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

Colchester review

CSP: Colchester Published: April 2023 Year of death: 2016 Extracted: 10 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 report highlights a lack of formal multi-agency coordination for adults with capacity making unwise decisions, gaps in police safeguarding referrals, and insufficient awareness of 'cuckooing' and prescription drug misuse. It also points to the need for better integration between domestic violence and adult safeguarding services.

Extracted recommendations

10 recommendations pulled from the report

#	Recommendation	Addressed to
1	Southend, Essex and Thurrock Safeguarding Adult Boards to revise the SET safeguarding adult procedures to make it explicit that there is a formal process for agencies concerned about safeguarding risks for an adult with needs for care and support to convene a multi agency meeting. This meeting should have representation from all partners involved who can share information and develop an action plan.	Southend, Essex and Thurrock Safeguarding Adult Boards
10	The Home Office to consider aligning the Domestic Abuse definition and the definition of a Domestic Homicide Review.	Home Office
2	Southend Essex and Thurrock Safeguarding Adult Boards to review the Safeguarding Enquiry form (SETSAF1) and guidance so that the person’s desired outcome is recorded in their own words and the significance of this is understood by practitioners.	Southend Essex and Thurrock Safeguarding Adult Boards
3	The Essex Safeguarding Adult Board to ensure appropriate training and development is provided by its partners to increase practitioners’ understanding of Making Safeguarding Personal, while working with people who have mental capacity but make what others may consider unwise decisions and people with fluctuating capacity, for example, people who misuse substances. This recommendation is to include external partners such as housing associations.	Essex Safeguarding Adult Board
4	NHS England and North East Essex Clinical Commissioning Group to further to raise awareness on the potential misuse of prescription drugs particularly Pregabalin and Gabapentin with GP practices and prescribers across Essex including circulation of the Public Health England guidance.	NHS England \| North East Essex Clinical Commissioning Group
5	Police – To provide assurance to the Essex Safeguarding Adult Board that the arrangements put in place since the victim’s death are sufficiently robust to collate police information to get a complete picture of adults at risk and appropriate triage in considering referrals for adult safeguarding.	Police
6	Southend, Essex and Thurrock Domestic Abuse Board to revise the MARAC referral form to require all members of the household to be named, to ensure MARAC can include them in their considerations.	Southend, Essex and Thurrock Domestic Abuse Board
7	The Safeguarding Adult Board, and Children’s Safeguarding Board to raise awareness of Cuckooing and County Lines, exploitation of children, young people and vulnerable adults with the general public and professional staff.	Safeguarding Adult Board \| Children’s Safeguarding Board
8	The Safeguarding Adult Board to run an awareness campaign surrounding adult safeguarding specifically targeting supermarket workers and other retailers.	Safeguarding Adult Board
9	The Safeguarding Adult Board and Essex Domestic Abuse Board to develop effective and clear links and arrangements in working with adults with care and support needs who experience domestic abuse,	Safeguarding Adult Board \| Essex Domestic Abuse Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗