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

Bristol review

CSP: Bristol Published: April 2023 Year of death: 2013 Extracted: 41 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 identifies systemic failures in following up domestic abuse disclosures, conducting risk assessments, and sharing information across agencies. It highlights a lack of holistic understanding of the victim's complex needs as a care leaver and the challenges in connecting mental health issues with domestic abuse.

Home Office classifications

25 tags

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

  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - post traumatic stress disorder (ptsd)
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - had been a victim of an abuser before
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - school recommendations
  • DHR process - other educational institution recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

41 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1

Addressed to Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership

Where disclosures of domestic abuse are made an appropriate risk assessment should be carried out

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

Recommendation 2

Addressed to Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership

On-going domestic abuse awareness training should be mandatory. This should cover asking about issues of domestic abuse and knowing what to do about disclosures for all statutory and commissioned agencies and organisations.

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

Recommendation 3

Addressed to South Gloucestershire Safer & Stronger Communities Strategic Partnership

To embed the CAADA DASH RIC for Young People within all safeguarding practices across all agencies, in a way which will ensure professionals and practitioners use this as a tool to ensure appropriate support, safety planning and onward referrals are considered where a young person discloses domestic abuse.

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

Recommendation 4

Addressed to South Gloucestershire Safer & Stronger Communities Strategic Partnership

Raise awareness of the CAADA DASH RIC for Young People by incorporating into all MARAC and DASH training programmes.

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

Recommendation 5

Addressed to South Gloucestershire Safer & Stronger Communities Strategic Partnership

Ensure that all contracts for commissioned services include adequate and appropriate training requirements that will ensure frontline practitioners are adequately trained, and understand the principles of safeguarding; and their responsibilities where Domestic Abuse is identified.

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

Recommendation 6

Addressed to Safer Bristol Partnership

To embed the CAADA DASH RIC for Young People within all safeguarding practices across all agencies, in a way which will ensure professionals and practitioners use this as a tool to ensure appropriate support, safety planning and onward referrals are considered where a young person discloses domestic abuse.

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

Recommendation 7

Addressed to Safer Bristol Partnership

Raise awareness of the CAADA DASH RIC for Young People by incorporating into all MARAC and DASH training programmes.

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

Recommendation 8

Addressed to Safer Bristol Partnership

Ensure that all contracts for commissioned services include adequate and appropriate training requirements that will ensure frontline practitioners are adequately trained, and understand the principles of safeguarding; and their responsibilities where Domestic Abuse is identified.

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

Recommendation 9

Addressed to Avon and Somerset Police

Share the findings of this DHR with all 999 call takers so that they are aware of the significance of recording incidents as ‘domestic’ where the circumstances suggest that may be the case.

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

Recommendation 10

Addressed to Avon and Somerset Police

Where the circumstances surrounding a silent 999 call suggest that the situation may be domestic abuse, to err on the side of caution and record the incident as domestic abuse.

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

Recommendation 11

Addressed to Avon and Somerset Police

To continue with developments relating to information sharing in relation to vulnerable people

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

Recommendation 12

Addressed to Youth Offending Service

to review policies and protocols in relation to disclosures of domestic violence and abuse, and ensure that all staff receive appropriate training.

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

Recommendation 13

Addressed to Avon and Wiltshire Mental Health Partnership Trust

a specific question about domestic abuse should be considered as part of the assessment process

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

Recommendation 14

Addressed to Avon and Wiltshire Mental Health Partnership Trust

review the template for letters sent to service users following assessment to ensure the format and contents are empathetic. To consider adding a foot note apologising for any potential factual inaccuracies and requesting that the service user contacts the author to amend these.

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

Recommendation 15

Addressed to Avon and Wiltshire Mental Health Partnership Trust

to ensure that staff involve families and significant others in considering the role they might have in helping to manage and/or mitigate risks.

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

Recommendation 16

Addressed to Children’s Social Care

Pathway Plans should be carried out to make sure the young person’s voice is always heard. They should be completed with young person and where possible signed by the young person and the supervisor responsible for overseeing the support worker.

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

Recommendation 17

Addressed to Children’s Social Care

Given that young people often lack the skills to make good choices on their own, care leavers should be provided with mentoring services where this is assessed as needed.

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

Recommendation 18

Addressed to Children’s Social Care

Disruption Meetings exploring the reasons for placement breakdown and identifying learning and actions required to prevent future breakdowns in a child/young person’s care arrangements must be held.

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

Recommendation 19

Addressed to Children’s Social Care

Pathway Plans must be focussed on the future, aspirational and led by the young person and reflects their changing needs and ambitions.

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

Recommendation 20

Addressed to South Gloucestershire Council

South Gloucestershire council should consider the viability of having Path way Plan reviews Independently chaired, post 18 years of age.

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

Recommendation 21

Addressed to Children’s Social Care

Where a care leaver is an adult but is known to be in an abusive or vulnerable situation a risk assessment should always be undertaken and completed with that young person.

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

Recommendation 22

Addressed to Children’s Social Care

As a pro-active corporate parent, where there are known risks to a young person’s welfare or safety, steps to obtain consent for sharing information with key agencies and partners should be explored prior to case closure, Where consent is declined this should be clearly recorded and advice obtained as to whether threshold is met for dispensing with consent.

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

Recommendation 23

Addressed to Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership

Any allegations or disclosures of abuse by a young person under 18yrs of age must be managed in accordance with the requirements of Working Together to Safeguard Children 2013.

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

Recommendation 24

Addressed to Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership

The views of the child /young person must be sought and clearly recorded as should information from them enabling workers to understand the child/young person’s experience of daily life.

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

Recommendation 26

Addressed to Carly’s School

Renewed attempts should be made to find innovative ways to engage with families such as the victim's.

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

Recommendation 27

Addressed to Bristol Clinical Commissioning Group on behalf of Primary Care

The surgery should consider additional training around patients with complex needs, and recognising the carer/abuser tension.

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

Recommendation 28

Addressed to Bristol Clinical Commissioning Group on behalf of Primary Care

To recommend that IRIS training emphasize the challenges of balancing protective and potential abusive factors in patients who have mental health issues or complex health needs, particularly those who require a significant amount of care from family members or people with whom they are in an intimate relationship.

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

Recommendation 29

Addressed to Bristol Clinical Commissioning Group on behalf of Primary Care

To recommend that the surgery checks that their IRIS training includes refresher training at three yearly intervals following the initial training package.

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

Recommendation 30

Addressed to 1625 Independent People

Training should be carried out with all staff around how to respond to disclosures of domestic violence and it should be a compulsory part of 1625 Independent People’s on-going programme of staff development.

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

Recommendation 31

Addressed to 1625 Independent People

This recommendation for training should extend to all services contracted to the council who support young people - using the young people’s CAADA DASH risk assessment tool should be routine in these organisations.

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

Recommendation 32

Addressed to 1625 Independent People

As a commissioned service, the contract should include an expectation that robust domestic abuse policies are in place, and training regarding safeguarding, including domestic abuse is implemented.

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

Recommendation 33

Addressed to 1625 Independent People

16-25 to support and encourage their staff to challenge young people in relation to unhealthy relationships, and to emphasise their role as a support organisation.

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

Recommendation 34

Addressed to Merlin Housing Society

Risk assessments and robust support plans should always be in place. If they are not completed there should be some written explanations as to why not.

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

Recommendation 36

Addressed to North Bristol NHS Trust

Domestic Abuse training in ED should be reviewed to ensure that the contents include a focus on the vulnerabilities of young people, particularly young people who are Looked After or are care leavers under 21years and include the use of the Young Peoples CAADA-DASH toolkit

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

Recommendation 37

Addressed to North Bristol NHS Trust

The process and forms for review health assessments for Looked After Children must be reviewed to ensure a holistic assessment is undertaken.

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

Recommendation 38

Addressed to North Bristol NHS Trust

Following Looked After Children health assessments robust care plan must be formulated which include active intervention when risks such as excessive drinking, drug use, concerning sexual behaviour and relationships are identified and this must include a process to ensure follow up of any onward referrals.

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

Recommendation 39

Addressed to North Bristol NHS Trust

All professionals must use the Young People’s CAADA-DASH toolkit in cases where a Looked After Child is identified as being in a potentially abusive relationship. They should also consider asking the sort of questions a parent would be asking if a young person was in a potentially coercive relationship.

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

Recommendation 40

Addressed to Knightstone Housing

As part of the provision of housing related support, to routinely request Risk Assessments from other agencies working with residents in order to gain a fuller picture of their circumstances

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

Recommendation 41

Addressed to Knightstone Housing

To deliver specialist domestic abuse training to staff to enable them to better identify potential domestic abuse

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