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: BristolPublished: April 2023Year of death: 2014Extracted: 16 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review highlights a significant lack of third-party reporting of domestic abuse, stemming from public reluctance to interfere and limited awareness of support services. It also identifies missed opportunities by health and social care agencies to identify domestic abuse and ensure timely, holistic assessments and inter-agency information sharing.
Home Office classifications
32 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - housing issues
Victim - pregnancy
Victim - had been a victim of an abuser before
Children - under 18 shared parental responsibility (between victims)
Children - subject to child protection or domestic abuse prior to homicide
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - housing issues
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to friends as a domestic abuse perpetrator
Perpetrator - immigration involvement
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - sexual abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - family attended dhr panel
DHR process - police recommendations
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - idva or other domestic abuse support service 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 - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
16 recommendations pulled from the report · 8 matched to organisations in the index
Addressed to
Home Secretary | Immigration Enforcement
That the Home Secretary completes the introduction of the exit checks programme in relation to people leaving the UK and that intelligence gathered as a result is passed to Immigration Enforcement to tackle those who overstay their leave.
Addressed to
Bristol Domestic and Sexual Abuse Strategy Group
That the Bristol Domestic and Sexual Abuse Strategy Group organizes a domestic abuse awareness campaign focused on third-party reporting from all communities, but particularly from people less able to easily access mainstream services.
Addressed to
Bristol Domestic and Sexual Abuse Strategy Group Partner Agencies
All partner agencies of the Bristol Domestic and Sexual Abuse Strategy Group and the DHR Panel will take action to pro-actively raise awareness of domestic and sexual abuse amongst their staff and service users and promote a third party reporting campaign.
Addressed to
Leicester Social Care and Safeguarding Service
Within this process, the need to seek and evidence decision-making, inter-agency discussion, and third-party or triangulating information (e.g. health information which corroborates or reduces concern about a child) should be reinforced to social work staff. Relevant procedures e.g. Leicester Safeguarding Children’s Board (LSCB) procedures should also be highlighted. The need to ensure that an inter-agency perspective is maintained throughout an assessment or intervention should be highlighted.
Addressed to
Leicester Social Care and Safeguarding Service
Within this process, the importance of completing timely, thorough and holistic social work assessments which take fully into account the overall needs of each child, the overall circumstances of each carer or parent, and any relevant environmental issues or issues for the wider family should be reinforced. In particular, reminders should be offered about promoting and ensuring effective cross-boundary working. Again, relevant procedures e.g. LSCB procedures should be highlighted. Dissemination of IMR findings should comment on the need to ensure that contact or residence issues or disputes do not falsely obscure or hinder focus on children’s day-to-day and safeguarding needs.
Addressed to
Leicester Social Care and Safeguarding Service
Within this process, reminders should be offered about the importance of ensuring that families are given appropriate information about social work processes, expected timescales for assessment, appropriate contact information and complaints and appeals information.
Addressed to
Bristol Domestic and Sexual Abuse Strategy Group
The Bristol Domestic and Sexual Abuse Strategy Group will remind agencies of the importance of domestic and sexual abuse training for staff and to offer help in designing training to those organisations.
Addressed to
University Hospitals Bristol NHS Foundation Trust
Emergency Department (ED) Bristol Royal Infirmary (BRI) Staff to consider domestic violence and safeguarding when patients attend the unit, and take the appropriate action.
Addressed to
University Hospitals Bristol NHS Foundation Trust
Staff should not leave messages about patients and clinical information on answer phones but speak directly to colleagues or send written information if time allows.
Addressed to
NHS Bristol Clinical Commissioning Group | NHS England
Bristol NHS Provider services staff should consider asking people attending the service with symptoms or injuries which could indicate domestic or sexual abuse, whether they have been the victim of abuse
Force processes need to be examined to ensure that front-line officers are able to accurately identify foreign nationals and conduct relevant checks, and that any intelligence gathered is routinely shared with the Immigration Enforcement Department and other relevant agencies
That Avon and Somerset Constabulary continues to raise the profile of domestic abuse and encourages all victims, friends, family and neighbours to seek advice and support. Methods of anonymous reporting to be publicised to increase intelligence where members of the public do not wish to come forward directly when they are aware of domestic abuse. This, in turn, will provide more opportunities for third-party reporting of incidents and intelligence from a wide range of agencies and organisations, including, as an example in this case, abortion clinics and midwifery services
That where third-party intelligence is captured in respect of potential domestic abuse, that it is disseminated to neighbourhood policing teams and to the Safeguarding Co-ordination Units who will assess and develop a safety plan. Where appropriate, as part of a considered safety plan the relevant information is shared sensitively with immediate neighbours to establish a ‘cocoon watch’ to look out for the welfare of the victim and immediately report any signs of disturbance. This ‘cocoon watch’ must be fully briefed and supported by the local policing team to ensure they are familiar with how and whom to report concerns to.