Home / Sources / Domestic Homicide Reviews / Colchester · Apr 2023
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.

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

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

35 tags

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

  • Victim - housing issues
  • Victim - physical disability
  • Victim - serious or life limiting illness
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • 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 - community safety partnership 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 - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

10 recommendations pulled from the report · 5 matched to organisations in the index

Recommendation 1

Addressed to Southend, Essex and Thurrock Safeguarding Adult Boards

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.

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

Recommendation 2

Addressed to Southend Essex and Thurrock Safeguarding Adult Boards

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.

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

Recommendation 3

Addressed to Essex Safeguarding Adult Board

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.

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

Recommendation 4

Addressed to NHS England | North East Essex Clinical Commissioning Group

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.

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

Recommendation 5

Addressed to Police

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.

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

Recommendation 6

Addressed to Southend, Essex and Thurrock Domestic Abuse Board

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.

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

Recommendation 7

Addressed to Safeguarding Adult Board | Children’s Safeguarding Board

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.

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

Recommendation 8

Addressed to Safeguarding Adult Board

The Safeguarding Adult Board to run an awareness campaign surrounding adult safeguarding specifically targeting supermarket workers and other retailers.

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

Recommendation 9

Addressed to Safeguarding Adult Board | Essex Domestic Abuse Board

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,

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

Recommendation 10

Addressed to Home Office

The Home Office to consider aligning the Domestic Abuse definition and the definition of a Domestic Homicide Review.

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