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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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

Recommendation 17.1.1

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.1

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

Addressed to Leicester Social Care and Safeguarding Service

IMR findings to be cascaded where relevant with Child in Need Service heads of service and service managers, via senior management meetings.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

Addressed to Leicester Social Care and Safeguarding Service

IMR findings to be cascaded where relevant to Child in Need team managers and social workers, via team meetings or briefing session

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.2

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.3

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.3

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.3

Addressed to University Hospitals Bristol NHS Foundation Trust

Adult Services to inform Maternity Services of any attendance of a pregnant woman to A and E or any admission to an Adult ward.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.3

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.2.4

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.3.1

Addressed to Avon and Somerset Constabulary

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.3.1

Addressed to Avon and Somerset Constabulary

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17.3.1

Addressed to Avon and Somerset Constabulary

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.

Verified wording from the published review · Original review (PDF) ↗