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
Colchester review
CSP: Colchester
Published: April 2023
Year of death: 2014
Extracted: 28 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 concerns regarding access to firearms, integration of patient care, and overarching themes of information sharing and training between agencies.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | That Essex Police inform GPs of current firearms licence holders as soon as possible, requesting them to flag patient records, and do not wait to the licence renewal date. This recommendation should be considered nationally. | Essex Police | Home Office |
| 10 | That it should be a prerequisite to the grant/renewal of a Firearms Licence that the applicant allow their GP to share relevant information to the holding of a Firearms Licence, with other agencies; which may otherwise fall within patient privilege. | Home Office |
| 11 | Agencies should report to the Community Safety Partnership compliance rates with mandatory safeguarding training. | Colchester Community Safety Partnership | All Agencies |
| 12 | That the Colchester Community Safety Partnership organise a seminar to facilitate joint training and learning between Agencies in North East Essex on safeguarding and particularly their separate roles in preventing and addressing Domestic Abuse. | Colchester Community Safety Partnership |
| 2 | That the Home Office review and broaden the medical conditions within the Home Office Guidance on Firearms Licensing Law 2014 regarding psychiatric assessment, to specifically include consideration of Dementia. | Home Office |
| 3 | A patient's GP should be notified of any assessment of risk completed in the course of a memory clinic appointment; this will allow the GP to have a more complete picture in assessing any required disclosure to Police in respect of the continuing suitability to hold a Firearm. | North Essex Partnership NHS University Foundation Trust |
| 4 | That the Home Office approved Firearms Licensing - Medical Pilot Scheme, which strengthens the grant and renewal process by notifying GPs that a patient holds a firearms licence and requiring that record to be flagged , be rolled out for adoption nationally. | Home Office |
| 5 | The principle of promoting individual well-being as set out in Care Act 2014 Part 1 and Promoting integration of care and support with health services Care Act 2014 Section 3 should be taken forward. Care Act 2014 training should include material to ensure that any care assessment broadens its focus to embrace an holistic approach which considers impact and effect of other family members and life changing situations. | Essex County Council - Adult Operations |
| 6 | Previous legislation with regard to Carers rights to advice, assessments and services/support is updated by provisions in Care Act 2014. Training/re-training for all practitioners likely to be involved in assessments or reviews of carers will therefore be required and should be mandatory. This should include practitioners at all stages of the customer journey. | Essex County Council - Adult Operations |
| 7 | That the DASH template includes the impact of significant life changing events. | Home Office |
| 8 | Agencies should, within legal guidelines, review their information sharing to ensure that they have not drifted into a position whereby, in the worst case, information is only shared when the holding Agency assess it as high risk. Information may be assessed as low risk but will still be relevant to the effective performance of partner. | All Agencies |
| 9 | Liaison and communication between the care providing agencies is improved by the provision of a strategic pathway of care, coordinated through a single point of contact or care manager to assist information gathering, analysis, assessment and sharing. There may be an opportunity to link current procedures. The provisions of the Care Act 2014, particularly sections 3 and 6 should drive a working group to establish guidance for Essex. | Essex County Council - Adult Operations |
| IMR_ACE1 | The domestic violence policy should be reviewed within the next three months to cover the services of both child and adult. | Anglian Community Enterprises |
| IMR_ACE2 | Set up a Working group to design a strategic pathway for identification of key workers/case managers for vulnerable adults with mental health needs. Within the next 6 months | Anglian Community Enterprises |
| IMR_ACE3 | Establishment of a working group within the next three months to support Methods of monitoring of Clinical supervision offered to staff across the organisation | Anglian Community Enterprises |
| IMR_ACE4 | All referral systems should be reviewed to include a section that prompts the referrer to identify any mental health needs or safeguarding matters. Communication could be improved with external agencies to support vulnerable adults with mental health needs. Practitioners need to be appropriately informed in relation to these needs to enable them to critically analyse situations and support individuals as effectively as possible | Anglian Community Enterprises |
| IMR_CHUFT1 | Care arrangements should have been identified earlier on admission to CHUFT to avoid confusion as to what care was already in place for the victim and the perpetrator and to assist social care in identifying whether a carers assessment was required. | Colchester Hospital University Foundation NHS Trust |
| IMR_ECCAO1 | Work is already in hand to replace the two current databases used by ECC Adult Operations with one new database MOSAIC. This will hopefully centralise, simplify and improve the efficiency of recording accessing and retrieving relevant information regarding ECC customers | Essex County Council - Adult Operations |
| IMR_ECCAO2 | The previous legislation with regard to Carers rights to advice, assessments and services/support is updated by provisions in Care Act 2014. Training/re-training for all practitioners likely to be involved in assessments or reviews of carers will therefore be required and should be mandatory. This should include practitioners at all stages of the customer journey | Essex County Council - Adult Operations |
| IMR_EP1 | Having taken part in a Home Office approved Firearms Licensing- Medical Pilot Scheme regarding the renewal of Firearms Licences this review recommends that Essex Police progress their liaison with the Home Office in an effort to have this scheme adopted nationally and a formal information sharing agreement put in place | Essex Police | Home Office |
| IMR_EP2 | Firearms Enquiry Officers to be reminded that where there is a change in referees/counter signatories the reason for the change should be recorded. The referee/counter signatory on the previous application should be contacted to ascertain if they have been asked to be a referee and refused and if they refused, the reasons must be obtained and recorded | Essex Police |
| IMR_NEECCG1 | All new clinical services will be commissioned via a standard NHS contract. | NHS North East Essex Clinical Commissioning Group |
| IMR_NEECCG2 | Safeguarding KPI’s to be included in all NHS contracts with providers of services. | NHS North East Essex Clinical Commissioning Group |
| IMR_NEECCG3 | The contracting team, business managers and quality team to work collaboratively. | NHS North East Essex Clinical Commissioning Group |
| IMR_NEP1 | Recommended from the Trust Serious Incident Investigation Review was that risk (including if none identified) to be documented in the GP letter following routine memory monitoring appointments – this has been implemented fully. | North Essex Partnership NHS University Foundation Trust |
| IMR_NHMG1 | To continue the rolling programme of safeguarding training for practice staff as per practice policy. | North Hill Medical Group |
| IMR_NHMG2 | Inform the out of hours service of firearms licence holders as they do not access our computer records. | North Hill Medical Group |
| IMR_SHG1 | To consider working with GP’s on referral regardless of referral route to identify any presenting risks that they are aware of including gun licences. We will communicate with our commissioners (North East Essex Clinical Commissioning Group) to establish if this is a process that could effectively be implemented. | Swan Housing Group |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||