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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review identified systemic weaknesses in multi-agency processes (MARAC, DVIC, MASH) including poor information sharing, inadequate risk assessment, and a lack of strategies for non-engagement. Failures to follow policy and address root causes of domestic abuse, alongside limited public awareness for reporting, hindered effective safeguarding.

Extracted recommendations

33 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	People’s Services
10	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	Merseyside Police
11	Assessments need to take full account of historical information and ensure it is fully reflected within the assessment process and in formulation of plans.	People’s Services
12	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).	People’s Services
13	A single assessment should link to a plan of intervention that is subject to regular multi-agency review.	People’s Services
14	Assessments need to be rigorous in determining the extent of which individuals are victims and/or perpetrators of domestic violence	Community Safety Partnership \| People’s Services
15	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.	People’s Services
16	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	People’s Services
17	That DVIC be reviewed to consider whether appropriate assessment and mechanisms can be put in place that address children at risk.	People’s Services
18	Supervision and monitoring of MARAC takes place in order to ensure that the MARAC is provided with full disclosure concerning perceived victims and perpetrators.	Community Safety Partnership
19	That the MARAC consider and document support available to both victim and perpetrator where alcohol abuse is prevalent.	Community Safety Partnership
2	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.	People’s Services
20	That the MARAC question and document their considerations when counter allegations/complaints are evident	Community Safety Partnership
21	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	St Helens and Knowsley Teaching Hospitals NHS Trust
22	Review advice/pathways in place relating to alcohol related attendances/admissions	St Helens and Knowsley Teaching Hospitals NHS Trust
23	Review advice/pathways in place relating to bereavement issues	St Helens and Knowsley Teaching Hospitals NHS Trust
24	Review advice/pathways in place relating to substance misuse issues	St Helens and Knowsley Teaching Hospitals NHS Trust
25	Audit the current use of electronic alerts to Domestic Abuse and Safeguarding Children	St Helens and Knowsley Teaching Hospitals NHS Trust
26	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.	Bridgewater Community Healthcare NHS Foundation Trust
27	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.	Public Health
28	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.	Public Health
29	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.	Public Health
3	Development of a strategy to overcome a lack of engagement by the victim or the perpetrator.	People’s Services
30	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).	Public Health
31	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.	Public Health
32	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.	Public Health
33	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.	Public Health
4	Revision of membership to MARAC and DVIC is undertaken with necessary changes made following that review.	Community Safety Partnership \| People’s Services
5	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.	Community Safety Partnership \| People’s Services
6	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.	All Panel Agencies
7	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.	Community Safety Partnership \| People’s Services
8	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	Merseyside Police
9	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	Merseyside Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗