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

Leeds review

CSP: Leeds Published: May 2023 Extracted: 22 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 fragmented multi-agency responses, limited information sharing, and an inadequate understanding of the cumulative impact of stalking and harassment. There were missed opportunities to address the victim's complex needs, including domestic abuse, mental health, and alcohol use, exacerbated by barriers to accessing culturally sensitive specialist services.

Extracted recommendations

22 recommendations pulled from the report

#	Recommendation	Addressed to
1	Safer Leeds, Leeds Adult Safeguarding Board and Leeds Safeguarding Children Board should respond collectively to gaps in practitioner knowledge and training needs by delivering multi-agency training, e-learning, shadowing and mentoring to: • Increase understanding of the impact of stalking and harassment to improve risk assessments. This should include exploration of the factors that increase risk in stalking such as substance misuse, history of violence and coercive control (including perpetrator tactic changes) • Explore the ways in which victim blaming and the concept of “deserving victims” can affect professional judgement and risk assessment • Develop skills around working with resistance and disengagement • Improve skills in engagement, critical questioning and professional enquiry • Support routine and triggered enquiry in appropriate settings to encourage early identification and timely intervention • Increase understanding of the help seeking process and opportunities for engagement and intervention • Increase understanding of the links between to the misuse of alcohol, domestic abuse and access to support services • Increase understanding of depression, self-harm and domestic abuse	Safer Leeds \| Leeds Adult Safeguarding Board \| Leeds Safeguarding Children Board
2	All agencies involved in this review should implement good practice to ensure a proactive approach to disclosures and risk including: • Identifying key individuals in agencies to provide a lead on domestic abuse advice and consultancy • Developing a disengagement protocol • Promoting NICE guidance on responding to self-harm • Evaluating training needs for IMR authors to address gaps in analysis skills to improve the quality of IMRs • Evaluating the Leeds response to “Improving the police response to domestic abuse” (HMIC: 2014) and WYP training on domestic abuse (WYP) and offer opportunities to increase understanding of stalking and harassment • Providing guidance to promote a proactive approach to disclosures of partner abuse, stalking and/or harassment to increase involvement with MARACs, improve risk assessments and increase knowledge of available support • Continue the requirement of commissioners to include a standard in all LCC commissioned services and LCC direct services to attain the Leeds Domestic Violence Quality Mark or other required minimum standards in responding to domestic abuse	All agencies involved in this review
3	All agencies involved in this review should improve their responses to working with BME communities. This should include: 3. Utilising the Leeds Domestic Violence Quality Mark to quality assure support and information to individuals from some BME communities. 4. Promoting anti-racist, culturally sensitive responses that address the complex and additional issues facing BME victims within their communities as well as the barriers they face in accessing services. 5. Ensure that providers are more aware of the limited resources and lack of specialist services as referral sources, and identify and promote alternatives where available. 6. Strategy and Commissioning in Public Health to evaluate the Leeds response to working with BME communities as part of the domestic violence commissioning review. This should include the voice of service users and BME community based service providers to identify gaps and recommend how culturally sensitive services can be improved and developed. 7. Delivering culturally sensitive services and helping marginalised individuals to overcome issues and barriers to access generic services 8. Identifying how referral information can be improved to ensure that the ethnicity of each referral is recorded and considered in service delivery and that relevant referrals are linked such as family members and ex-partners	All agencies involved in this review
4	Improving Inter-Agency Working • Safer Leeds to co-ordinate a response to identified gaps in inter-agency working and information sharing • All agencies involved in this review should make themselves aware of relevant Information Sharing Protocols and Agreements including any recent amendments • Safer Leeds and CPS to respond to the findings that CPS has been identified as a critical partner in more than one DHR and CPS needs to be included and actively contributing to the process. • Leeds Domestic Violence Strategy group to investigate the potential for a model where service users have one support plan created with input from all agencies involved rather than a separate plan from each agency which is rarely shared. This would offer the opportunity for a more comprehensive background to inform risk assessments and interventions. • Investigate the principle of agencies identifying a single point of contact to act as a “care co-ordinator” to help overcome gaps in information and sustain engagement. Identify how a lead professional would enhance service responses for individuals reporting domestic abuse; and if the practice implications can be overcome. • Safer Leeds and Adult Social Care to address threshold issues raised in recent DHR panel meetings and facilitate agreement for a consistent response and understanding of safeguarding referrals without consent and choices for adults with capacity not to access services • Strategy and commissioning to evaluate the contract specification and domestic violence and abuse policies for housing support providers relating to housing discretion in providing alternative accommodation:  To explore how this would apply to Registered Social Landlords  To ensure that safety is a key priority where a person is identified as requiring re-housing as a result of domestic abuse and this will not be denied as a result of rent arrears  To promote the wider use of DASH risk assessments across agencies  to include risk management as part of case closure • All agencies in this review should include the following in their assessment procedures:  Ethnicity is asked and recorded  Links are made between referrals to identify where abusive relationships exist between clients using the same service  A standard of “asking the question” identifying if domestic abuse is a current or a historic issue  Where possible and safe, ask if the name of the perpetrator can be recorded to ensure joint access to services does not increase risk  Appropriate information sharing of perpetrator information with agencies providing services to the victim to assess potential risk of harm  Ensuring that if a referral fails to meet the threshold for particular service practitioners are referring to appropriate support as a recorded action; rather than closing cases without ensuring information or support to access alternative services has been given	Safer Leeds \| All agencies involved in this review \| CPS \| Leeds Domestic Violence Strategy group \| Adult Social Care \| Strategy and commissioning
ADS	• Develop strong effective links with MARAC team; ADS staff to fully engage with the process • Include MARAC training for current and new staff team • Transform GP based Tier 2 services into a Tier 3 service • Review current case notes system	Addiction Dependency Solutions (ADS)
ASC	• Recording is of a high standard, ensuring defensible decision-making and effective accountability • Risks are assessed when an adult with care and support needs experiencing domestic abuse is referred to ASC for support • ASC staff understand the interface between safeguarding and domestic abuse • ASC staff to understand and exercise their role and responsibilities within the City Council ‘Think Family’ approach • ASC staff to be clear about their statutory duties in relation to children and young people	Adult Social Care (ASC)
HM Court	Leeds Magistrates Court Legal Training Manager to promote opportunities for learning from this DHR such as exclusion requirements, non molestation orders and the process of analysing risk.	Leeds Magistrates Court
Housing	Housing support agencies to evaluate information sharing and knowledge of partner resources, services and support including how specialist domestic violence services can provide added value without duplicating resources. • Housing support agencies to evaluate their domestic violence and abuse policy relating to housing discretion in providing alternative accommodation to ensure that where a person is identified as requiring re-housing as a result of domestic abuse this will not be denied as a result of rent arrears.	Housing support agencies
Leeds City Council:	• Leeds Housing Options should ensure that all frontline staff and the relevant support staff complete training in the DASH risk assessment, its use with victims and the evidence base behind the risk factors. DASH risk assessment training should be provided annually • Leeds Housing Options should have internal Quality Assurance functions in place to enable increased management oversight of assessment through regular audit • Case management framework should allow identification of safeguarding cases and case prioritisation during staff absences • Leeds Housing Options should continue to work with the LCC Domestic Violence team to attain the Safer Leeds Domestic Violence Quality Mark, Level 1	Leeds City Council: Housing Options
Leeds Community Heal	• Reflect learning from DHR back to PCMH team managers- to include clarity in documentation & decision-making processes; referral criteria; information-sharing & good practice • Domestic Abuse- identification of risk factors, triggers, referral for support and referral to MARAC - review NICE guidance for Domestic Violence; joint project with children’s safeguarding - include in safeguarding team work plans for 2014/15 - develop One Minute Guide (OMG) for Domestic Violence or adapt children’s OMG for Adult services and profile to every clinical practitioner - make recommendations for training – options to be identified • Review LCH representation on MARAC - named nurse to attend MARAC steering groups & ascertain any gaps in service representation, effectiveness of information/risk sharing & make recommended changes - scope effectiveness of ‘flag & tag’ for adults at risk without children under 18 years.	Leeds Community Healthcare NHS Trust (LCH)
Leeds Domestic Viole	• Consider that when clients are moved on from refuge or other locations and may still be at risk from a perpetrator, that appropriate referrals could/should be made for specialist support e.g. LDVS, outreach/IDVA or resettlement regardless of whether there is generic support in place. LDVS senior managers consider publicity of LDVS services for generic services providing support for DV Victims • That MARAC paperwork sent out after meetings gives clear information on agencies already involved, actions to be taken and by whom. • The criteria for closing cases at MARAC are raised for discussion.	Leeds Domestic Violence Service (LDVS)
Leeds Housing Concer	• MARAC processes need to be fully embedded into LHC risk management process, MARAC cases need to be viewed as High Risk and incorporated into the LHC Risk Register for Senior Management oversight. • Front line staff have regular refresher training for the recording of information • All new information gathered is utilised in subsequent risk assessments and management plans to improve the level of enquiry • MARAC and DV to be addressed within Adult Safeguarding and to be incorporated into the bi-monthly safeguarding reviews currently undertaken. • Incorporating MARAC updates into LHC’s quarterly safeguarding newsletter • Staff to attend refresher training in MARAC processes and receive in house training update regarding Risk Management Processes • Client handbooks to be updated to include DV in the Safeguarding/Keeping Yourself Safe Section. • Update the Risk Matrix guidelines for completion to include the risks of carrying knives/weapons to ensure personal safety. • Provide feedback regarding DHR9 recommendations and the reasons for these to the organisation via the LHC safeguarding newsletter, team meetings, and individual supervisions.	Leeds Housing Concern (LHC)
Leeds MARAC - Safer	• The MARAC Strategy Group should review how information is documented at MARAC meetings and shared among MARAC partners and the action planning and recording process should be reviewed. Additionally, MARAC minutes to more accurately reflect attendance at MARAC, by highlighting which attendees are present for specific cases, and which attendees leave early. • Investigate and implement a process for GP’s, and alcohol/ substance misuse services to input into, and receive feedback from MARAC. • Flagging and tagging processes across agencies should be reviewed and strengthened, including periodic auditing of this arrangement across MARAC partners. • Consideration to how agencies respond to high risk victims’ disengagement from support service should be given generally and specifically as to whether it becomes an automatic trigger for a repeat MARAC. • The MARAC develops a full range of tactical options (both civil and criminal) available to manage the behaviour of the perpetrator and ensure that a perpetrator focussed action plan is developed within the MARAC. • Options for increasing the administrative resource to be explored. • Risk management plans are developed for victims, who may pose a risk to staff or other service users. • All BME victims to be invited to express their wishes about how best services can respond to their support needs, acknowledging that not all BME victims want to be supported by someone from the same/ similar background. • MARAC to agree a single point of contact for each case discussed at MARAC to be identified as the support point for informing the subject of the MARAC and checking their welfare and views on the safety plan and intervention. This person is likely to be the representative who is having most contact with the individual or the IDVA. - MARAC to agree which agency is best placed to provide on-going support to victim as part of each case discussion. • MARAC to ensure a process for the Chair (or identified person) to identify significant gaps in information and follow up after the meeting if the representative does not attend. • MARAC Strategy group to look at how reporting back on actions agreed at MARAC can be strengthened, to ensure all updates are effectively captured in a timely manner.	Leeds MARAC - Safer Leeds
Leeds Teaching Hospi	• LTHT to undertake training needs analysis to identify staff requiring training on domestic abuse issues. This analysis should identify high priority specialties and pathways including Emergency Department and maternity Services. This will include types of abuse that are non-physical. It is to be ensured that this training links in with the National Institute for Clinical Excellence (NICE) guidelines. • Review the current PAS and Symphony Systems (electronic recording systems in LTHT) to determine whether it is possible and appropriate to include a Domestic Abuse alert flag. • There has been work done on mapping the process flow for case note recording and storage for the different departments within the Trust. There should be an educational focus on the mapping process with staff to raise awareness of the process review. • Review the compliance and monitoring arrangements of the Trust policy on the releasing medical records to a coroner if a post-mortem is to be conducted at a site external to LTHT. • LTHT to review its involvement with and receiving information from the MARAC process. This needs to include reviewing the process of ‘completed’ MARAC cases, when the victim of domestic violence is no longer deemed to be at risk. • Recommend that the Emergency Department develops a Standard Operating Procedure to inform staff of the procedures when patients attend with cases of suspected and known domestic violence. • Review the Trust safeguarding policies to ensure there is a specific reference to domestic violence and link to any domestic violence standard operating procedures.	Leeds Teaching Hospitals NHS Trust (LTHT)
MARAC	MARAC Strategy Group to evaluate administration systems to support timely distribution of Minutes and action plans; and to ensure agencies are updated with relevant changes in circumstances which indicate a potential increase in risk • MARAC Strategy Group to identify potential gaps in MARAC information sharing and include contact with A&E and other relevant providers	MARAC Strategy Group
National Probation S	• Victim Services - Further development of signposting practices when specific vulnerabilities are identified of a victim. - Develop disclosure guidance where risk issues are identified from the victim. - To follow up appointment when the victim is unable to engage with disclosures. • Information Sharing - To refine process for obtaining details of police domestic violence call outs pre and post-sentence. - To ensure that the process for communicating call outs whilst a service user is on a domestic violence programme. • Offender Management - Pre-Sentence Report guidance in the Domestic Violence Practice Guidelines to be reviewed. - Guidance on the completion of SARA for domestic violence perpetrators should be reviewed. - The learning agreement for PQF students should be reviewed to include clear accountability for risk. - Reporting and recording MARAC processes need a full review. - Develop guidance on frequency of contact with specific reference to dropping frequency before the identified risk has reduced.	National Probation Service
NHS England (GP)	• Interventions and referrals to reduce alcohol intake should be made as soon as a problem is identified. • Support practitioners to encourage disclosure of domestic abuse, offer advice and guidance on local support and signposting to local services. • For Leeds CCGs to work with MARAC to establish mechanism for effective communication between MARAC and GP practices in Leeds	NHS England \| Leeds CCGs
NHS England: GPs	GP practices to include recording who the perpetrator of the violence is when a disclosure is made. • GPs to access identified guidance and implement any relevant service improvements	GP practices
Victim Support	• Victim Support should receive agenda’s for all MARAC meetings in advance • A member of Victim Support staff should attend all MARAC meetings when any support, no matter how brief, has been given to any victim on the agenda or submit a written report to outline the same, including any referral to, or contact with Witness Service • There should be a robust Information Sharing Agreement between Victim Support, Leeds MARAC and all other MARACs across West Yorkshire • All victims of domestic violence and abuse not wishing to engage with Victim Support Service, either after contact or when contact has been denied, should be flagged up with a supervisor who should decide on what further action to take, if any. • In high risk cases, support should be proactive and the victim should not be left to find out, or follow up information themselves, unless they request to. This should be done at all and any point of contact with Victim Support. • Refresher training for Witness Service staff and volunteers to remind that witnesses should be offered a referral back to community service for further support should they be anxious or concerned when a trial is finished • Refresher training for Victim Care Officers (VCO) in the completion of CAADA RIC (risk assessment) forms to ensure that all VCOs are completing them completely and correctly • Feedback should be given at regular intervals to any police officer or any other agency who refer cases of domestic violence and abuse to Victim Support, concerning progress on the case, whether the victim has been contacted or not.	Victim Support
West Yorkshire Commu	• Information Sharing - To refine process for obtaining details of police domestic violence call outs post-sentence. - To ensure that the process for communicating call outs whilst a service user is on a domestic violence programme. • Offender Management - Guidance on the completion of SARA for domestic violence perpetrators should be reviewed. - Reporting and recording MARAC processes need a full review. - Develop guidance on frequency of contact with specific reference to dropping frequency before the identified risk has reduced. • Activities Team - Review communication guidelines when a risk to the victim is identified. - Develop recording practice to ensure information is recorded on the system that the Offender Manager can access.	West Yorkshire Community Rehabilitation Company
West Yorkshire Polic	West Yorkshire Police to identify how referral information can be improved; particularly to ensure that the ethnicity of each person is recorded in referrals to partner agencies, and that linked referrals are identified. • To consider appropriate information sharing and risk assessments of perpetrator information to partner agencies that may also be providing services to the victim to assess whether there is a potential risk of harm if they are unknowingly accommodated by the same provider or receiving support in the same building.	West Yorkshire Police
West Yorkshire Polic	• That the Force conducts an audit of the current standards of management of stalking and harassment reports to ensure that recording and investigation is in accordance with Force Policy and national best practice and in compliance with National crime Recording Standards identifying any remedial action required. • The Force consider how repeat calls for service which are not initially tagged or recognised as domestic abuse can be flagged to the District Control Room supervisors for review and consideration of referral to appropriate staff, such as Neighbourhood Policing Teams or the Police Safeguarding Unit	West Yorkshire Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗