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
Cannock Chase review
CSP: Cannock Chase
Published: May 2023
Year of death: 2019
Extracted: 40 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 systemic failures in risk assessment, inter-agency information sharing, and tailored support for a vulnerable adult in an alcohol-fuelled, co-dependent relationship. Agencies underestimated the risk due to unclear relationship definition and a lack of understanding of same-sex domestic abuse, missing opportunities for early intervention and engagement with the victim and his family.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | There are no specific recommendations for WMAS at this time, but the service will continue to provide training and raise awareness to ensure all WMAS staff have the confidence, opportunity, and resources to make timely referrals to the appropriate agencies. | West Midlands Ambulance Service |
| 1 | Ensure trust staff continue to provide expert support and advice relating to the Mental Health and Mental Capacity Act. | South Staffordshire and Shropshire Healthcare NHS Foundation Trust |
| 1 | Liaise with voluntary groups to deliver domestic abuse training to staff: | University Hospitals of North Midlands NHS Trust |
| 1 | Discuss this case at a meeting of the clinical team, to ensure staff are aware of the importance of considering safeguarding referrals for a patient presenting with injuries on multiple occasions. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 1 | Staffordshire Police to ensure that a corporate operating model exists across vulnerability hubs with specific regard to the identification and management of risk to vulnerable people – Independent of Domestic Abuse Force Procedures. | Staffordshire Police |
| 1 | Social care staff to make specific enquiry regarding MARAC in all cases involving domestic abuse and make referrals to MARAC when appropriate. | Staffordshire County Council |
| 1 | In order to ensure appropriate risk analysis, allocation of action and to ensure consideration of alternate agency support. A risk assessment process within a case conference or multi-agency setting MUST be carried out within ALL cases that demonstrate a high level of risk or ‘refusal of intervention’. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 1 | Irrespective of the gender make up of victims and perpetrators active checks should be made with the police when writing reports for courts no matter what type of report or timescale. If the information cannot not be accessed in the time frame allowed, an adjournment should be requested to avoid re victimisation. | National Probation Service |
| 1 | To improve information sharing protocols between the MASH and Cannock CSH (Community Safety Hub) and consider adopting this protocol across the County. | Cannock Community Safety Partnership | Multi-Agency Safeguarding Hub | Cannock Community Safety Hub |
| 10 | NPS and police to discuss whether WWOB warrants can have a priority rating to ensure that those taken out on high risk of harm serious offenders are executed swiftly. | National Probation Service | Staffordshire Police |
| 2 | The practice team should review their existing safeguarding policies to ensure they meet current guideline. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 2 | Staffordshire Police to deliver revised domestic abuse training package developed in partnership with the University of Gloucester to all Constable, Sergeant and Inspector Police Officers, Police Community Support Officers, and police staff. | Staffordshire Police |
| 2 | Where agency risk assessment principles and policy guidance is not adhered to, due to lack of awareness – agencies to promote and redistribute appropriate training and policy guidance, an outcome being to improve risk assessment/risk management practice and potential risk management for the individual concerned. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 2 | The alcohol screening tool should be completed in all relevant cases at the report stage to ensure the correct targeting of provision takes place. | National Probation Service |
| 2 | To enhance the profile and understanding of the role and function of the CSH. | Cannock Community Safety Hub |
| 3 | Keep an up to date assault data base to flag at risk patients. | University Hospitals of North Midlands NHS Trust |
| 3 | To ensure all clinical staff have received training on domestic abuse, adult safeguarding. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 3 | A case co-ordinator to be identified within high-risk cases – To provide liaison to the individual, to coordinate and assure agency actions are carried out and to promote engagement, choice and control for the individual concerned. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 3 | Report writers and court probation staff should give active consideration to continuing to protect the victim when there have been bail conditions to prevent contact between victim and perpetrator. | National Probation Service |
| 3 | In ALL cases agencies should ensure that an evidence-based decision is recorded when a professionals meeting is NOT pursued. In particular where: • There is non- engagement from the client • High risk • Multi agency involvement | Cannock Chase Community Safety Partnership member agencies |
| 4 | All trained staff to prioritise attendance to Level one Safeguarding Adult training. | University Hospitals of North Midlands NHS Trust |
| 4 | To ensure the practice has a lead for adult safeguarding. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 4 | Any agency intervention MUST be clearly documented in line with agency ‘recording with Care’ principles. The promotion and redistribution of appropriate training and policy guidance in order to achieve improved recording outcomes. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 4 | When probation officers are undertaking OASys assessments, where there is domestic abuse, regular contact with the police needs to be written into the risk management plan section and then regular checks undertaken. | National Probation Service |
| 4 | To identify a mechanism to share information with the CSH where acute medical services have identified high risk/frequent flyer status, in order to promote effective partnership working. | Cannock Community Safety Hub | Acute Medical Services |
| 5 | To audit current caseload of patients with recorded alcohol abuse to ensure appropriate referrals to addiction services have been offered or made. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 5 | In order to achieve improved domestic violence awareness, guidance and information MUST be promoted within agency settings. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 5 | When offenders attend the office with injuries, as well as active questioning in the interview, concerns should be triangulated with the police. | National Probation Service |
| 5 | Sexual orientation is one of the protected characteristics under the Equality Act 2010. It is recommended that all agencies, particularly those that have a duty under the Public Sector Equality Duty (s149 of Equality Act 2010) record data relating to sexuality, in order to promote inclusivity, develop standards of service, and develop good equality practice. This information should be sought from both victims and perpetrators. | All agencies with Public Sector Equality Duty |
| 6 | To ensure all clinical staff have received training on the Mental Capacity Act. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 6 | Where agency actions are not reflective of the Staffordshire and Stoke on Trent Safeguarding guidance, promotion, and training, where appropriate, MUST be undertaken in order to reduce actual or perceived risk to the individual. | Staffordshire & Stoke-on-Trent Partnership NHS Trust |
| 6 | When cases are assessed as medium risk of harm and there are concerns as to the safety of ongoing living arrangements home visits should be undertaken. | National Probation Service |
| 6 | To share the learning from this review within agencies and to disseminate it across the CSP to promote partnership working. | Cannock Chase Community Safety Partnership member agencies |
| 7 | To review referral pathway for addiction services due to non-attendance closing the referral; consideration should be built into the pathway for referral to other services e.g. social care. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 7 | When a case is escalated to high risk this should trigger a home visit automatically. | National Probation Service |
| 7 | To coordinate a campaign raising awareness on issues affecting the hard to reach as well as those with vulnerabilities as highlighted in this case: alcohol /substance misuse, mental health, male victims of violence. | Cannock Chase Community Safety Partnership |
| 8 | Pathway should ensure GP is made aware of the lack of engagement due to potential capacity issues whilst under the influence of alcohol. | South East Staffs & Seisdon Peninsula Clinical Commissioning Group |
| 8 | To promote sufficiently tenacious contact with victims; promoting access to pathways for support services where there is a known, repeat perpetrator. | All agencies within the Cannock Chase Community Safety Partnership |
| 9 | When offenders state they are attending various provisions in the community this should always be triangulated. | National Probation Service |
| 9 | The Community Safety Partnership to co-ordinate an awareness campaign for members of the Public around Clare’s Law. | Cannock Chase Community Safety Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||