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

Blackburn With Darwen review

CSP: Blackburn With Darwen Published: April 2023 Year of death: 2015 Extracted: 7 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 report highlights failures in safeguarding procedures, risk assessment, and inter-agency information sharing, particularly in underestimating the risk posed by an elderly perpetrator with declining health and potential dementia. It notes a lack of timely action and police referral, and insufficient consideration of the victim's safety.

Home Office classifications

15 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - was a carer
  • Victim - carer for perpetrator
  • Victim - serious or life limiting illness
  • Perpetrator - physical disability
  • Perpetrator - mental ill health
  • Perpetrator - cognitive disorder (dementia or alzheimer's disease)
  • Perpetrator - serious or life limiting illness
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - social services recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes

Extracted recommendations

7 recommendations pulled from the report

Recommendation i

Addressed to Blackburn with Darwen Safeguarding Adult Board

Blackburn with Darwen Safeguarding Adult Board satisfies itself that its constituent agencies understand the adult safeguarding alert procedures and when to apply them, including cases involving threats to kill;

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

Recommendation ii

Addressed to Blackburn with Darwen Community Safety Partnership

Blackburn with Darwen Community Safety Partnership satisfies itself, that its constituent agencies, know that it is necessary to search all of its databases and paper records, to produce a full picture of the domestic abuse risk factor they hold;

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

Recommendation iii

Addressed to Blackburn with Darwen Community Safety Partnership

Blackburn with Darwen Community Safety Partnership satisfies itself, that its constituent agencies know;
 That threats to kill can be domestic abuse;
 When it is necessary to refer people for mental health assessments, including the application of the Mental Health Act 1983;
 When to undertake carer’s assessments;
 How to assess risk of serious harm;
 How to produce good risk management plans;
and
 Review their domestic abuse policies to ensure that they address the need to refer older people with mental health problems to appropriate service

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

Recommendation iv

Addressed to Blackburn with Darwen Safeguarding Adult Board | Blackburn with Darwen Community Safety Partnership

Blackburn with Darwen Safeguarding Adult Board and Blackburn with Darwen Community Safety Partnership determines whether its present training and single agency training on domestic abuse specifically includes abuse between elderly people, including coercive and controlling behaviour {and the new legislation13} and factors in recognition of dementia and what that might mean for risk, and if not consider how the lessons from this case can be incorporated into domestic abuse training;

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

Recommendation v

Addressed to Blackburn with Darwen Community Safety Partnership

Blackburn with Darwen Community Safety Partnership use the findings of this review in staff briefing and training.

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

Recommendation vi

Addressed to Blackburn with Darwen Community Safety Partnership

Any future domestic homicide reviews within the Blackburn with Darwen Community Safety Partnership area include training for agencies on the DHR process and completion of IMR’s.

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

Recommendation vii

Addressed to Blackburn with Darwen Adult Social Care

Blackburn with Darwen Adult Social Care ensure that staff responsible for securing the welfare of individuals recognise the importance of not creating perceptions with victims and their families that financial considerations have a higher priority than reducing the risk of harm.

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