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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Where disclosures of domestic abuse are made an appropriate risk assessment should be carried out | Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 10 | 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. | Avon and Somerset Police |
| 11 | To continue with developments relating to information sharing in relation to vulnerable people | Avon and Somerset Police |
| 12 | to review policies and protocols in relation to disclosures of domestic violence and abuse, and ensure that all staff receive appropriate training. | Youth Offending Service |
| 13 | a specific question about domestic abuse should be considered as part of the assessment process | Avon and Wiltshire Mental Health Partnership Trust |
| 14 | 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. | Avon and Wiltshire Mental Health Partnership Trust |
| 15 | to ensure that staff involve families and significant others in considering the role they might have in helping to manage and/or mitigate risks. | Avon and Wiltshire Mental Health Partnership Trust |
| 16 | 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. | Children’s Social Care |
| 17 | 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. | Children’s Social Care |
| 18 | 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. | Children’s Social Care |
| 19 | Pathway Plans must be focussed on the future, aspirational and led by the young person and reflects their changing needs and ambitions. | Children’s Social Care |
| 2 | 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. | Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 20 | South Gloucestershire council should consider the viability of having Path way Plan reviews Independently chaired, post 18 years of age. | South Gloucestershire Council |
| 21 | 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. | Children’s Social Care |
| 22 | 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. | Children’s Social Care |
| 23 | 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. | Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 24 | 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. | Safer Bristol Partnership | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 25 | The School’s self-harm support procedures should be reviewed. | Carly’s School |
| 26 | Renewed attempts should be made to find innovative ways to engage with families such as the victim's. | Carly’s School |
| 27 | The surgery should consider additional training around patients with complex needs, and recognising the carer/abuser tension. | Bristol Clinical Commissioning Group on behalf of Primary Care |
| 28 | 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. | Bristol Clinical Commissioning Group on behalf of Primary Care |
| 29 | To recommend that the surgery checks that their IRIS training includes refresher training at three yearly intervals following the initial training package. | Bristol Clinical Commissioning Group on behalf of Primary Care |
| 3 | 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. | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 30 | 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. | 1625 Independent People |
| 31 | 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. | 1625 Independent People |
| 32 | 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. | 1625 Independent People |
| 33 | 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. | 1625 Independent People |
| 34 | 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. | Merlin Housing Society |
| 35 | There should be better engagement with clients and more detailed record keeping. | Merlin Housing Society |
| 36 | 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 | North Bristol NHS Trust |
| 37 | The process and forms for review health assessments for Looked After Children must be reviewed to ensure a holistic assessment is undertaken. | North Bristol NHS Trust |
| 38 | 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. | North Bristol NHS Trust |
| 39 | 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. | North Bristol NHS Trust |
| 4 | Raise awareness of the CAADA DASH RIC for Young People by incorporating into all MARAC and DASH training programmes. | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 40 | 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 | Knightstone Housing |
| 41 | To deliver specialist domestic abuse training to staff to enable them to better identify potential domestic abuse | Knightstone Housing |
| 5 | 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. | South Gloucestershire Safer & Stronger Communities Strategic Partnership |
| 6 | 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. | Safer Bristol Partnership |
| 7 | Raise awareness of the CAADA DASH RIC for Young People by incorporating into all MARAC and DASH training programmes. | Safer Bristol Partnership |
| 8 | 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. | Safer Bristol Partnership |
| 9 | 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. | Avon and Somerset Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||