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: 2014 Extracted: 16 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 a general lack of public awareness and reluctance to report domestic abuse, particularly third-party reporting, and highlights limited agency contact with the victim and the perpetrator, leading to missed opportunities for intervention by some services.

Extracted recommendations

16 recommendations pulled from the report

#	Recommendation	Addressed to
17.1.1	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.	Home Office
17.2.1	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.	Bristol Domestic and Sexual Abuse Strategy Group
17.2.2	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.	Bristol Domestic and Sexual Abuse Strategy Group \| DHR Panel
17.2.2a	IMR findings to be cascaded where relevant with Child in Need Service heads of service and service managers, via senior management meetings.	Leicester Social Care and Safeguarding Service
17.2.2b	IMR findings to be cascaded where relevant to Child in Need team managers and social workers, via team meetings or briefing session	Leicester Social Care and Safeguarding Service
17.2.2c	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.	Leicester Social Care and Safeguarding Service
17.2.2d	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.	Leicester Social Care and Safeguarding Service
17.2.2e	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.	Leicester Social Care and Safeguarding Service
17.2.3	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.	Bristol Domestic and Sexual Abuse Strategy Group
17.2.3a	Emergency Department (ED) Bristol Royal Infirmary (BRI) Staff to consider domestic violence and safeguarding when patients attend the unit, and take the appropriate action.	University Hospitals Bristol NHS Foundation Trust
17.2.3b	Adult Services to inform Maternity Services of any attendance of a pregnant woman to A and E or any admission to an Adult ward.	University Hospitals Bristol NHS Foundation Trust
17.2.3c	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.	University Hospitals Bristol NHS Foundation Trust
17.2.4a	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	NHS Bristol Clinical Commissioning Group \| NHS England
17.3.1a	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	Avon and Somerset Constabulary
17.3.1b	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	Avon and Somerset Constabulary
17.3.1c	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.	Avon and Somerset Constabulary
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗