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
Leicester review
CSP: Leicester
Published: May 2023
Year of death: 2015
Extracted: 29 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 identifies systemic failures in multi-agency domestic violence risk assessment and management, including missed opportunities to consider the perpetrator's history and the victim's homelessness. Inconsistent application of procedures and breakdowns in MARAC processes contributed to the inability to safeguard the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | It is recommended that supervisory officers are reminded of their responsibility to supervise domestic abuse investigations and the importance of fully recording the rationale for their decision making. | Leicestershire Police |
| 1 | Consider how services are withdrawn for victims of Domestic Abuse | Leicester City Council Homeless Prevention & Support Service |
| 1 | Provide further guidance to Officers as feedback from completing this process of lessons learnt and examples of good practice. | Leicester City Council Housing Options Service |
| 1 | A DVA lead be designated to lead on this area of work and ensure the practice remains up to date in its protocols and activity. | GP Practice 1 |
| 1 | Improve staff knowledge and awareness of domestic abuse and where to seek specialist advice by incorporating domestic abuse information / training into the mandatory adult safeguarding e-learning module. | University Hospitals of Leicester NHS Trust |
| 1 | Leicestershire Police should review operating procedure, guidance and training for domestic violence risk assessments using DASH, to include a requirement that checks must be made on police records (Police National Computer and Police National Database) to ascertain whether the perpetrator has a history of reported domestic violence incidents and / or criminal convictions. Where such a history exists, but the current risk score has not reached the threshold for automatic referral to MARAC, officers should consider a MARAC referral based on professional judgement. (Key learning point 3) | Leicestershire Police |
| 1a | Improve awareness of the agencies (such as UAVA) and processes (such as MARAC) involved with supporting people experiencing Domestic Abuse within the team. | GP Practice 1 |
| 1b | Improve understanding of CAADA-DASH risk assessment process | GP Practice 1 |
| 1c | Ensure appropriate training for clinical and non-clinical staff | GP Practice 1 |
| 1d | Guard against desensitisation to risks and optimise understanding of HIGHER risks in mutually violent relationships | GP Practice 1 |
| 1e | Engage with local safeguarding and DVA organisations and systems to improve primary care involvement more generally. | GP Practice 1 |
| 2 | It is recommended that officers are reminded of the various support agencies that are available to persons who are alcohol dependent in order that they are signposted to the most appropriate agency to receive the required support. | Leicestershire Police |
| 2 | Service Users presenting with Alcohol Issues should receive additional support to encourage access to treatment. | Leicester City Council Homeless Prevention & Support Service |
| 2 | Case Management procedures reviewed. | Leicester City Council Housing Options Service |
| 2 | Systems to flag both victims and perpetrators of DVA within the clinical system (IT) are sought and that routine queries and offers of support and referral take place when flags are present. | GP Practice 1 |
| 2 | Revise the face to face training on domestic abuse for ED / UCC staff to incorporate the learning from this review. | University Hospitals of Leicester NHS Trust |
| 2 | There should be a multi-agency review of the MARAC procedure and domestic violence training needs, in the light of learning from this case, to include Systems for sending, receiving and recording MARAC referrals Potential need for clarification of guidance for specialist domestic violence staff, particularly around the requirement that any victim of domestic violence identified as high risk in CAADA-DASH must be considered at a multi-agency MARAC meeting. (Key learning points 11 & 12) Need for wider agency training and awareness raising about domestic violence and the role of MARAC, with a specific focus on training needs in primary healthcare and housing and homelessness services, to include appropriate use of the DASH risk assessment tool in cases where there are presenting concerns relating to domestic abuse. Supporting and training staff responsible for assessing domestic violence risks where there are multiple and complex needs, including evidence of mutually violent behaviours. (Key learning point 9) Ensuring that service users’ wishes and intentions are clearly accounted for in safety planning and that follow actions are in place; particularly when the service user is identified as being high risk. | Safer Leicester Community Safety Partnership |
| 3 | It is recommended that officers are reminded of the need to adopt a more lateral problem solving approach to domestic abuse when faced with a victim who is reluctant / reticent to engage beyond the initial report of the abuse. | Leicestershire Police |
| 3 | Ensure that Homelessness Services staff are fully aware of ASC responsibilities for vulnerable adults. | Leicester City Council Homeless Prevention & Support Service |
| 3 | Review and revise the Emergency Department Standard Operating Procedure for Domestic Abuse, in line with the Trust’s overarching DA Policy and best practice. This should include routine enquiry where domestic abuse is disclosed or suspected. | University Hospitals of Leicester NHS Trust |
| 3 | There should be work to increase awareness about local services which carry out specialist and targeted work with serial domestic abuse perpetrators. Perpetrators who have a history of criminal domestic abuse offences should be prioritised for such targeted interventions, which may be on a voluntary basis or as an element of criminal court imposed sanctions. If this recommendation highlights issues of insufficient capacity to meet demand, this should be considered by commissioners as a potential area for increased resource allocation. (Key learning point 14) | Safer Leicester Community Safety Partnership | Leicester City Clinical Commissioning Group |
| 4 | It is recommended that the police DASH risk assessment be amended with notes of guidance in the ‘professional judgement’ field, to guide decision makers regarding factors, outside of the main DASH questions, which should lead an assessor to increase the risk level. These are to include: History of DV offending against other separate victims (serial perpetrator) Significant increase in frequency of Standard and Medium risk incidents This change will be marketed to all officers involved in completing DASH risk assessment and otherwise reviewing DV (DAST team) | Leicestershire Police |
| 4 | Assist One Roof to compile a referral form to highlight indicators of DV. | Leicester City Council Homeless Prevention & Support Service |
| 4 | Review and revise the Emergency Department Standard Operating Procedure for Safeguarding Adults, in line with the Trust’s overarching SA Policy and the Care Act. | University Hospitals of Leicester NHS Trust |
| 4 | All key learning points from this DHR should be disseminated as widely as possible to local health, social care, housing, homelessness and criminal justice agencies likely to be working with people affected by domestic violence. (All Key learning points) | Safer Leicester Community Safety Partnership |
| 5 | Ensure the learning from this IMR is shared amongst Homelessness Services Management Team. | Leicester City Council Homeless Prevention & Support Service |
| 5 | Increase ED / UCC staff knowledge, awareness and confidence when dealing with domestic abuse, in light of this review (by implementing the above). | University Hospitals of Leicester NHS Trust |
| 6 | Explore the possibility of securing additional funding to recruit a permanent IDVA to work across UHL, alongside the UHL safeguarding teams | University Hospitals of Leicester NHS Trust |
| 7 | Ensure that the organisation maintains a secure record of all MARAC referrals made by ED / UCC staff. | University Hospitals of Leicester NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||