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

St Helens review

CSP: St Helens Published: April 2023 Year of death: 2014 Extracted: 33 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The report highlights systemic weaknesses in multi-agency coordination (DVIC, MARAC, MASH), inconsistent information sharing, and policy non-compliance. These issues, coupled with failures to address root causes like alcohol misuse and manage non-engagement, led to missed opportunities for effective risk assessment and safety planning.

Home Office classifications

37 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - school recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

33 recommendations pulled from the report · 5 matched to organisations in the index

Recommendation 1

Addressed to People’s Services

Appointment of individual with clear management oversight and responsibility delivering structured supervision of DVIC, MARAC and Children Safeguarding meetings including MASH is established. Ensure that there is effective coordination between the meetings and a thorough and accurate awareness amongst participants of the actions and outcomes delivered by others working with these vulnerable families.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to People’s Services

Short term require intrusive supervision of DVIC, MARAC, MASH and Safeguarding meetings. Retraining program for all Chairs of the meetings and their participants to ensure processes are delivering as complete and accurate assessment of safety needs as possible.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to People’s Services

Development of a strategy to overcome a lack of engagement by victim or perpetrator.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Community Safety Partnership | People’s Services

Revision of membership to MARAC and DVIC is undertaken with necessary changes made following that review.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Community Safety Partnership | People’s Services

Chairs and those supporting the Chair at these meetings apply a strong problem solving approach to the work of the meeting with the aim of prevention repeat victimisation by addressing root causes of conflict within the relationship.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Merseyside Police | Merseyside CRC | St Helens Council | Chrysalis Centre for Change | St Helens Clinical Commissioning Group | Helena Partnerships | National Probation Service

It is recommended that compliance with policy forms a key part of the supervision of domestic abuse within single agencies and of future MARAC, DVIC and all other Safeguarding meetings. Additionally these policies should be an integral part of the retraining of MARAC, DVIC and Safeguarding Chairs and meeting participants.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Community Safety Partnership | People’s Services

Community safety, Children’s Services and Safeguarding Boards development of an education and awareness program/campaign to encourage family and friends to act and report when someone they know is the victim of ongoing domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Merseyside Police

When a victim calls the Police to report a ‘domestic abuse’ incident and states that violence has taken place, and then refutes this on the arrival of a patrol, the reporting officer must ensure that there has been no undue influence placed on the reporting party to change their story. The reason for any such change in the circumstances of an incident should be recorded on the VPRF 1 and considered during the risk assessment

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Merseyside Police

If a complaint is made by a person involved in domestic conflict with another, that a knife or other deadly weapon was in the possession of, or used by that other, whether current or historical, then a VPRF 1 must be completed and an assessment of the risk to those involved undertaken

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Merseyside Police

When creating and indexing Niche logs or records, the perpetual abuse of alcohol by any of the parties involved should be highlighted on their Niche record as a warning sign, even if the person is a victim

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to People’s Services

Assessments need to take full account of historical information and ensure it is fully reflected within the assessment process and in formulation of plans.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to People’s Services

A management process to be developed to monitor service user engagement when they are referred to support services such as Addaction, the HELP Project or Freedom Project as part of an intervention plan. The purpose will be to determine if engagement (or otherwise) improves outcomes for children and/or provides evidence of non-compliance (disguised).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 13

Addressed to People’s Services

A single assessment should link to a plan of intervention that is subject to regular multi-agency review.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 14

Addressed to Community Safety Partnership | People’s Services

Assessments need to be rigorous in determining the extent of which individuals are victims and/or perpetrators of domestic violence

Verified wording from the published review · Original review (PDF) ↗

Recommendation 15

Addressed to People’s Services

The voice of the child should be clearly heard and reflected in all social work children and families assessments encompassing both direct input but also any consistent deficiencies in parenting.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 16

Addressed to People’s Services

Assessments plans and monitoring arrangements need to take account of the potential for disguised non-compliance of service users and the impact of this on outcomes for the child

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17

Addressed to People’s Services

That DVIC be reviewed to consider whether appropriate assessment and mechanisms can be put in place that address children at risk.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 18

Addressed to Community Safety Partnership

Supervision and monitoring of MARAC takes place in order to ensure that the MARAC is provided with full disclosure concerning perceived victims and perpetrators.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19

Addressed to Community Safety Partnership

That the MARAC consider and document support available to both victim and perpetrator where alcohol abuse is prevalent.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 20

Addressed to Community Safety Partnership

That the MARAC question and document their considerations when counter allegations/complaints are evident

Verified wording from the published review · Original review (PDF) ↗

Recommendation 21

Addressed to St Helens and Knowsley Teaching Hospitals NHS Trust Acute Hospitals

Use of this case to address learning in a multi-agency setting to include: Emergency Department, Alcohol Services, Mental Health Liaison, Domestic Abuse and Safeguarding Leads with an emphasis on developing skills in Accurate social history taking Identifying the hidden males

Verified wording from the published review · Original review (PDF) ↗

Recommendation 22

Addressed to St Helens and Knowsley Teaching Hospitals NHS Trust Acute Hospitals

Review advice/pathways in place relating to alcohol related attendances/admissions

Verified wording from the published review · Original review (PDF) ↗

Recommendation 23

Addressed to St Helens and Knowsley Teaching Hospitals NHS Trust Acute Hospitals

Review advice/pathways in place relating to bereavement issues

Verified wording from the published review · Original review (PDF) ↗

Recommendation 24

Addressed to St Helens and Knowsley Teaching Hospitals NHS Trust Acute Hospitals

Review advice/pathways in place relating to substance misuse issues

Verified wording from the published review · Original review (PDF) ↗

Recommendation 25

Addressed to St Helens and Knowsley Teaching Hospitals NHS Trust Acute Hospitals

Audit the current use of electronic alerts to Domestic Abuse and Safeguarding Children

Verified wording from the published review · Original review (PDF) ↗

Recommendation 26

Addressed to Bridgewater Community Healthcare NHS Foundation Trust

Conduct an audit of the use of MeRIT risk assessment checklist for domestic abuse by the Health Visiting, School Nursing and Family Nurse Partnership Services. In order to establish if victims and their children are being reassessed in terms of risk being reduced or elevated.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 27

Addressed to Public Health

A training needs analysis to be undertaken in relation to alcohol awareness and effects on parenting/hidden harms across Police, Children’s and Adult Social Care, G.P.’s MARAC and DVIC staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 28

Addressed to Public Health

Ensure that reducing harm to children from parental problem drug and alcohol use is a priority aim of the Borough’s Alcohol Strategy 2016 – 2017 onwards.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 29

Addressed to Public Health

Terms of reference for DVIC and MARAC to include identifying alcohol and drug related challenges especially where there is evidence of or the potential for compromised parenting and take action to address that challenge.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 30

Addressed to Public Health

All schools should identify at least one trained designated person able to deal with the problems that might arise with the children of problem drug users (Hidden Harms, 2003).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 31

Addressed to Public Health

All services should ensure that the voices of the children of problem drug users are heard and listened to. Work is required to develop means of enabling the children of problem drug users safely to express their thoughts and feelings about their circumstances.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 32

Addressed to Public Health

Public Health will explore the Borough offer in relation to providing appropriate support for the children of parents with drug and alcohol problems. Support should be available even if parents are unwilling or unable to change their use of drugs or alcohol.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 33

Addressed to Public Health

Learning from this review should be cascaded to drug and alcohol treatment services who will consider when developing plans for the outreach elements of their service.

Verified wording from the published review · Original review (PDF) ↗