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
South Gloucestershire review
CSP: South Gloucestershire
Published: May 2023
Year of death: 2015
Extracted: 44 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 report identifies concerns regarding the victim's drug dependency, chaotic lifestyle, and vulnerability as a male sex worker. It highlights challenges in agencies' recognition of domestic abuse in same-sex relationships, inter-agency communication, and the timeliness of interventions.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| Avon and Somerset Co | 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. | Avon and Somerset Constabulary |
| Avon and Somerset Co | 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 |
| Avon and Somerset Co | 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. | Avon and Somerset Constabulary |
| Avon and Wiltshire M | Learning from this incident to be shared with the BSDAS teams, particularly in relation to more inquisitive questioning about potential risk issues to include training in the use of the DASH risk assessment. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| Avon and Wiltshire M | 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. | Avon and Wiltshire Mental Health Partnership NHS Trust | Bristol Drugs Project |
| Avon and Wiltshire M | BSDAS to explore accessing Illy electronic case records for continuity of care purposes for service users attending South Gloucester Drug and Alcohol services. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| Bristol Drugs Projec | BDP will establish a centralised system of recording where issues pertaining to Domestic Abuse are recognised and Centralising of response and involvement with MARAC | Bristol Drugs Project |
| Bristol Drugs Projec | Training provision to be reviewed in light of lessons learned through DHR process especially around issues of pertaining to DV within same sex relationships. | Bristol Drugs Project |
| Bristol Drugs Projec | Integration of DASH risk assessment tool into practice where DV is highlighted | Bristol Drugs Project |
| Cross Agency_1 | 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. | Avon and Somerset Constabulary | South Gloucestershire Council |
| Cross Agency_2 | 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 Council | Bristol City Council |
| Cross Agency_3 | 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 Gloucestershire Community Safety Partnership | Bristol Community Safety Partnership |
| Cross Agency_4 | 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. | South Gloucestershire Council Drug and Alcohol Action Team | Bristol City Council Substance Misuse Team |
| Cross Agency_5 | Commissioners to require agencies successful in tendering for contracts to have effective policies around domestic abuse that recognise issues relating to LGBT community | South Gloucestershire Council Drug and Alcohol Action Team | Bristol City Council Substance Misuse Team |
| Developing Health an | Triage risk assessment tool to be reviewed and revised risk assessment tool agreed, revised risk assessment tool adopted | Developing Health and Independence |
| Developing Health an | Workflow timescales between triage and assessment to be established | Developing Health and Independence |
| Developing Health an | Cross organisational information sharing. Review of all local MARAC/safeguarding information sharing arrangements. 2. Implement a new working model for information sharing across and within the organisation, to include a single point of reference for all client record databases held by the organisation. | Developing Health and Independence |
| Developing Health an | 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 | Developing Health and Independence |
| Developing Health an | Domestic Abuse - develop a specific policy | Developing Health and Independence |
| Developing Health an | Ensure team and the service are culturally competent. | Developing Health and Independence |
| Government Equalitie | Enhancement or amendment to Equality Act 2010 to ensure the consistency of monitoring of protected characteristics and consistency of training. | Government Equalities Office |
| North Bristol NHS Tr | Safeguarding training to be reviewed to include reinforcement that DA can and does occur in same sex partnerships | North Bristol NHS Trust |
| North Bristol NHS Tr | Information sharing at MARAC to be audited to ensure information is shared when it is in the possession of NBT | North Bristol NHS Trust |
| Sirona Care and Heal | 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. | Sirona Care and Health |
| Sirona Care and Heal | 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. | Sirona Care and Health |
| South Gloucestershir | To discuss the outcomes of this report with all Senior Access Team Practitioners. | South Gloucestershire Council |
| South Gloucestershir | To ensure all correspondence from MARAC is copied to Senior Access Practitioners. | South Gloucestershire Council |
| South Gloucestershir | To ensure that any post relating to possible risk is sent 1st class. | South Gloucestershire Council |
| South Gloucestershir | To devise scripts when contacting Service User by phone who may have an abuser present. | South Gloucestershire Council |
| South Gloucestershir | To ensure that all cases with potential domestic abuse are prioritised and utilising the DASH risk assessment where appropriate within adult safeguarding. | South Gloucestershire Council |
| South Gloucestershir | Ensure all recommendations are followed and reviewed regularly in Supervisions | South Gloucestershire Council |
| South Gloucestershir | Contact with named police officers and discussion with alternative officers colleagues when not available | South Gloucestershire Council |
| South Gloucestershir | Building on DASH risk assessment completed by other agencies to ensure a more complete comprehensive assessment of risk and consistent approach | South Gloucestershire Council |
| South Gloucestershir | Adherence to agreed time scales for actions and feedback, avoidance of drift setting that is measurable | South Gloucestershire Council |
| South Gloucestershir | 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). | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | 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 | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | 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. | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | 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 Michael – an appropriate method of contact for him and liaison with relevant Bristol agencies. | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | The MARAC Referral Form should be reviewed to ensure it is fit for purpose and reflects best practice. | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | The MARAC Steering Group to consider implementing appropriate quality assurance and audit functions | South Gloucestershire Multi Agency Risk Assessment Conference |
| South Gloucestershir | 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. | South Gloucestershire Clinical Commissioning Group |
| South Gloucestershir | Awareness raising and training about the links between mental health and substance misuse and domestic abuse to be reinforced. | South Gloucestershire Clinical Commissioning Group |
| South Gloucestershir | Training in recognition of domestic abuse in men to be made available to all GPs. | South Gloucestershire Clinical Commissioning Group |
| St. Mungo's Broadway | 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. | St Mungos Broadway |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||