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

Cheltenham review

CSP: Cheltenham Published: May 2023 Year of death: 2014 Extracted: 28 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 review identifies systemic failures in multi-agency responses to domestic abuse involving young people, including delayed interventions, inadequate risk assessment for coercive control, and challenges in balancing adolescent autonomy with safeguarding duties.

Home Office classifications

38 tags

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

  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - had been a victim of an abuser before
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • 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 school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - school 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 - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

28 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1

Addressed to Home Office

Further national guidance on risk management is given to professionals when the victim is under 16 and advice on expectations as to professional response in the context of statutory safeguarding systems.

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

Recommendation 1A

Addressed to Gloucestershire Multi Agency Quality Assurance Sub-Group (MAQuA) | GSCB

For the Gloucestershire Multi Agency Quality Assurance Sub-Group (MAQuA), on behalf of the GSCB to carry out a review to test the effectiveness of existing arrangements for young people having access to preventative work on healthy relationships.

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

Recommendation 1B

Addressed to Gloucestershire Children’s Partnership | SLG

For the Gloucestershire Children’s Partnership to ensure that the DHR recommendations are fully reflected in the new Children and Young People’s Plan that is being developed and for the SLG to support the GCP in this piece of work.

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

Recommendation 1C

Addressed to Gloucestershire County Council

For Gloucestershire County Council to work with localities to review the Early Help ‘offer’ to ensure it includes sufficient advice, guidance and information for professionals, carers and community groups in respect of relationship issues/abuse

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

Recommendation 1D

Addressed to Police

In circumstances of relationship harm (criminal abuse or assault) among young people the Police should take a robust enforcement approach. That would normally mean seeking the arrest of the perpetrator

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

Recommendation 1E

Addressed to Gloucestershire Healthy Living and Learning (GHLL)

For Gloucestershire Healthy Living and Learning (GHLL) to continue to update their work on PSHE including the on-line PinK Curriculum and to support school staff with training.

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

Recommendation 1F

Addressed to GHLL | Schools safeguarding network

GHLL/Schools safeguarding network to reflect on how young people can be encouraged to alert staff to concerns they have about their peers

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

Recommendation 1G

Addressed to Cheltenham Partnerships | GDASS

Cheltenham Partnerships to work with GDASS and other partners to facilitate a conference for practitioners to reiterate the importance of preventative work on healthy relationships for young people

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

Recommendation 2

Addressed to Home Office | National Oversight Group

The Home Office work with the national data agencies to capture national information on the incident and trend relating to domestic abuse in under 18’s. It is recommended that this is be facilitated by National Oversight Group

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

Recommendation 2A

Addressed to Cheltenham Strategic Leadership Group

Further embed restorative practice across the wider partnership in order to work more inclusively with families - even when families don’t engage

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

Recommendation 2B

Addressed to Cheltenham Partnerships

Cheltenham Partnerships to support the development of a local partnership model that provides oversight over the early help graduated pathway.

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

Recommendation 3

Addressed to Home Office

The Home Office to review the national definition of domestic abuse to reflect on younger victims and provide clarity for professionals.

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

Recommendation 3A

Addressed to Cheltenham Strategic Leadership Group

Carry out a review of the local Futures in Mind plan* in the light of this DHR and consider how well young people access emotional health and wellbeing support and services in a timely manner.

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

Recommendation 4

Addressed to Department of Education | Ofsted

PSHE should be a statutory requirement in education and can play an important part in keeping young people safe. This should be an inspection standard for scrutiny by Ofsted.

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

Recommendation 4A

Addressed to GSCB | CSC | YST

GSCB to ensure that risks in adolescents are appropriately identified and managed by considering training for professionals in respect of management of risk in adolescence and monitoring the effectiveness of work being undertaken by CSC/YST to review the safeguarding system for adolescents

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

Recommendation 4B

Addressed to Cheltenham Strategic Leadership Group

Undertake dedicated public campaigns aimed toward all ages supported by all agencies around the elements of coercive control and that it is an offence in its own right.

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

Recommendation 4D

Addressed to GSCB

Specific policy guidance should be developed around the use of split conferences. This should include clear direction for CP Conference Chairs in relation to conferences for child victims where the perpetrator may be present. This needs to take into account that while a child may agree for a perpetrator to attend this may be coercion and/or control to stop the victim being honest and open during the conference

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

Recommendation 4E

Addressed to Children’s Social Care

Raise awareness that social care cases are not allocated to student social workers and all professionals need to engage with the allocated social worker. The allocated social worker must ensure that they have proper oversight over the case i.e. engaging with the family.

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

Recommendation 5

Addressed to Home Office

There should be a national campaign by the Home Office in partnership with others, to educate the public, including young people around coercive control.

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

Recommendation 5A

Addressed to Children’s Social Care | Youth Support Service

Children’s Social Care and the Youth Support Service will implement the BASE practice model* (developed through DfE Innovations Programme) and evaluate its effectiveness in managing adolescent risk.

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

Recommendation 5B

Addressed to Cheltenham Strategic Leadership Group

When working with young people, agencies are able to identify who the child has the strongest rapport with and use that professional to work with the young person and to support them though the system supported by the multi-agency team and legal advice if necessary

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

Recommendation 6A

Addressed to Safer Gloucestershire

Work with Safer Gloucestershire to explore options for increasing perpetrators programmes for under 21’s in the county.

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

Recommendation 6B

Addressed to Cheltenham Strategic Leadership Group

Review current resources for professionals and ensure development of guidance documents to support professionals in identifying and responding to domestic abuse.

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

Recommendation 6C

Addressed to Safer Gloucestershire

Continued development of www.glostakeastand.com to ensure section specifically for professionals so they can access relevant information on domestic abuse.

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

Recommendation 6D

Addressed to Safer Glos | GDASV Commissioning Group

To ensure that the analysis of need overseen by Safer Glos and the GDASV Commissioning Group includes research into the prevalence of domestic abuse affecting young people to shape future commissioning arrangements of support for young people and their families

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

Recommendation 6E

Addressed to Cheltenham Strategic Leadership Group

To scope options to develop an advice guide for parents on abuse in teenage relationships.

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

Recommendation 6F

Addressed to Cheltenham Strategic Leadership Group

Explore engagement opportunities with community groups and sports clubs to increase awareness of domestic abuse and encourage a zero tolerance stance.

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