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: 2016
Extracted: 31 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 review identified shortcomings in multi-agency information sharing, record-keeping, and the effectiveness of multi-agency meetings. It also highlighted a need for enhanced professional training on domestic abuse, including controlling behaviour and gender bias, and consideration of harm reduction models for individuals with complex needs like the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Home Office reviews both the title of Domestic Homicide Reviews and the content of its Guidance document in the context of deaths occurring from suicide. | Home Office |
| 10 | Line Managers to check case recording accuracy as part of the file audit that is undertaken at each supervision e.g. ensuring correct terminology is used documents named and attached correctly Case closure summary to be written in every case, in line with section 4.1 of “Recording Guidance: Principles and Standards when recording Client and Carer Information”. | Adult Social Care – Line managers |
| 11 | Teams to follow the “Recording Guidance: Principles and Standards when recording Client and Carer Information”. If the need is identified as a result of this, practitioners to attend the “Recording Skills and report Writing” training. | Adult Social Care |
| 12 | Additional clarity to be provided and added to the Bournemouth, Dorset and Poole Multi-Agency Safeguarding Adults Procedures; Safeguarding Strategy Meeting Attendance. To ensure that all invited parties provide information and/or a substitute attendee should they be unable to attend. Review Templates - A mandatory action review mechanism in the review minute template to identify why actions were not completed and how this can be rectified. | Bournemouth and Poole Safeguarding Adults Board (SAB) |
| 13 | Domestic Abuse Awareness and MARAC training is made mandatory for all front line workers within the drug and alcohol workforce. | Bournemouth DACT |
| 14 | Review the Treatment System Risk Assessment Process to make sure: identifies risk in relation to domestic abuse, appropriate risk status is identified, tangible, is shared, information is up to date and easily identifiable on HALO – the case management system new/updated risks to other appropriate workers and attach evidence. | Bournemouth DACT |
| 15 | Develop a Domestic Abuse Protocol for treatment providers to adhere to that links into Borough Policy and the Pan Dorset Strategy. | Bournemouth DACT |
| 16 | Develop a procedure for the drug and alcohol workforce in relation to working with the ‘couples’. | Bournemouth DACT |
| 17 | Treatment providers commissioned by the DACT / PHD in Bournemouth to have agency specific Domestic Abuse Policies in place that are understood by the workforce. | Bournemouth DACT |
| 18 | Review of the Treatment System involvement with MARAC so a pathway can be developed. | Bournemouth DACT |
| 19 | Improve record keeping practice in the following areas: contain more detail, evidence why decisions are made or not, and why appointments are cancelled, notes need improving. with couples, information relevant to both parties must go on both of the parties’ case notes. | Bournemouth DACT |
| 2 | As part of the consideration of the DHR process, greater flexibility could be given to Community Safety Partnerships to only review those suicides where Domestic Abuse appears to have been a significant and primary influence on the decision of the person to take their own life. | Home Office |
| 20 | Review service provider safeguarding meeting processes: safeguarding sub intervention on HALO. recording information on to HALO from safeguarding meetings. standards of Safeguarding Leads. | Bournemouth DACT |
| 21 | Drug and Alcohol Statutory Social Work Team to keep records on HALO when joint working BEAT clients. | Bournemouth DACT |
| 22 | Ensure allowance for provision for pets is known to the workforce. | Bournemouth DACT | Bournemouth Borough Council |
| 23 | Synopsis of Learning to be Developed and shared with DHC to detail the learning from the DHR. | Dorset Healthcare NHS University Foundation Trust – Safeguarding adults lead |
| 24 | DHC staff to be supported with the application of the MARM process for people who self-neglect of do not engage with services | Dorset County Council | Dorset Healthcare NHS University Foundation Trust | NHS Dorset CCG |
| 25 | Ensure that the requirements of the Mental Capacity Act 2005 are embedded in practice across all agencies, including the appropriate use of advocacy. | Dorset Healthcare NHS University Foundation Trust |
| 26 | Review process to ensure all staff check all records within Locata when dealing with enquiries. | Bournemouth Borough Council – Housing & Customer |
| 27 | Record keeping training to be introduced to the staff training matrix to ensure accurate and appropriate recording takes place. | Bournemouth Borough Council – Housing & Customer |
| 28 | Process for people moving on from supported into council stock to include the Housing Officer and floating support worker making contact to establish relationship and ensure joint engagement with new tenant. | Bournemouth Borough Council – Strategic Housing and Housing Landlord |
| 29 | Review the process of key information from Locata being transferred to Northgate and EDRMS at the start of a tenancy to provide background knowledge for Housing Officers | Bournemouth Borough Council – Strategic Housing and Housing Landlord |
| 3 | The Community Safety Partnership to consider how it prioritises and delivers its services, and those for whom it can no longer provide. | Bournemouth Community Safety Partnership | Bristol Community Safety Partnership |
| 30 | Review the Rent Vulnerability Assessment which now takes place for people moving into a tenancy, to ensure it instigates the appropriate action for people who are at risk of falling into rent arrears. | Bournemouth Borough Council – Housing Rent Landlord |
| 31 | Staff are to be reminded of the importance of recording and to keep all agencies updated of non-engagement and signs of deterioration or withdrawal. | Bournemouth Borough Council – Housing & Customer |
| 4 | Partners to consider whether alternative routes to detox may decrease risk, particularly in cases of domestic abuse. Staff should and can challenge where only traditional routes to detox are being considered/offered. | Primary Care Commissioners |
| 5 | Domestic Abuse training for all staff. (Not limited to domestic abuse services) | BCHA |
| 6 | Training – risk management planning specific to domestic abuse. (Not limited to domestic abuse services) | BCHA |
| 7 | Ensure a Trauma Informed Approach in all Supported Housing Services | BCHA |
| 8 | Risk Management: Non-acceptance of referral for perpetrator to same supported housing service when victim is still in residence. | BCHA |
| 9 | Consider provision of access to Adult Social Care case recording systems to relevant safeguarding experts in the Housing and Communities Service – Directorate. (Better information sharing will enable better practice.) | Bournemouth Borough Council – Adult Social Care | Bournemouth Borough Council – Housing and Communities Directorates |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||