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

Torfaen review

CSP: Torfaen Published: May 2023 Year of death: 2012 Extracted: 13 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 inter-agency information sharing, risk assessment, and recognition of domestic abuse and child sexual exploitation, leading to missed opportunities to intervene and protect the victim and her family from escalating threats.

Extracted recommendations

13 recommendations pulled from the report

#	Recommendation	Addressed to
1	That the Home Office reviews the existing system of flagging of perpetrators using guns and knives on the Police National Computer and the Police National Database and to extend the flagging system to include perpetrators who use fire as a weapon in a domestic context.	Home Office
10	Sharon expressed her concerns about her daughter frequently to agencies. We consider that these were perceived as low risk because at no point was a risk assessment generated. Managing these high volume low risk concerns is a recognised challenge, but effective models do exist. For example, in Northern Ireland, the Early Authoritative Intervention adversity matrix is a model where the threshold to intervene lowers as the frequency of concerns increases, thereby ensuring that low-risk-high-volume cases are not ignored. In Gwent the nearest model to this is the Gwent Missing Children Hub. We recommend that the Gwent Missing Children Hub model is expanded to address teen domestic abuse and child sexual exploitation cases, where a child or young person may not be missing but where there are frequent concerns expressed by Recommendation agencies or families.	Gwent Missing Children Hub \| Gwent Police \| Local Authorities \| NHS Trusts
11	Correspondingly, the multi-agency nature of the response and the specialist CSE input by Barnardos into the Hub will need to be enhanced by the addition of a Young Persons Independent Domestic Abuse Advocate. We recognise this will require funding but at present much agency time is spent in an uncoordinated response to these young people, and a coordinated response promises far greater efficacy.	Gwent Missing Children Hub \| Barnardos
12	Within the ABU Health Board the All Wales Routine Enquiry is fully embedded in practice. An audit to be undertaken on the extent to which Routine Enquiry has been implemented and an action plan developed to address any issues identified. The Health IMR acknowledges there is no evidence that the All Wales Domestic Abuse Antenatal Care Pathway was followed. The panel acknowledges that, had Mary been asked if she were experiencing abuse, she was unlikely to have identified it herself. However the questions recommended by the pathway are subtler than a direct enquiry and are designed to provoke thought and encourage disclosure.	Aneurin Bevan University Health Board
13	We recommend that a SERAF assessment is undertaken on all women under the age of 18 years presenting in pregnancy.	NHS
2	Future revisions of the Domestic Abuse, Stalking and Honour Based Violence Risk checklist (DASH) are revised to include the threat of arson or history of fire setting..	Home Office
3	That the NICHE system be recommended for National roll out to ensure information between forces is shared in an accessible and format which allows it to inform real time Police responses to offenders.	Home Office
4	That the Welsh Government’s Christmas domestic abuse TV campaign that focussed on third party reporting by a family member is re-run as and when finance permits. The materials from 10,000 Safer Lives the Welsh Government domestic abuse campaign should also now be used in all current Welsh Government family intervention programmes and in schools, forming part of the healthy schools package delivered by the All Wales Schools Programme, which reaches 98% of schools across Wales. The uptake of its Safer Relationships module varies significantly across Wales and Torfaen should identify which Secondary Schools so far have not taken up this offer of free materials and inputs for schools. Local domestic abuse service providers have significant material which should be displayed in all settings where young people are present. That domestic abuse service providers ensure their promotional / advice literature and websites are clear that concerned relatives can access advice, information and support and identifies the risk this poses to them as individuals.	Welsh Government \| Torfaen Borough Council \| Domestic Abuse Service Providers \| Schools
5	That young people’s resilience is developed through education so they can better face domestic abuse, sexual abuse and sexual exploitation both in the online and offline world. The proposed Gender-based Violence, Domestic Abuse and Sexual Violence (Wales) legislation for Wales plans to take this forward through a ‘whole school’ approach. The current All Wales Schools Programme, although well regarded, is both expensive and limited in its capacity to deliver as it is staffed by Police Officers. In order to increase capacity and to recognise that many young people will not feel comfortable with disclosing information that could lead to the arrest of a parent or intimate partner to a Police Officer, the voluntary sector should be considered as a delivery mechanism for the future delivery of this programme. That Gwent undertakes a pilot of this approach in schools, colleges, pupil referral units and youth service settings and does not wait for the legislation. A wide range of agencies have existing ‘healthy relationships’ packages but need staff for pilots. We are aware that there are cost implications when increasing the frequency of delivery - but the costs of not informing young people are more significant. An ‘invest to save’ bid could be considered as this proposal fits the criteria of a prevention approach.	Welsh Government \| Gwent Police \| Schools \| Colleges \| Pupil Referral Units \| Youth Services \| Voluntary Sector
6	That Gwent agencies, which have a good history of training around domestic abuse and the use of the Domestic Abuse Stalking and Honour (DASH) assessment tool, immediately ensure that all agencies need to have procedures in place to ensure a DASH form is completed for all identified victims of domestic abuse. Once completed, a victim could be referred to MARAC and /or a standardised safety planning tool may be used. The proposed Gender-based Violence, Domestic Abuse and Sexual Violence (Wales) legislation will place a duty on Wales’ public bodies for staff to ‘ask and act’ about domestic abuse. All professionals will be required to pro-actively enquire about domestic abuse and act upon information in order to seek to protect the victims they are in contact with, whatever the context of their relationship with that victim. All agencies need to have procedures in place that ensure a DASH form is completed for all identified victims of domestic abuse. This case highlights that agencies and professionals do not have access to a standardised safety planning tool and we recommend that this is developed and piloted by the pan Gwent Domestic Abuse Forum. This will ensure consistency across services for victims, whoever they choose to disclose to.	Gwent Police \| Torfaen Borough Council \| Aneurin Bevan University Health Board \| Pan Gwent Domestic Abuse Forum
7	Torfaen Local Safeguarding Children Board (superseded by the South East Wales Safeguarding Children Board in April 2013) states it had undertaken a proactive approach to Child Sexual Exploitation from late 2011 with the then Operation Artemis. Their IMR notes that training to identify grooming was cascaded from 2008 onwards although grooming was identified in this case no appropriate action was taken to address it. That an appropriate response to Child Sexual Exploitation using the Grooming training or SERAF model was fully operational was the responsibility of the then Local Safeguarding Children Board and ultimately the Local Service Board in Torfaen. We recommend that future revisions of or additions to the All Wales Child Protection Procedures which are not being delivered systematically in Torfaen are identified by agencies as a risk and made known to the South East Wales Safeguarding Children Board and the Local Service Board this will ensure the LSB Executive Leadership Group can review risk, understand what measures are in place to mitigate risk and ultimately hold agencies to account. Gwent Police according to the HMIC March 2014 Domestic Abuse Inspection report identified that the force does not have a specific domestic abuse policy or procedural guidance in relation to the identification and response to incidents of domestic abuse. That this gap in policy and procedure is addressed to ensure frontline Police Officers and staff has clarity, middle managers have a process to scrutinise and the leadership a clear and publically well defined position.	South East Wales Safeguarding Children Board \| Local Service Board \| Gwent Police
8	Despite extensive domestic abuse awareness and DASH training availability in Gwent (more so than in the rest of Wales), existing courses are undersubscribed wasting valuable resource. The Social Services Department are now undertaking DASH Training and Gwent Police are incorporating details from this case into their training to ensure Domestic Abuse is identified. Agencies must ensure all staff receive appropriate fit for purpose training and monitor attendance. A systematic approach to ensure all staff is appropriately trained is a management responsibility.	Gwent Police \| Torfaen Borough Council \| Aneurin Bevan University Health Board \| Other Gwent Agencies
9	The failure of services to engage the alleged perpetrator of domestic abuse in this case suggests that this is a skill that needs to be embedded in existing training. The skills of engaging and challenging perpetrators are already present in the criminal justice workforce and these should be translated to the social care, substance abuse and other relevant public service workforce. This creates a culture where all staff feels confident and are skilled to engage alleged perpetrators, both safely and constructively (for themselves as well as for victims and their families). That the resources and content of training be reviewed to ensure that the outcome is an increase in referrals and relevant and proportionate information sharing in domestic abuse cases. That this review addresses • The identification and management of perpetrators • How management can provide effective monitoring and oversight of practice	Gwent Police \| Local Authorities \| NHS Trusts \| Substance Abuse Services \| Other Public Services
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗