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
Lincoln review
CSP: Lincoln
Published: May 2023
Year of death: 2012
Extracted: 53 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 identified systemic failures in multi-agency information sharing, risk assessment, and management of domestic abuse, particularly concerning the victim's vulnerability and fluctuating capacity. Agencies often failed to recognise familial abuse, leading to uncoordinated responses and missed opportunities for intervention.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 10.10.1 | ULHT to develop, implement and embed into working practice a policy / practice guidance for domestic abuse for ULHT staff. | United Lincolnshire Hospital Trust |
| 10.1.1 | Provide guidance to staff to ensure assessments are based upon full information and that historic records are accessed and utilised. | Lincolnshire Police | Addaction | Lincoln City Council Housing | East Midlands Ambulance Service | Lincolnshire Community Health Service | Lincolnshire Partnership NHS Foundation Trust | NHS Lincolnshire Primary Care Trust | Lincolnshire Probation Trust | United Lincolnshire Hospital Trust | Victim Support | Lincolnshire County Council Adult Care |
| 10.11.1 | Victim Support to monitor the effectiveness of the new CMS system in relation to identifying repeat victims and near misses. | Victim Support |
| 10.1.2 | Develop improved inter agency information sharing and multi agency working together, in relation to DA, in order to arrive at a shared and robust risk management plan. | Lincolnshire Police | Addaction | Lincoln City Council Housing | East Midlands Ambulance Service | Lincolnshire Community Health Service | Lincolnshire Partnership NHS Foundation Trust | NHS Lincolnshire Primary Care Trust | Lincolnshire Probation Trust | United Lincolnshire Hospital Trust | Victim Support | Lincolnshire County Council Adult Care |
| 10.12.1 | GPs should be held to account to report cases of attempting to obtain controlled drugs by deception to the accountable officer for controlled drugs. This will be done via NHS England Leicestershire and Lincolnshire area team the CCGs who have a role both to inform and hold GPs to account. | NHS Lincolnshire Primary Care Trust |
| 10.1.3 | Review the use of the MARAC referral process to ensure all agencies are clear about the procedure and their role in referring to MARAC. | Lincolnshire Police | Addaction | Lincoln City Council Housing | East Midlands Ambulance Service | Lincolnshire Community Health Service | Lincolnshire Partnership NHS Foundation Trust | NHS Lincolnshire Primary Care Trust | Lincolnshire Probation Trust | United Lincolnshire Hospital Trust | Victim Support | Lincolnshire County Council Adult Care |
| 10.1.4 | Provide evidence of a quality assurance process in relation to the effective management of DA cases. | Lincolnshire Police | Addaction | Lincoln City Council Housing | East Midlands Ambulance Service | Lincolnshire Community Health Service | Lincolnshire Partnership NHS Foundation Trust | NHS Lincolnshire Primary Care Trust | Lincolnshire Probation Trust | United Lincolnshire Hospital Trust | Victim Support | Lincolnshire County Council Adult Care |
| 10.1.5 | Provide evidence of a DA training plan including learning arising from this DHR. | Lincolnshire Police | Addaction | Lincoln City Council Housing | East Midlands Ambulance Service | Lincolnshire Community Health Service | Lincolnshire Partnership NHS Foundation Trust | NHS Lincolnshire Primary Care Trust | Lincolnshire Probation Trust | United Lincolnshire Hospital Trust | Victim Support | Lincolnshire County Council Adult Care |
| 10.2.1 | Lincolnshire Community Safety Partnership to develop an overall policy for the prevention and management of domestic abuse that describes expectations of all agencies and partnerships including all public protection arrangements. | Lincolnshire Community Safety Partnership |
| 10.2.2 | Lincolnshire Community Safety Partnership to ensure there is multi agency DA training available to enable practice staff to understand other agencies DA processes and the importance of each agency's contribution to a positive outcome. | Lincolnshire Community Safety Partnership |
| 10.2.3 | Lincolnshire Community Safety Partnership to review public protection arrangements to ensure domestic abuse is recognised and understood across arrangements for vulnerable adults and safeguarding. | Lincolnshire Community Safety Partnership |
| 10.3.1 | Addaction to carry out a review of domestic abuse safeguarding referral processes to ensure staff are both aware and confident in those processes and procedures, incorporating DASH and MARAC. | Addaction |
| 10.3.2 | Addaction to formally establish staff confidences and competences relative to identification and recognition of domestic abuse and the appropriate response to such incidents. | Addaction |
| 10.3.3 | Addaction to ensure continued staff attendance on domestic abuse training provided by the County Domestic Abuse Team and / or Addactions Learning and Development Team. | Addaction |
| 10.3.4 | Develop a dedicated organisational domestic abuse policy (had previously been part of the safeguarding policy). | Addaction |
| 10.3.5 | Further develop improved partnership working and joint working with Mental Health Services across Lincolnshire. | Addaction |
| 10.3.6 | Further develop improved partnership working with LSCB and LSAB for both adults and children. | Addaction |
| 10.3.7 | Revise current assessment paperwork to incorporate information regarding family circumstances in order to assist recovery and ascertain wider risks. Incorporate financial abuse in assessment as a form of assessment. | Addaction |
| 10.3.8 | Revise current assessment paperwork to further incorporate assessment of Domestic Abuse (including financial) ensuring appropriate support for those disclosing and keyworkers where necessary. | Addaction |
| 10.4.1 | Adult Care should put in place effective measures to ensure that assessment and case management activity promotes holistic assessments of the person's needs, strengths and outcomes which puts the person at the centre of the intervention and supports them to live safely in their environment. | Lincolnshire County Council Adult Care |
| 10.4.10 | All staff involved in Adult Care should have an understanding of the Multi-Agency MARAC operating protocol and understand what it means for their own practice. | Lincolnshire County Council Adult Care |
| 10.4.11 | Develop and implement a specific DA policy and protocol to enable staff to be clear about what is expected of them. | Lincolnshire County Council Adult Care |
| 10.4.2 | Risks must be recorded and evaluated in all assessments of need and risk management plans are to be put in place where significant risks are identified. | Lincolnshire County Council Adult Care |
| 10.4.3 | All staff involved in assessments should understand the Mental Capacity Act and be able to apply its principals in practice. | Lincolnshire County Council Adult Care |
| 10.4.4 | All staff should have an awareness of domestic abuse and be able to respond to such concerns effectively where they are identified. | Lincolnshire County Council Adult Care |
| 10.4.5 | Adult Care should ensure that effective measures are in place to determine the nature and complexity of cases and ensure that cases are allocated to staff with the appropriate experience and skills to manage them. | Lincolnshire County Council Adult Care |
| 10.4.6 | Information gathering and sharing should be improved by:- • The important components of a case history should be available to the allocating officer at the point of allocation. • Case file hazard warning should be clear and unambiguous • Allocating officers should obtain all relevant information for cases where concerns have been identified. | Lincolnshire County Council Adult Care |
| 10.4.7 | Quality assurance should be improved and managers must be able to produce evidence that cases are being effectively managed and service standards are being complied with. | Lincolnshire County Council Adult Care |
| 10.4.8 | Adult Care should ensure that measures are in place to improve and assure the consistency and quality of case recording. Also ensure that electronic recording consistently evidences that the key components of case history and hazards are shown in the record. | Lincolnshire County Council Adult Care |
| 10.4.9 | Competencies, training and management accountability to be improved by clear practice standards and evidence of compliance with those standards to be monitored. Also Adult Care should have a clear training plan which maintains the level of competency required of its staff. | Lincolnshire County Council Adult Care |
| 10.5.1 | A referral form template and referral pathway into LCHS Adult Community Nursing Services to be developed and be available for use and the process audited. The referral form must highlight the need to record a description of any risk that the patient presents and a description of the existing or suggested controls to mitigate the risk. The referral form to be scanned and attached to the patient’s electronic record. | Lincolnshire Community Health Service |
| 10.5.2 | A chronology of significant events is to be added to the clinical tree on adult electronic health records. Staff working with adults are to receive training on the use and importance of recording a chronology of significant events. | Lincolnshire Community Health Service |
| 10.5.3 | A process of group / team case discussion from which practitioners can share the lessons learnt from case reviews and be supported is to be developed and formalised within community nurse teams. | Lincolnshire Community Health Service |
| 10.5.4 | To develop a formal 12 month schedule of random record keeping reviews for community district nursing staff to identify risk assessment record keeping skills. | Lincolnshire Community Health Service |
| 10.6.1 | Housing Tenancy Management staff should be provided with advice and training to raise awareness of the impact of drug and alcohol abuse on families and in particular older members of the household. Details should be provided on how to sign post those families to other Agencies to consider appropriate levels of support and advice. | Lincoln City Council Housing |
| 10.6.2 | In dealing with repeat reports of anti-social behaviour Housing Tenancy Management staff should amend procedures and guidelines to include analysis and identification of potential high risk cases of domestic abuse. The whole life history of the tenancy should be considered and cross referenced to other electronic records including housing repair records, housing benefit records and related housing and homelessness applications. | Lincoln City Council Housing |
| 10.6.3 | The effectiveness and Agency participation in the Anti-social Behaviour Risk Assessment Conference (ASBRAC) arrangements should be reviewed periodically. | Lincoln City Council Housing |
| 10.6.4 | Following adoption of the Multi-Agency Domestic Abuse Charter 2013 / 2016 the City Council should ensure compliance with the ten standards set out in the Charter. | Lincoln City Council Housing |
| 10.6.5 | In investigating cases of Benefit Fraud, staff should be provided with advice and training to raise awareness and identify potential cases of financial abuse in the household. | Lincoln City Council Housing |
| 10.7.1 | To ensure that the 2013 / 2014 Safeguarding Work Plan pays particular focus to embedding the domestic abuse risk assessment across all areas of the Trust. | Lincolnshire Partnership NHS Foundation Trust |
| 10.7.2 | The Trust to develop a clear protocol through the Domestic Abuse Operational Management Board to ensure that when abuse is identified via a perpetrator, Agencies are able to access the victim through a standard process. | Lincolnshire Partnership NHS Foundation Trust |
| 10.7.3 | The Trust to review all the clinical systems that it currently uses in relation to how information is stored and shared between teams within the same organisation operating on different electronic record keeping systems. This is with a view to ensuring a more holistic assessment of risk can be achieved as standard. | Lincolnshire Partnership NHS Foundation Trust |
| 10.8.1 | All officers and staff should be reminded of the importance of assessing the full circumstances and nature of every incident and considering whether those circumstances fit the definition of domestic abuse as described by force policy. If the incident is one of domestic abuse then attending officers must complete a P548 and the FCR should give the incident the Final Classification Code P07 and Qualifier P06 and put the incident on the PPU Message Group prior to closing the incident. | Lincolnshire Police |
| 10.8.2 | The force needs to ensure that officers who attend domestic abuse incidents investigate all allegations of offences thoroughly and record the result of the investigation accurately on the incident log or within the crime report. | Lincolnshire Police |
| 10.8.3 | The force needs to ensure that all officers and staff involved in the investigation of offences involving domestic abuse give the case the appropriate level of priority and care, all aspects are investigated thoroughly and every effort is made to bring about a positive and satisfactory conclusion for the victim. | Lincolnshire Police |
| 10.8.4 | The importance of policy and procedures relating to domestic abuse is reinforced to ensure that all officers and staff are knowledgeable, comply with policy and are able to fulfil the force’s expectations of them. | Lincolnshire Police |
| 10.8.5 | Sergeants and supervisors should be reminded that they have a responsibility to ensure that all domestic abuse incidents are dealt with positively, effectively and in accordance with force policy. Also that all allegations and offences are investigated thoroughly and information is shared with other Agencies in accordance with information sharing agreements and protocols. | Lincolnshire Police |
| 10.8.6 | Senior officers should be reminded of their responsibility to ensure that force policies and procedures relating to issues such as domestic abuse, dangerous offenders and vulnerable adults (now adults at risk) are implemented and adhered to by police officers and staff under their command. | Lincolnshire Police |
| 10.8.7 | All officers and staff should be reminded of the importance of completing P548 ACPO DASH risk assessments fully and accurately and in accordance with force policy. The force must ensure that P548’s continue to be audited and quality assured and any shortcomings addressed through appropriate supervision and management. | Lincolnshire Police |
| 10.8.8 | The force needs to ensure that all officers and staff who attend domestic abuse incidents or are involved with domestic abuse matters do not deal with incidents in isolation. All historical information must be considered and taken account of to provide a holistic assessment of risk and every opportunity to manage and minimise that risk by a Multi-Agency approach is taken. | Lincolnshire Police |
| 10.8.9 | The force must ensure that all officers and staff are aware of the importance of sharing information with other agencies to enable a Multi-Agency approach to be taken to deal with domestic abuse and remind all officers and staff of their responsibility to refer appropriate cases to MAPPA, the Safeguarding Adults Board and MARAC. | Lincolnshire Police |
| 10.9.1 | The domestic abuse and adult safeguarding strategies to be aligned in order to identify the cross over between the two areas of risk. | Lincolnshire Probation Trust |
| 10.9.2 | Ongoing training should be provided to staff in relation to domestic abuse with familial domestic abuse being considered as opposed to collective notions of traditional domestic violence. Sentencers and legal representatives could be invited to join the training to ensure a common understanding. | Lincolnshire Probation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||