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

Kirklees review

CSP: Kirklees Published: May 2023 Year of death: 2014 Extracted: 26 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 a lack of professional curiosity and missed opportunities for routine enquiry about domestic abuse. Agencies struggled with coordinated multi-agency support for individuals with complex needs and those engaging in risky behaviours not meeting safeguarding thresholds.

Extracted recommendations

26 recommendations pulled from the report

#	Recommendation	Addressed to
1	Consideration should be given to the development of an overarching training plan to ensure that staff are clear about how to recognise the basic signs and symptoms of domestic violence and abuse which agencies can then tailor or access according to service specific needs.	All agencies
10	To ensure that Locala clinicians and Lifeline staff have access to an up to date list of walk-in centres in Kirklees so they can identify when patients access NHS services as opposed to the services of their regular General Practitioner.	Locala \| Lifeline
11	That Lifeline’s child safeguarding policies should make specific reference to MARAC procedures, where the procedures can be located and information about the role of the in-house nominated lead manager.	Lifeline
12	To strengthen the interface between SWEET and Safeguarding Adults so as to ensure that when a vulnerable adult is linked to a sex-worker, SWEET is informed.	SWEET
13	To review the MARAC briefing training pack and make sure it includes the impact of domestic abuse on sex-workers and the relevance of referring cases to MARAC.	South West Yorkshire Partnership NHS Foundation Trust
14	To make sure that the MARAC briefing is delivered to Single Point of Access staff, Kirklees Community Mental Health Team, and the Supporting Peoples Team.	South West Yorkshire Partnership NHS Foundation Trust
15	To ensure that specific family related questions are asked at SPA and point of referral, such as: Who lives with you? Does anyone support you? What is important in your life? Do you care for anyone? Do you have child(ren) / extended family? Do you need support if you are in a parenting role?	Kirklees Council Single Point of Access
16	To ensure that managers and staff increase their knowledge and awareness around a ‘Think Family’ approach to develop strong working relationships across departments and agencies.	Kirklees Council Single Point of Access
17	To develop strategies for the management of referrals where the situation is complex or there is a risk of poor outcomes for children and parents.	Kirklees Council Single Point of Access
18	To develop new or adapt existing management information tools to ensure the quality and information gathered by SPA is fit for purpose.	Kirklees Council Single Point of Access
19	Update ‘Think Family’ training to raise awareness of the different groups who face domestic violence and abuse and how services can respond effectively.	Kirklees Council Single Point of Access
2	The training should ensure all staff know how to routinely ask questions and record the answers about the potential for domestic violence and abuse when someone presents as a potential victim of it.	All agencies
20	To review guidance as to when staff should discuss a case with a manager to obtain support and guidance with decision making.	Kirklees Council Single Point of Access
21	To ensure that all patients are routinely asked about domestic violence and abuse when triaged in accident and emergency departments and that appropriate and proportionate action is taken immediately. Where there is a history of patients leaving the department before being seen, an appropriate triage risk assessment should take place and that patients are seen promptly	Calderdale and Huddersfield NHS Foundation Trust
22	There should be an improvement in the recognition of adults at risk of abuse or neglect when they attend accident and emergency	Calderdale and Huddersfield NHS Foundation Trust
23	Where the patient has been the victim of an assault or sexual abuse, to ensure that safety risks and social support needs are assessed and that safety and support arrangements are in place prior to discharge from both accident and emergency and inpatient hospital wards	Calderdale and Huddersfield NHS Foundation Trust
24	To consider how CHFT can be more involved in multi-agency working with patients who have complex health and social care needs and who are difficult to engage with	Calderdale and Huddersfield NHS Foundation Trust
25	To raise awareness about male victims of domestic violence and abuse with accident and emergency service users and members of staff	Calderdale and Huddersfield NHS Foundation Trust
26	To ensure that mental capacity is assessed and the outcome recorded for all decisions where capacity is questioned in accident and emergency departments.	Calderdale and Huddersfield NHS Foundation Trust
3	The Kirklees Community Safety Partnership and Kirklees Safeguarding Adult Board's current and ongoing work on self-neglect should consider the feasibility of developing a coordinated case management/information sharing approach to the care of people who for whatever reason engage in risky behaviours that are not captured by other safeguarding processes. The Community Safety Partnership and the Kirklees Adults safeguarding Board are best placed to collaborate and facilitate discussion around this, with a view to agreeing and implementing a multi-agency protocol.	Kirklees Community Safety Partnership \| Kirklees Safeguarding Adult Board
4	Because of the significant problems within Kirklees of street sex-workers, who through their lifestyles and who they engage with make themselves vulnerable to exploitation and violence, the Safeguarding Adult’s Board in Kirklees should consider whether sex-workers should be identified as ‘Adults at Risk’ and therefore whether a multi-agency safeguarding response would be appropriate.	Kirklees Safeguarding Adult Board
5	That HSS ensure staff receive training in options available for people experiencing domestic abuse and refresher training is provided as appropriate, underpinning the existing guidance to support staff in identifying the most appropriate option, where domestic violence or abuse is disclosed or becomes evident.	Housing Solutions Service
6	That HSS puts in place a quality assurance system to ensure that accurate case notes and records are maintained so that actions and interactions with customers are fully recorded.	Housing Solutions Service
7	That KNH review and update their anti-social behavior policy and procedures which include reference to clear policies and procedures for KNH staff to follow around domestic abuse.	Kirklees Neighbourhood Housing
8	That KNH look into enabling a system prompt to ensure that failed initial tenancy visits are followed up with further communication with the tenant, to ensure appropriate welfare checks are made as appropriate.	Kirklees Neighbourhood Housing
9	To ensure that all keyworkers in Lifeline should have attended training refreshed every 3 years in domestic abuse, MARAC procedures and the use of the DASH risk assessment.	Lifeline
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗