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

Cornwall review

CSP: Cornwall Published: April 2023 Year of death: 2013 Extracted: 14 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

Key concerns include professionals' limited recognition of domestic abuse risk factors, inadequate risk assessments focused on self-harm rather than risk to others, and insufficient multi-agency information sharing regarding the perpetrator's escalating anxieties and controlling behaviour towards the victim.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
1	The DHR recommend that there should be clear domestic abuse policies/policy written for all GP surgeries in the county. These policies should be regularly reviewed by practice managers and subject to audit at regular intervals. Such a policy should be distinct and separate from policies relating to safeguarding.	NHS Kernow \| Kernow CIC
10	Agree and design joint approaches and thresholds for multi-agency working when risks to individuals have been noted and include further exploration of the needs of the wider family to enhance joint family care.	MARAC Steering Group
11	The full impact of understanding and acting in a timely way where individuals display symptoms of depression, particularly where it is apparent that other family members are being identified is one of the key causal factors. A requirement for relevant early history, such as fostering, to be included as an integral part of GP records.	NHS England
12	That the learning from domestic homicide reviews are routinely shared with children’s safeguarding teams to facilitate early joint approaches where children may be involved	NHS England
13	That consent issues pertaining to engaging and sharing information in a timely way for the purposes of contributing to this Domestic Homicide review, is clearly understood by all health partners, to minimise any unnecessary disputes or delays.	Home Office \| General Medical Council
2	The DHR Panel recommend that a training needs analysis for GPs, mental health workers and others for example, NHS Kernow commissioned services such as psychological therapies should be conducted to identify which staff would benefit from training in recognising high risk markers for domestic abuse. Further work should be undertaken across local agencies to ensure the dissemination of regular training and information in relation to domestic abuse. In particular the use of a specialist package like IRIS to support GPs in their responses to domestic abuse should be used.	NHS Kernow \| Kernow CIC
3.1	The DHR Panel recommend that direct enquiry into domestic abuse is used by all agencies in any assessment or risk assessment process. In addition we recommend that pastoral care in schools have issues relating to domestic abuse as part of their work plans and processes. Direct enquiry should be considered as part of the tool kit of skills and interventions to be utilised within the pastoral care process. There weren’t indicators of abuse regarding concerns relating to Child C. The consideration of domestic abuse in these circumstances should not be reliant on specific indicators, it should form part of routine enquiry when a child presents with anxiety issues.	Safeguarding Standards Unit \| Learning and Achievement Service
3.2	Create a Culture of TELL, ASK and REFER by;  Raising awareness of Domestic Abuse in the Community to encourage increased reporting to REACH  Ensuring the commissioned provider delivering LSCB Safeguarding Children Training includes a Domestic Abuse Specific module including the DASH Risk Assessment.  Including a specific Domestic Abuse DASH module on the Safeguarding Adults Board Training  Ensuring all Designated Child Protection Officers working for the Cornwall Education Authority attend DASH training as part of enhanced Child Safeguarding Training.  Commission Domestic Abuse & DASH Training for Multi Agency Practitioners including the Voluntary Community Sector, Probation, Mental Health, Drug & Alcohol Services and the Health Sector.  Provide DASH Training to all Special Constables, First Response Officers, Supervisors (including Communication staff), Call Handlers and Sexual Offences Domestic Abuse Investigation Teams.	The DASV & SOC Strategy Lead
4	The DHR Panel recommends a programme of work be developed to raise public awareness of domestic abuse. It should include information about where members of the public can appropriately and safely share concerns or information about individuals they believe may be at risk of domestic abuse or at risk of perpetrating domestic violence. A public communication and marketing strategy should be developed to increase public confidence to report concerns by;  Educating the Public on what constitutes abuse;  Highlighting all forms of Domestic Abuse and the signs and symptoms of sustained abuse;  Educating the Public on when and how to intervene/report concerns;  Advertising a single point of contact for all concerns.	The DASV & SOC Strategy Lead
5	The DHR Panel recommend that guidance relating to the identification and management of morbid jealousy by primary care workers and those working in primary care mental health services should be developed to aid those workers in supporting individuals who may be exhibiting those symptoms.	NHS Kernow \| Kernow CIC
6	The DHR Panel recommend that assessment and risk assessment processes in health and social services be reviewed to ensure clearer guidance about the need to consider and respond not only to the needs of the presenting individual, but to spouses, partners and children within the family unit.	NHS Kernow \| Cornwall Council Mental Health Services and Children Social Care Services
7	The DHR Panel recommend that a focused themed review of previous DHRs in Cornwall be undertaken to identify common themes and issues, from which focused learning and practice development can take place with local organisations. We make this recommendation in the context of there having been three previous DHRs in Cornwall where the perpetrator has exhibited symptoms and risk assessed as risk to self as opposed to risk to others. This emerging theme around quality of risk assessment in the wider context of an individual and the effect this may have on understanding whether they pose a risk to others is an area of practice that should be considered for wider learning and practice development. There may be other commonalities and it would be of benefit to the local system to know and understand these so that a co-ordinated approach to learning and development can be undertaken in response to DHRs undertaken as a whole rather than seeing each in isolation.	DASV & SOC Strategy Lead
8	Review of service specification for Outlook South West  The Service Treatment guidance should be reviewed and updated to include guidance on pathological jealousy  It is further recommended that a) cases are referred on for specialist psychological therapy in secondary care, and b) that specific risk questions are asked.  Staff should receive training in identifying morbid jealously  Assessment tool used by therapists to assess the risk of harm to others.  Clinical Governance team will co-opt a working group to develop a tool for risk screening to others  Fast track referring to High Intensity therapy for priority patients if there is an urgent need should be developed. This is to be discussed and reviewed by the Clinical Pathway team.  Guidance is to be produced for staff relating to situations where a proposal to refer to the CMHT is refused by the patient.	NHS Kernow \| Cornwall Foundation Partnership Trust
9	NHS England in association with the Care Quality Commission audit/confirm the completion of training by GP’s and other primary care practitioners to ensure that appropriate training has been completed. GP’s undertake an agreed formal process to identify thresholds that trigger joint multi professional assessments of particular cases. Paper record search to ensure that all relevant information is included on electronic record Consideration of how to tighten documentation regarding any referrals, outcomes or follow up?	NHS England
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗