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
Leeds review
CSP: Leeds
Published: April 2023
Year of death: 2013
Extracted: 42 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
Agencies failed to recognise the perpetrator's controlling behaviour and risk, leading to poor risk assessments and lack of effective intervention for escalating abuse. Substance misuse services did not address domestic abuse, and there was inadequate support for the victim, especially after child removal.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1a | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Leeds Partnership will develop plans for skilling up workers to: explore domestic abuse with service users; recognise controlling and manipulative behaviour as domestic abuse; understand when and how to undertake DASH risk assessments or refer victims to another agency who can conduct such an assessment; understand when to make referrals and to who; have confidence to undertake safety planning. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Leeds Partnership |
| 1b | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Leeds Partnership will undertake a review of the use of anger management with perpetrators of domestic abuse. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Leeds Partnership |
| 2 | Safer Leeds will put in place a strategy for a co-ordinated approach to perpetrator and offender management. | Safer Leeds |
| 3 | Leeds health agencies will put in place a strategy for delivering holistic services for women with substance misuse issues that address experiences of violence and abuse. | Leeds health agencies |
| 4 | The Safeguarding Children Board, Safeguarding Adult Board and Safer Leeds will extend the availability of training for front-line practitioners. | Safeguarding Children Board | Safeguarding Adult Board | Safer Leeds |
| CSWS1 | Children’s Social Work Service to review with drugs and alcohol agencies the thresholds for when a pregnancy should be referred for substance misusing parents. | Leeds Children’s Social Work Service |
| CSWS2 | Children’s Social Work Service should develop a service which supports parents who have their children removed through care proceedings. | Leeds Children’s Social Work Service |
| LCH1 | Feedback learning to team leaders at York St Health Practice – to include information sharing challenges & attendance at child protection meetings. | Leeds Community Health – York Street Practice GP and Drug Treatment Services |
| LCH2 | Guidelines for urine screening for drugs & alcohol. | Leeds Community Health – York Street Practice GP and Drug Treatment Services |
| LCH3 | Raise profile of Domestic Abuse; identification of risk factors; triggers; referral for support & referral to MARAC. | Leeds Community Health – York Street Practice GP and Drug Treatment Services |
| LTHT1 | The antenatal guidelines in relation to the Domestic Violence Care Pathway should be reviewed in light of the findings of this individual management report. Consideration should be given to include a summary of factors which might indicate domestic violence and risk factors. | Leeds Teaching Hospitals NHS Trust |
| LTHT2 | LTHT to undertake a training needs analysis to identify staff requiring training on domestic abuse issues. This analysis should identify high priority specialties and pathways including Emergency Department and maternity Services. This will include types of abuse that are non-physical. It is to be ensured that this training links in with the National Institute for Clinical Excellence (NICE) guidelines on Domestic Abuse. | Leeds Teaching Hospitals NHS Trust |
| LTHT3 | Review the current PAS and Symphony Systems to determine whether it is possible and appropriate to include a Domestic Abuse alert flag. | Leeds Teaching Hospitals NHS Trust |
| LTHT4 | To explore how relevant clinical information held by mental health services such a mental health assessments and risk assessments can be communicated to and recorded by LTHT. | Leeds Teaching Hospitals NHS Trust |
| LTHT5 | Recommend that the Emergency Department develop a Standard Operating Procedure to inform staff of the procedures when patients attend ED with cases of suspected and known domestic violence. | Leeds Teaching Hospitals NHS Trust |
| LTHT6 | To develop a system to enable to a link of relevant information about domestic abuse between relevant patient records such as family members where there is the same address. | Leeds Teaching Hospitals NHS Trust |
| LYPFT1 | Develop a clear threshold within the Leeds Addiction Unit for safeguarding adult alert/referral. | Leeds and York Partnership NHS Trust |
| LYPFT2 | For Domestic violence (where any past or present incidents are known) to be routinely noted within the FACE risk document. | Leeds and York Partnership NHS Trust |
| LYPFT3 | Enhance the knowledge of Domestic Violence within specific Self Harm/Crisis Assessment Teams. That this aims to raise the profile of domestic violence (as related to both victim and perpetrator) in crisis assessments particularly where the individual is subject to repeated assessments over a period of time. | Leeds and York Partnership NHS Trust |
| LYPFT4 | Share the learning with team involved in this case. | Leeds and York Partnership NHS Trust |
| LYPFT5 | Leeds Addiction Unit should work with Children’s Social Work Service to review the thresholds for when a pregnancy should be referred for substance misusing parents. | Leeds and York Partnership NHS Trust |
| NHSE1a | The GP practice to access information on Leeds Health Pathways to ensure practice response reflects domestic violence pathway; and ensuring referral information to appropriate agencies is available to those experiencing abuse and practice intervention follows identified guidance | NHS England |
| NHSE1b | Areas of practice relating to the role of the GP in bereavement support are enhanced; identifying links to depression and anxiety in the context of bereavement, coping strategies which can be defined as risk taking or self harming and increasing knowledge of referral sources for specialist services or local bereavement counselling. | NHS England |
| NHSE1c | Learning from the review process is shared to wider GP practices through training and West Yorkshire newsletter. | NHS England |
| NHSE2a | Evaluate training needs for GPs and ensure this meets professional requirements in relation to areas identified in the review i. Domestic abuse ii. Depression and self harm iii. Bereavement and loss | NHS England |
| NHSE3a | Safer Leeds to continue to support developments in routine enquiry through opportunities of training for GP clinical and non clinical staff | NHS England |
| NHSE4a | Evaluate and identify appropriate systems to identify and flag case notes where domestic abuse is a risk to ensure that any record of domestic abuse can be seen within the context of the whole patient record to evaluate if a wider pattern of repeated consultations for depression, or of any multiple problem, may be connected to the violence. | NHS England |
| NHSE4b | Ensuring a system is effective where adults do not have children under the age of 18 | NHS England |
| NHSE4c | Ensuring there is a system of reevaluating risk and removing “flagged” alerts | NHS England |
| NHSE4d | Link to other objectives in Leeds plans to flag domestic abuse. | NHS England |
| SACS1 | St Anne’s community services require their own domestic violence policy and procedure. The policy will explain the need and the procedure will offer guidance and support for those dealing with clients who are suffering from domestic violence. | St Anne’s Community Services |
| SACS2 | For all agencies involved in the treatment and care of a patient/ client, to have access to a standardised passport/ document which includes details of the patients/clients past history and present circumstances. Such information would include, the patient/clients relationship status, their current living situation, family relationships/ history, potential risk factors in detail, details of any ongoing treatment and medical history. | St Anne’s Community Services |
| SACS3 | St Anne’s Community Services should ensure that internal training is provided to our colleagues who work in services where domestic violence features. Guidance and ongoing support should also be given to colleagues in relation to domestic violence. | St Anne’s Community Services |
| SACS4 | St Anne’s Community services will provide further support, guidance and training provided where applicable in relation to completing risk management plans within Alcohol services. | St Anne’s Community Services |
| WYP1 | West Yorkshire Police to refresh guidance to staff about the use of powers to arrest for breach of the peace, emphasising the need to identify a substantive offence which can be accompanied by bail conditions; | West Yorkshire Police |
| WYP2 | West Yorkshire Police to implement its refreshed guidance on the management of Medium and Standard incidents; | West Yorkshire Police |
| WYP3 | West Yorkshire Police to introducea formal induction training package for all new police staff entering the Safeguarding Unit as domestic abuse clerks and coordinators; | West Yorkshire Police |
| WYP4 | West Yorkshire Police to review the requirements on staff to evidence that victim safety has been considered prior to the release of arrested persons where no charges are laid. | West Yorkshire Police |
| YAS1 | A bulletin will be placed in OU to remind staff that Police should be requested to attend 999 calls where children of substance misusing parents & carers are at significant risk from the event (e.g. needle stick injuries, cross-infection, ingestion / Overdose. | Yorkshire Ambulance Service |
| YAS2 | A bulletin will be placed in OU to remind staff that Police presence on scene does not mitigate YAS staff responsibilities to signpost and make an onward referrals to other agencies. | Yorkshire Ambulance Service |
| YAS3 | YAS will ensure the 3 staff that are currently non-compliant in safeguarding level 2 are update within 3 months. | Yorkshire Ambulance Service |
| YAS4 | YAS will remind the local management teams of their responsibility for ensuring frontline staff are up to date with level 2 safeguarding training. | Yorkshire Ambulance Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||