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

Ceredigion review

CSP: Ceredigion Published: April 2023 Year of death: 2014 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 review identified concerns regarding the management and transfer of the perpetrator's severe mental illness records, leading to a lack of monitoring. It also highlighted missed opportunities by health services to identify potential domestic abuse and a lack of formal information sharing procedures within local authorities.

Extracted recommendations

10 recommendations pulled from the report

#	Recommendation	Addressed to
11.10	Consideration should be given to developing a template for a public information notice to be inserted in local newspapers. The media should be encouraged to be more involved in assisting DHRs particularly in identifying any background knowledge of the case from members of the public.	DHRs \| media
11.11	While not arising directly from this review but mindful of the implementation of the Violence against Women, Domestic Abuse and Sexual Violence (Wales) Act 2015, all Agencies should encourage the speedy adoption of a Domestic Abuse designated lead in line with the VAWDASV Act. Thought should be given to expanding this to all GP Surgeries by having Domestic Abuse Lead Partners along the same lines as existing Child Protection Leads.	all Agencies \| GP Surgeries
11.2	General practitioners and Health Boards should review their procedures and ensure that: a. the decision to remove patients from the Severe Mental Illness Register or from recall should be made by the medical practitioner responsible for the patient. The clinician must record the reason for doing so including identifying any ongoing concerns; b. medical records are transferred to a new surgery in a timely manner; and c. the procedures for summarising patients’ records should be in line with current best practice to ensure that areas of potential concern, particularly in relation to mental health, are clearly identifiable.	General practitioners \| Health Boards
11.3	Hospitals, General Practitioners and primary care contractors must have procedures, for ensuring that possible concerns are properly identified, recorded and shared, on a confidential basis, with appropriate practitioners or agencies including primary care. These procedures must be reviewed periodically. Front line staff must be trained to identify signs of domestic abuse and ensure that any concerns they have are fed into the procedure without delay. Staff uptake of training should be monitored. The Domestic Abuse Forum should have an overview of the procedure and the monitoring of uptake.	Hospitals \| General Practitioners \| primary care contractors \| Domestic Abuse Forum
11.4	The training of all staff to a level appropriate to their need, in identifying, recording and sharing concerns should be a key priority within Health Boards and Hospitals. Joint training with General Practitioners and primary care contractors will promote a greater understanding on how to share concerns. The training programme should be reviewed regularly and an overview of both the training programme review and the monitoring of uptake.	Health Boards \| Hospitals \| General Practitioners \| primary care contractors
11.5	For local authorities: a. procedures should be introduced that reinforce the duty of all frontline staff across all departments in local authorities to record and share information within and outside of the authority relating to concerns about the suspicion or disclosure of domestic violence; b. Local Authority Domestic Abuse policies should be widely disseminated to all staff and management as a matter of urgency.	local authorities
11.6	The Police, in collaboration with other agencies on the Domestic Abuse Forum, must continue to develop and implement a Multi-Agency Safeguarding Hub (MASH) to ensure the sharing of all information on possible cases of domestic abuse.	Police \| Domestic Abuse Forum
11.7	The third sector should play a pivotal role in developing information sharing protocols.	third sector
11.8	All the agencies involved in Domestic Abuse Forums (or equivalent) need to review current measures to identify additional opportunities to increase awareness of domestic abuse including greater use of the media. Similarly, all agencies involved in the forum must have procedures relating to identifying, recording and sharing concerns and for the provision of training. This must include considering what are the indicators of abuse and identifying coercive conduct by the perpetrator. In designing these, lessons may be learnt from child protection and adult safeguarding procedures. These procedures should be considered by the forum and revised when appropriate. The training programme should be regularly reviewed and participation monitored. Monitoring reports should be considered by the forum.	agencies involved in Domestic Abuse Forums
11.9	In order to encourage open discussions at DHR meetings, minutes should not normally be discoverable. This will facilitate open discussion in the DHR meetings. Only in the case of a public interest to disclose being established should they be made available.	DHR meetings
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗