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

North Worcestershire review

CSP: North Worcestershire Published: April 2023 Year of death: 2016 Extracted: 21 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identifies systemic failures in multi-agency understanding and application of adult safeguarding, domestic abuse, and mental capacity legislation, particularly concerning a vulnerable victim with a learning disability. It highlights missed opportunities for intervention and inconsistent responses to the victim's alcohol dependency and the perpetrator's coercive control.

Home Office classifications

20 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - housing issues
  • Victim - physical disability
  • Perpetrator - case heard in court
  • Perpetrator - housing issues
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

21 recommendations pulled from the report · 13 matched to organisations in the index

Recommendation 1

Addressed to Worcestershire Acute Hospitals NHS Trust

Worcester Acute Hospitals NHS Trust to review the number of previous Accident and Emergency Department attendances upon admission of a person and to consider any potential safeguarding concerns.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups

GPs and Clinical Practice Staff in Worcestershire to complete Safeguarding Adults Level 3 Training which includes Domestic Abuse (DA) training and PREVENT.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Redditch Borough Council

Redditch Borough Council to produce policy and procedures regarding domestic abuse, which should include risk assessment and risk management.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to West Mercia Police

West Mercia police to provide assurance to partners around notifications of Domestic Violence Protection Orders and to ensure there is a revised programme of training in their application.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Worcestershire Adult Social Care | Worcestershire Health and Care NHS Trust

Worcestershire Adult Social Care and Worcestershire Health and Care NHS Trust to ensure that an assessment by the most appropriate team should take place to determine whether a person has eligible needs.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Worcestershire Acute Hospitals NHS Trust

Worcester Acute Hospitals NHS Trust to ensure compliance with NICE Public Health guideline on ‘Domestic Violence and Abuse: how services can respond effectively’ (PH50); recommendation 6 (Ensure trained staff ask people about domestic violence and abuse).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups

CCG to audit Safeguarding Adult Level 3 training as part of the CCG Programme of Audit for GP Practices.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Redditch Borough Council

Redditch Borough Council to provide training in domestic abuse for all home visiting staff relevant to their role.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to West Mercia Police

West Mercia Police to ensure that when RMPs are in place for combined issues domestic abuse policy and procedure is always pursued.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Worcestershire Adult Social Care

Worcestershire Social Care to amend the guidance on the risk assessment of people who do not engage with services to include lack of engagement with professionals and disseminate to staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups

CCG to communicate current Domestic Abuse Guidance to all Worcestershire GP Practices.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Redditch Borough Council

Redditch Borough Council to promote awareness amongst its staff of the adult safeguarding process and escalation procedures.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to West Mercia Police

West Mercia Police should equip officers and staff with the required knowledge and understanding of behaviours and legislation in relation to coercive and controlling behaviour.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to West Mercia Police

West Mercia Police to produce a local policy and procedure on Adult Safeguarding given the current absence of Approved Professional Practice.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to West Mercia Police

West Mercia Police to raise staff and officer’s awareness of the Care Act with particular regard to adult safeguarding.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to West Mercia Police

WMP to review the process of referrals to partner agencies following response to incidents involving vulnerable adults.

Verified wording from the published review · Original review (PDF) ↗

Recommendation O1

Addressed to National Policing Lead for Adult Safeguarding

DHR author to write to the National Police Lead for Adult Safeguarding DCC Pilling, Greater Manchester Police to highlight the need to produce Approved Professional Practice on Adult Safeguarding.

Verified wording from the published review · Original review (PDF) ↗

Recommendation O2

Addressed to Department of Work and Pensions (DWP)

DHR author to write to the Local Government Association (LGA) who are currently working with DWP for the LGA to seek assurance that governance arrangements exist within the Department to ensure effective policies and procedures are in place in respect of adult safeguarding, domestic abuse and compliance with the Mental Capacity Act 2005.

Verified wording from the published review · Original review (PDF) ↗

Recommendation O3

Addressed to Worcestershire Office of Data Analytics project

The chair of the Worcestershire DHR sub group on behalf of the North Worcestershire Community Safety Partnership to write to the Worcestershire Office of Data Analytics project who is working on the development of shared systems and/or data. To share the themes and learning from this review to inform the future of data capture and sharing arrangements.

Verified wording from the published review · Original review (PDF) ↗

Recommendation O4

Addressed to Worcestershire Public Health

On behalf of the North and South Worcestershire Community Safety Partnerships to develop scope and commission domestic abuse training which seeks to bring together both Children and Adult social care and wider partners, making the links to safeguarding.

Verified wording from the published review · Original review (PDF) ↗

Recommendation O5

Addressed to West Mercia Women’s Aid | Worcestershire Adult Social Care

To develop a joint working protocol around clients with complex needs that are suffering domestic abuse.

Verified wording from the published review · Original review (PDF) ↗