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
Swindon review
CSP: Swindon
Published: May 2023
Year of death: 2014
Extracted: 32 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 agency responses to domestic abuse, including inadequate police action, inconsistent medical practitioner adherence to safeguarding guidelines, and insufficient risk assessment by support services. These issues hindered effective intervention and support for the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 7.1.1 | That the Church of England updates the 2006 domestic abuse policy document, “Responding to Domestic Abuse. Guidelines for those with pastoral responsibilities" and publishes its new guidance before June 2016. | Church of England |
| 7.1.2 | That the Church of England’s new guidance should be brought to the attention of those with pastoral responsibilities as promptly and clearly as possible and not later than June 2016. | Church of England |
| 7.1.3 | That the Church of England ensures that all those with pastoral responsibilities receive domestic abuse training by December 2017. | Church of England |
| 7.1.4 | That the Church of England shares its new domestic abuse policy with other Faiths in England and Wales before the end of June 2016. | Church of England |
| 7.1.5 | That Her Majesty’s Inspector of Constabulary includes a focus on the supervision of domestic abuse cases when carrying out its current programme of domestic abuse inspections of police forces in England and Wales. This has already been implemented and will be ongoing during future Police Force inspections. | Her Majesty’s Inspector of Constabulary |
| 7.2.1 | That Swindon Community Safety Partnership links with religious leaders to engage with them in raising awareness of domestic abuse and the availability of specialist domestic abuse support services in Swindon. This will be fully implemented by March 2016. | Swindon Community Safety Partnership |
| 7.2.2 | That Swindon Community Safety Partnership uses good practice material from other areas to update current literature informing the public and general organisations about domestic abuse and what action to take if they become aware of abuse taking place. This will be fully implemented by March 2016. | Swindon Community Safety Partnership |
| 7.2.3 | That Swindon Community Safety Partnership leads partnership agencies in raising public awareness of domestic abuse and the availability and scope of specialist support services in Swindon and adjoining areas. This will be fully implemented by March 2016. | Swindon Community Safety Partnership |
| 7.2.4 | That Swindon Community Safety Partnership agencies appoint Domestic Abuse Champions/Leads to ensure that their organisation’s domestic abuse policies are up to date and implemented positively by all personnel; that staff receive regular appropriate level training and that they are available to provide advice and support if required. This will be fully implemented by March 2016. | Swindon Community Safety Partnership |
| 7.2.5 | That the Swindon Community Safety Partnership, with the support of Woman’s Aid and Wiltshire Police assist with the training of the new domestic abuse champions/lead officers. This will be fully implemented by March 2016. | Swindon Community Safety Partnership | Woman’s Aid | Wiltshire Police |
| 7.3.1a | The LIFT Psychology service will reinforce the current safeguarding protocols, including Domestic Violence procedures with the staff team. This has been implemented, and will be ongoing. | Avon and Wiltshire Mental Health Partnership NHS Trust | SEQOL |
| 7.3.1b | The LIFT Psychology service had a training session on the 22nd July 2015 which included further specific training on possible indicators of Domestic violence and the need to ask specific questions when indicated. This will be a feature in training new staff on induction. | Avon and Wiltshire Mental Health Partnership NHS Trust | SEQOL |
| 7.3.2a | That the organisation review personnel awareness of the company’s domestic abuse policy and knowledge of their responsibilities if they suspect a client may a victim or perpetrator. This was fully implemented with existing staff on 22nd July 2015 and will be part of induction training for any new personnel. | CP Counselling |
| 7.3.3a | A performance review was held with the Telephone Counsellor and their line manager to revisit assessment protocols and the importance of Red Flags. This was completed in April 2015. | Optum |
| 7.3.3b | Assessment protocols and the importance of Red Flags has been revisited in weekly team meetings. Discussion included risk assessment, clarity of note taking and evidence of a clear rationale for all care plans and escalation protocols. This was completed in April 2015. | Optum |
| 7.3.4a | That Swindon CCG will identify and arrange the training of a GP to be the Safeguarding lead with a special responsibility for domestic abuse. This role will include advising GPs and other medical service providers on what action to take when faced with issues relating to domestic abuse. This will be cascaded by NHS England to CCGs. This was agreed in June 2015 and the post holder will be in place by September 2015. | Swindon CCG | NHS England |
| 7.3.4b | The Swindon CCG website will include a link to Women's Aid to inform medical practitioners about the specialist domestic abuse support services available locally. This was completed in June 2015. | Swindon CCG |
| 7.3.4c | When domestic abuse is disclosed to a medical practitioner, the patient’s vulnerability and safety should be considered against their autonomy. This has been agreed and fully implemented by June 2015. | NHS England | Swindon CCG |
| 7.3.4d | When domestic abuse is disclosed in a GP consultation, up to date and appropriate information should be available to the individual. This has been agreed with GPs and implemented by June 2015. | NHS England | Swindon CCG |
| 7.3.4e | Leaflets in a locality should be readily accessible on search engines, clearly labelled, in accessible appropriate, supportive language and dated to ensure they are current. This is ongoing and will be completed by September 2015. | NHS England | Swindon CCG |
| 7.3.4f | Each GP Practice in the Swindon area will have a safeguarding lead who will receive specialist domestic abuse training by Woman’s Aid. Courses have already commenced and are ongoing. | Swindon CCG |
| 7.3.4g | When domestic abuse is disclosed in a GP consultation it should be discussed with the safeguarding lead in the Practice in order to assess the risk and appropriate actions to be taken and services to be offered. All GP Practices in the Swindon area have agreed to implement this recommendation immediately. | Swindon CCG |
| 7.3.4h | If a joint consultation for marital disharmony is offered this should only be done if the GP has appropriate qualification in counselling. This must not proceed if there is any suspicion of domestic abuse. This has been communicated to and agreed by all Swindon GP practices. | Swindon CCG |
| 7.3.5a | With immediate effect the practice of interviewing perpetrators by way of a contemporaneous note interview should cease. If an arrest cannot be justified the perpetrator should be interviewed on tape at a police station under invitation. The domestic abuse policy has now been amended to reflect this. Completed prior to June 2015. | Wiltshire Police |
| 7.3.5b | Create and circulate a ‘best practice document’ and policy document for existing operational staff dealing with incidents by way of contemporaneous notes. This has been fully implemented. | Wiltshire Police |
| 7.3.5c | Establish, agree and circulate procedures regarding the timely submission of report files for summons recommending that in domestic abuse cases this should be within 24hrs, or as soon as practicable, due to the non-availability of CPS for non-custody offences over weekends. This recommendation has been completed, June 2015. | Wiltshire Police |
| 7.3.5d | Create a policy for the submission of summons files for Wiltshire Police. This must incorporate a process to ensure priority for domestic abuse cases submitted for summons. This recommendation has been completed, June 2015. | Wiltshire Police |
| 7.3.5e | Amend the current domestic abuse policy to incorporate timescales for the submission of all types of domestic abuse court files. This recommendation has been completed, June 2015. | Wiltshire Police |
| 7.3.5f | Develop a flow chart process map to reaffirm the requirement to review the DASH risk assessment upon new intelligence and history. Communicate this using e-brief & managers briefing. This will be completed by the end of July 2015. | Wiltshire Police |
| 7.3.5g | Front line staff and control room staff to be given refresher training regarding safeguarding measures available for victims of domestic abuse. The training to include an understanding of the information required to correctly complete the PPD1, the DASH risk assessment process and review. This training will take place during Autumn 2015. | Wiltshire Police |
| 7.3.5h | Effective training should be rolled out to supervisors regarding their duties and responsibilities to effectively manage domestic abuse investigations. Specifically, supervisors must satisfy themselves that the DASH risk assessments have been completed accurately and that incidents have been dealt with appropriately. This training will take place during Autumn 2015. | Wiltshire Police |
| 7.3.5i | The PPD1 should be redesigned to allow for consistency in supervisor endorsement with the support of effective training enabling supervisors to demonstrate due consideration concerning victim safeguarding and risk. This has commenced and will be completed by Autumn 2015. | Wiltshire Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||