South Gloucestershire review

Enhancement or amendment to Equality Act 2010 to ensure the consistency of monitoring of protected characteristics and consistency of training.

Where a victim may have links or associations across Local Authority boundaries, that the MARAC and its participating agencies ensure that the MARAC in the relevant adjoining area and organisations in that area are informed and invited to share information.

All agencies taking part in this Review and organisations which are members of the South Gloucestershire and Bristol Community Safety Partnerships have role commensurate Equalities training including competencies in working with Lesbian, Gay, Bisexual and Trans communities.

South Gloucestershire and Bristol Community Safety Partnerships will assist those none specialist organisations that do not have appropriate domestic abuse policies to introduce fit for purpose domestic abuse policies.

South Glos and Bristol substance misuse services to ensure communication between treatment providers and pharmacies- with particular focus on information being shared on the initiation and cessation of opiate substitution therapy prescriptions.

Commissioners to require agencies successful in tendering for contracts to have effective policies around domestic abuse that recognise issues relating to LGBT community

The method of making contact with a vulnerable victim should be considered extremely carefully, particularly if it is known that the perpetrator controls access to/use of a mobile telephone.

Where unusual/less frequently occurring cases requiring support present themselves, Lighthouse staff should be encouraged to seek support by discussing the case with a supervisor before making referrals/deciding upon the method of communicating with the victim.

Avon and Somerset Constabulary should seek new partnerships with charities working with men, including men and sex working men who are at risk of exploitation/abuse from their partners, including risk of DA.

Learning from this incident to be shared with the BSDAS teams, particularly in relation to more inquisitive questioning about potential risk issues.

BDP and BSDAS to review procedures for transferring service users from shared care to BSDAS specialist prescribing, to explore whether there are ways of more effectively facilitating service users attendance and engagement with the new team.

BSDAS to explore accessing Illy electronic case records for continuity of care purposes for service users attending South Gloucester Drug and Alcohol services.

BDP will establish a centralised system of recording where issues pertaining to Domestic Abuse are recognised.

Training provision to be reviewed in light of lessons learned through DHR process

Integration of DASH risk assessment tool into practice where DV is highlighted

Triage risk assessment tool to be reviewed and revised risk assessment tool agreed, revised risk assessment tool adopted

Workflow timescales between triage and assessment to be established

Cross organisational information sharing.

Undertake a ‘lessons’ learnt meeting with the team in relation to this case, to include the lessons learnt above, plus potential assumptions about risk, boundaries of role in supporting client in relation to person in treatment i.e. where they are not directly working with the person in treatment

Domestic Abuse - develop a specific policy

Ensure team and the service are culturally competent.

Safeguarding training to be reviewed to include reinforcement that DA can and does occur in same sex partnerships

Information sharing at MARAC to be audited to ensure information is shared when it is in the possession of NBT

Amend initial assessment forms to assess equality and diversity needs at the start of the assessment process when a client first enters the service. As required using guidance from the Diversity Trust.

Sirona managers responsible for the MIU to provide additional training for staff to ensure that the full checklist of safeguarding questions (including questions about mental health) are completed in every case.

The Safeguarding Lead for Sirona to meet with MIU staff as a matter of urgency and provide additional bespoke training on safeguarding and domestic violence issues.

To discuss the outcomes of this report with all Senior Practitioners.

To ensure all correspondence from MARAC is copied to Senior Practitioners.

To ensure that any post relating to possible risk is sent 1st class.

To devise scripts when contacting Service User by phone who may have an abuser present.

To ensure that all cases with potential domestic abuse are prioritised and utilising the DASH risk assessment where appropriate within adult safeguarding.

Ensure all recommendations are followed and reviewed regularly in Supervisions

Contact with named police officers and discussion with alternative colleagues when not available

Building on DASH risk assessment completed by other agencies to ensure a more comprehensive assessment of risk and consistent approach

Adherence to agreed time scales for actions and feedback, avoidance of drift

The MARAC Operating Protocol should be reviewed to ensure it is fit for purpose and ensure confidence that it is a process not a meeting. § Best practice in terms of safe phone contact with victims (e.g for those who have stated their phone is monitored by the perpetrator, or for those in same sex relationships where it is likely to be difficult to confirm the person you are speaking to).

The MARAC Steering Group should review the standing invite list for MARAC on a quarterly basis for accuracy and appropriateness. In addition, a process should be agreed in terms of responsibility for identifying and including additional agencies in any MARAC case

The MARAC Steering Group should review best practice in terms of MARAC Minutes and make any necessary amendments to the South Gloucestershire process / template as required.

Increase the time between the referral deadline and circulation of the MARAC agenda to allow time to seek further information and identify additional agencies to attend. E.g. In the case of the victim – an appropriate method of contact for him and liaison with relevant Bristol agencies.

The MARAC Referral Form should be reviewed to ensure it is fit for purpose and reflects best practice.

The MARAC Steering Group to consider implementing appropriate quality assurance and audit functions

Practices to be encouraged to consider implementing a system of identifying and allocating known drug users to a specific GP who should co-ordinate their care, with flagging of records to indicate which GP they should be directed to.

Awareness raising and training about the links between mental health and substance misuse and domestic abuse to be reinforced.

Training in recognition of domestic abuse in men to be made available to all GPs.