle 33 Housing Trust Ltd |
| 27 | That Neighbourhood Officers at Circle 33 are reminded of the Domestic Abuse and ASB policies and their relevance to this case | Circle 33 Housing Trust Ltd |
| 28 | That each Neighbourhood Team in the Circle Group acquires equipment to provide additional security and reassurance to victims of domestic abuse e.g. door braces and alarms | Clarion Housing Group |
| 29 | That the Clarion Group (Circle 33) considers a Community Safety Strategy which prioritises domestic abuse and identifies improvements to the current offer to its customers | Clarion Housing Group |
| 3 | It is recommended that when a Clare’s Law disclosure is pending, the police system Athena, should be updated so that any officer who goes into the record will see that there is an outstanding disclosure and can contact the specialist officers in the case. | Norfolk Constabulary |
| 30 | It is recommended that consideration is given to how the needs of the whole family can be managed effectively across the processes of MARAC (focusing on the victim), MAPPA (focusing on the offender) and safeguarding (focusing on the children involved) | Norfolk County Community Safety Partnership | Home Office | Ministry of Justice |
| 31 | That for serial and/or repeat perpetrators, where there is evidence regarding violent or serious harmful offending, this should automatically be considered as an aggravating factor and longer-term prison sentences should follow with mandatory rehabilitation courses whilst in prison. | Ministry of Justice | Sentencing Council |
| 4 | It is recommended that the impact of this post is evaluated in order that its value can be clearly seen. | Leeway Domestic Abuse and Violence Services | Norfolk Constabulary |
| 5 | It is recommended that evaluation of Clare’s Law is commissioned to assess its use and effectiveness in protecting victims | Home Office |
| 6 | It is recommended that, where a person is reluctant to hear a disclosure, that it is referred back to the DVDS panel for consideration to be given to making the disclosure to a family member who may be in a position to offer some protection to the victim, subject to the points made above. | Norfolk Constabulary |
| 7 | It is recommended that Norfolk Police reviews the way in which intelligence and information about the relationships of known repeat perpetrators is analysed and acted upon. It is further recommended that, as a matter of course, when intelligence of information is received about a known perpetrator being in another relationship an application under the DVDS is always and automatically made. | Norfolk Constabulary |
| 8 | It is recommended that the East of England Crown Prosecution Service review their practices for achieving evidence led prosecution without victim complainant (victimless prosecutions) | Crown Prosecution Service (East of England) |
| 9 | It is recommended that the Ministry of Justice review the adequacy of staffing in the National Probation Service to ensure realistic caseloads, so that there is effective monitoring of high risk offenders and public protection is not compromised | Ministry of Justice |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||