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.
Extracted recommendations
21 recommendations pulled from the report · 13 matched to organisations in the index
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗
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) ↗