Somerset review

Additional training to be provided to all this agency’s staff in relation to identifying Domestic Abuse and Violence and making appropriate referrals.

This agency to ensure risk assessments are reviewed and completed in absence of the service user if they continually fail to engage in treatment and risk management plan to consider and address “past” issues as well as “present”.

This agency to consider developing “Crisis, Relapse & Contingency Plans” with details of emergency contacts and useful advice to use in the event of serious distress. This has now been implemented and is operational.

Information volunteered re relationship difficulties should stimulate further questioning / “professional curiosity” by staff involved to gain fuller understanding of what client is experiencing at that time. This could be fulfilled by emphasising the importance in safeguarding adults training and the Trust’s newsletter as a reminder.

Risk screen and information to be completed in relation to all MHA assessments to include recording current suicide risk. This would be achieved by monitoring this practice through supervision and caseload management.

This agency, with the support of the Chair, to seek further guidance and clarity to be sought from the Home Office in relation to sharing information about an ‘alleged perpetrator’ following a suicide.

In all cases of assault that attend the Emergency Department, the nature of the assault should be documented, and the victim should be asked who the perpetrator of the assault was. This should be clearly documented. If domestic abuse is identified staff should act in line with Trust policy.

This agency to continue with plans to employ a Homeless Health Support Worker for the Trust to assist with co-ordinating multi-agency intervention (including where domestic abuse identified) when required following attending the Emergency Department.

Review if improvements can be made to the Emergency Department’s response to domestic abuse e.g. Routine enquiry.

This agency to share the overall findings of the DHR with Emergency Department Staff

This agency to add a new powerpoint slide to the Emergency department training presentation outlining the issues raised by this case.

Learning from this review report to be shared with the Trust Safeguarding Committee and a summary of the key issues are shared with all staff through the Staff Bulletin.

All referrals to the Safeguarding team to be consider for flagging on the MAXIMS system. Flags to be added for medium risk cases (alongside current high-risk flagging) and to use professional judgment when considering flagging other cases.

This agency to change wording on front page of Domestic Abuse policy from ‘Women should be regularly asked if they are experiencing domestic abuse’ to ‘Ask any individuals whose attendance could be related to Domestic Abuse (such as assaults of physical injuries) if they are a victim of Domestic Abuse and to use more consistent terminology in the policy; using the term Domestic Abuse rather than Domestic Violence

‘Situational couple violence’ recognised as an issue and to be added to the current DA procedural guidance, to include information on screening techniques. In addition, this guidance will need to be disseminated through training

This agency to ensure that there is a process in place across the force where repeated DA reporting (including reports by third parties) are tasked for review and followed up by Neighbourhood Beat teams.

This agency to revise their safeguarding policy ensuring that domestic abuse is covered in detail with regards to spotting the signs of abuse, and steps that can be taken to help safeguard a victim from harm.

This agency to forge closer links with the domestic abuse specialist service in Taunton; Somerset Integrated Domestic Abuse Support Service to ensure that staff feel confident in signposting and making referrals to this agency.

BGSW CRC case managers to receive training in order to identify and take appropriate actions when there is potential domestic abuse in cases they manage.

This agency to ensure that staff demonstrate they clearly understand and adhere to BGSW CRCs approach to managing potential domestic abuse

Staff to clearly understand and adhere to BGSW CRCs approach to safeguarding

Case managers to develop an investigative approach when working with service users. With a particular emphasis on identifying potential domestic abuse, safeguarding, vulnerability and protected characteristics.

Case managers to develop effective information gathering/sharing practice with police and other key partner agencies.

To promote their services to all individuals who maybe experiencing abuse regardless of gender or sexuality.

Somerset Safeguarding Adult Board to lead on sharing learning from DHR19 in relation to professional curiosity across health economy in Somerset and gain assurance that this learning is embedded across all NHS Trusts and change is implemented.

All Panel members to raise awareness of male victims of domestic abuse amongst their organisation.

Police and BGSW CRC to consider how they could improve communication channels where an individual is on licence and repeated involved in domestic incidents or similar.

Home Office to consider mandating housing associations to become part of DHR Panels where they have had some involvement in order to improve awareness and responses for domestic abuse victims.