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
Somerset review
CSP: Somerset
Published: April 2023
Year of death: 2017
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 systemic failures in recognising the victim as a male victim of domestic abuse, a lack of professional curiosity across agencies, and poor information sharing. Agencies also struggled to adequately assess and manage risks for an individual with complex needs and a history of substance misuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 17.1.1 | Additional training to be provided to all this agency’s staff in relation to identifying Domestic Abuse and Violence and making appropriate referrals. | Somerset Drug and Alcohol Service |
| 17.1.2 | 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”. | Somerset Drug and Alcohol Service |
| 17.1.3 | 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. | Somerset Drug and Alcohol Service |
| 17.2.1 | 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. | Somerset Partnership NHS Foundation Trust |
| 17.2.2 | 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. | Somerset Partnership NHS Foundation Trust |
| 17.3.1 | 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. | Somerset Clinical Commissioning Group |
| 17.4.1 | 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. | Taunton and Somerset NHS Foundation Trust |
| 17.4.2 | 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. | Taunton and Somerset NHS Foundation Trust |
| 17.4.3 | Review if improvements can be made to the Emergency Department’s response to domestic abuse e.g. Routine enquiry. | Taunton and Somerset NHS Foundation Trust |
| 17.4.4 | This agency to share the overall findings of the DHR with Emergency Department Staff | Taunton and Somerset NHS Foundation Trust |
| 17.4.5 | This agency to add a new powerpoint slide to the Emergency department training presentation outlining the issues raised by this case. | Taunton and Somerset NHS Foundation Trust |
| 17.4.6 | 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. | Taunton and Somerset NHS Foundation Trust |
| 17.4.7 | 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. | Taunton and Somerset NHS Foundation Trust |
| 17.4.8 | 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 | Taunton and Somerset NHS Foundation Trust |
| 17.5.1 | ‘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 | Avon and Somerset Constabulary |
| 17.5.2 | 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. | Avon and Somerset Constabulary |
| 17.6.1 | 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. | Taunton Association for the Homeless |
| 17.6.2 | 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. | Taunton Association for the Homeless |
| 17.7.1 | 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. | BGSW Community Rehabilitation Company |
| 17.7.2 | This agency to ensure that staff demonstrate they clearly understand and adhere to BGSW CRCs approach to managing potential domestic abuse | BGSW Community Rehabilitation Company |
| 17.7.3 | Staff to clearly understand and adhere to BGSW CRCs approach to safeguarding | BGSW Community Rehabilitation Company |
| 17.7.4 | 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. | BGSW Community Rehabilitation Company |
| 17.7.5 | Case managers to develop effective information gathering/sharing practice with police and other key partner agencies. | BGSW Community Rehabilitation Company |
| 17.8.1 | To promote their services to all individuals who maybe experiencing abuse regardless of gender or sexuality. | Somerset Integrated Domestic Abuse Service |
| 17.9.1 | 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. | Somerset Safeguarding Adult Board |
| 17.9.2 | All Panel members to raise awareness of male victims of domestic abuse amongst their organisation. | Somerset County Council | Somerset Partnership NHS Foundation Trust | Somerset Clinical Commissioning Group | Avon and Somerset Constabulary | Liverty (SIDAS) | Turning Point (SDAS) | Community Rehabilitation Company | Taunton and Somerset NHS Foundation Trust | Taunton Association for the Homeless |
| 17.9.3 | 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. | Avon and Somerset Constabulary | BGSW Community Rehabilitation Company |
| 17.9.4 | 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. | Home Office |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||