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

Bournemouth review

CSP: Bournemouth Published: April 2023 Year of death: 2016 Extracted: 7 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 missed opportunities by agencies to identify and intervene in the victim's domestic abuse, stemming from inadequate information sharing, limited understanding of coercive control, and challenges in engaging the victim. Issues included health services' failure to link the perpetrator's history, police non-engagement procedures, and schools not following safeguarding guidance for child disclosures.

Extracted recommendations

7 recommendations pulled from the report

#	Recommendation	Addressed to
9.1	A campaign to educate and raise public awareness to enable early identification by potential victims, friends and family of risk factors and signs of abusive, controlling and coercive behaviour. A local publicity campaign to educate the public regarding Domestic Abuse that addresses: • What domestic abuse is • The profile, behaviour and motivations of perpetrators, who they target and why • The nature of coercive control is and why it is so dangerous • What you can do to protect family, friends, colleagues or others if you suspect they are in an abusive relationship.	Bournemouth Community Safety Partnership
9.2	The Local Safeguarding Children Board (LSCB) strongly encourage the promotion of Healthy Relationship Education within the curriculum so that all young people in the area receive age appropriate education on healthy relationships and use the annual safeguarding audit process to provide quality assurance. This review notes that the victim was a victim of considerable abuse during her relationships, her family believe she thought wrongly that she could manage her abusive partners. They do not know what education if any she had on the issue of domestic abuse, but think that young people should receive this formally to build resilience in them. Therefore, the Review recommends that the LSCB as part of its prevention strategy encourage the uptake of ‘Healthy Relationships’ education in its schools, academies and colleges to ensure all young people have an age appropriate understanding of abusive relationships, the concept of ‘consent’ and be empowered to understand and exercise their rights as citizens in personal and public relationships with others. Sex and Relationship Education (SRE) became mandatory in all schools in England, including Academies and Free schools from March 2017. The Government will be holding a public consultation on what should be taught and when, so the new SRE curriculum is not likely to come into effect until 2019.From that point it will be possible for the LSCB to be reassured by an audit process that children and young people in their area are receiving appropriate and timely education on these issues	Local Safeguarding Children Board (LSCB)
9.3	The Local Safeguarding Children Board (LSCB) work in partnership with schools and Academy Trusts to ensure that the relevant Safeguarding legislation and guidance are followed. In addition, that any local well-being initiatives introduced to secure the safety and well-being of children in their care do not comprise nationally agreed procedures. • The relevant legislation and guidance are Section 10 of the Children’s Act 2004, Keeping Children Safe in Education (2016) and Working Together to Safeguarding Children (2015) • Under section 14B of the Children Act 2004 the LSCB can require a school or college to supply information in order to perform its functions. The LSCB seeks reassurance from Governing bodies and proprietors of all schools and colleges that their safeguarding arrangements take into account the procedures and practice of the local authority as part of the inter-agency safeguarding procedures set up by the LSCB. • Section 175 of the Education Act 2002 puts a duty on local education authorities, maintained (state) schools and further education institutions, (including sixth form colleges) to exercise their functions with a view to safeguarding and promoting the welfare of children who are pupils and students under 18 years of age; in the case of schools and colleges. The same duty is put on independent schools, including academies, by regulations made under s157 of that Act. • Legislation maintains that all providers of training in relation to Safeguarding in Education for staff and designated leads address the prevalence and the presentation of domestic abuse, the multi -agency management of domestic abuse and the part schools or Academy Trusts can play in protecting children who witness domestic abuse.	Local Safeguarding Children Board (LSCB)
9.4	Health Service agencies adopt best practice for the assessment and management of domestic abuse. • That a whole system review of how Health Visitors and other Health staff address Domestic Abuse be undertaken • That Health staff know how to ‘ask and act’ about domestic abuse and are confident to discuss these issues safely with patients known to be victims and/or perpetrators. • Current training on engaging potential perpetrators of domestic abuse to be reviewed as this review has identified current training advises professionals not to address domestic abuse with the perpetrator even when they have been notified officially by the Police of a recorded incident. This approach could be interpreted by the perpetrator as collusive behaviour by the professional and increase their sense of power over their victims. • That an approach which identifies ‘making every contact count’ particularly with hard to reach and/or superficially engaged young people and young adults with children should be considered. • Training of Health Visitors on Disguised Compliance to include the learning from Serious Case Reviews on this presentation https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/disguised-compliance/ • An understanding of and using the tools of managing ‘Disguised Compliance’ should be an integral part of such an approach.	Dorset Health Care University Foundation Trust \| Dorset Clinical Commissioning Group
9.5	All GP practices across Dorset, Bournemouth and Poole to identify a lead for domestic abuse within the surgery and to embed the RCGP domestic abuse pathway. Michelle’s pattern of seeking emergency appointments meant that the GP practice that Michelle attended could not offer a consistent GP in her care. Managing patients who attend in this manner can only be done with consistent, full and reflective recording. At that time, the attending GP did not have ‘easy sight’ of the available SCARFs and this hampered recognition of the warning signs that were present. As a result of the review undertaken by the practice this Review has been assured that this has been remedied with the new Public Protection Notifications (PPNs) which replaced the SCARFs. The GP practices all now have a named domestic abuse lead in place and facilitated workshops are planned for GPs in November 2017. However, recent changes separating Health Visitors from GP Practices will mean the GP will no longer be able to rely on Police information being shared through this route and therefore further reassurance is necessary that a route of communication from the Police to GP practices will imminently be in place. In the six months before Michelle was killed she had no contact with the Police as incidents as described earlier were not reported. Such behaviour is not unusual in relation to abusive, coercive and controlling behaviour. It is therefore critical that professionals who work with the public are at the moment of contact able to create a relationship in which a dialogue about the person’s safety and wellbeing is undertaken and if needed appropriate advice given or referral made. In the Department of Health’s latest domestic abuse guidance for Health professionals – ‘Responding to domestic abuse’ published in March 2017, the responsibilities for commissioners and local strategic partnerships are clearly outlined. This resource draws on the National Institute for Health and Care Excellence multi-agency guidelines on domestic violence and abuse. It replaces two earlier Department of Health documents- ‘Domestic Violence: A Resource Manual for Health Care Professionals’ (2006) and ‘Improving Safety, Reducing Harm: Children, Young People and Domestic Violence – a Practical Toolkit for Front-line Practitioners’ (2010). All of these documents acknowledge that the role of Health professionals is to identify domestic abuse as early as possible, to make appropriate referrals to specialist services and to work closely with other agencies to ensure that the safety of the patient is paramount. www.gov.uk/government/publications/domestic-abuse-a-resource-for-health-professionals The Royal College of General Practice -Responding to domestic abuse: Guidance for general practices was published in March 2013. This guidance produced was to enable general practices to respond effectively to domestic violence and abuse (DVA) in primary care and develop their DVA policy. This guidance is in line with the National Institute for Health and Care Excellence multi-agency guidelines on domestic violence and abuse. All of these documents direct General Practice towards an evidence based model for the identification and onward referral of patients that are victims of domestic abuse.	Dorset Clinical Commissioning Group
9.6	Dorset Police review police non-engaging victim procedure to provide clarity on how police identify, assess and manage a repeat domestic abuse victim where either the police are not able to offer a service that the victim can engage with or the victim is not able to engage with the service offered. Procedure to cover the roles and links between initial response, investigation, Maple Team and referring to wider partners. The Maple project run by Dorset Police is victim focussed and the Domestic Abuse Investigation Team deal with alleged offenders. The Dorset Police Service was aware of the perpetrator’s wider violent behaviour and that there was a pattern of many alleged victims - partners, family members, friends or members of the public who chose not to report incidents they were aware of either as victims or witnesses. The Police Service had contact with the victim over several years and during these contacts was unable to engage with her. That SCARFs were not completed as they should have been would mean that the Maple project would not contact the alleged victim. The review recommends that the current arrangements are reviewed in relation to hard to engage victims	Dorset Police
9.7	Ministry of Justice review the storage policy of Women Safety Worker records. Probation Women’s Safety Workers records were absent in this case having been destroyed after five in storage in accordance with current guidelines. I know this to be an issue for other DHRs and the Review requests that the Ministry of Justice review this guideline to better enable review of practice in such cases.	Ministry of Justice
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗