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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | 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. | Worcestershire Acute Hospitals NHS Trust |
| 1 | GPs and Clinical Practice Staff in Worcestershire to complete Safeguarding Adults Level 3 Training which includes Domestic Abuse (DA) training and PREVENT. | NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups |
| 1 | Redditch Borough Council to produce policy and procedures regarding domestic abuse, which should include risk assessment and risk management. | Redditch Borough Council |
| 1 | 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. | West Mercia Police |
| 1 | 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. | Worcestershire Adult Social Care | Worcestershire Health and Care NHS Trust |
| 2 | 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). | Worcestershire Acute Hospitals NHS Trust |
| 2 | CCG to audit Safeguarding Adult Level 3 training as part of the CCG Programme of Audit for GP Practices. | NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups |
| 2 | Redditch Borough Council to provide training in domestic abuse for all home visiting staff relevant to their role. | Redditch Borough Council |
| 2 | West Mercia Police to ensure that when RMPs are in place for combined issues domestic abuse policy and procedure is always pursued. | West Mercia Police |
| 2 | 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. | Worcestershire Adult Social Care |
| 3 | CCG to communicate current Domestic Abuse Guidance to all Worcestershire GP Practices. | NHS Redditch and Bromsgrove and NHS South Worcestershire Clinical Commissioning Groups |
| 3 | Redditch Borough Council to promote awareness amongst its staff of the adult safeguarding process and escalation procedures. | Redditch Borough Council |
| 3 | 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. | West Mercia Police |
| 4 | West Mercia Police to produce a local policy and procedure on Adult Safeguarding given the current absence of Approved Professional Practice. | West Mercia Police |
| 5 | West Mercia Police to raise staff and officer’s awareness of the Care Act with particular regard to adult safeguarding. | West Mercia Police |
| 6 | WMP to review the process of referrals to partner agencies following response to incidents involving vulnerable adults. | West Mercia Police |
| O1 | 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. | National Policing Lead for Adult Safeguarding |
| O2 | 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. | Department of Work and Pensions (DWP) |
| O3 | 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. | Worcestershire Office of Data Analytics project |
| O4 | 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. | Worcestershire Public Health |
| O5 | To develop a joint working protocol around clients with complex needs that are suffering domestic abuse. | West Mercia Women’s Aid | Worcestershire Adult Social Care |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||