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
Somerset review
CSP: Somerset
Published: June 2023
Year of death: 2017
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 systemic failures in recognising and responding to domestic abuse for a vulnerable victim with complex needs, including inconsistent information sharing, inadequate risk assessment, and gaps in multi-agency support. Barriers to accessing help, such as potential gender bias and lack of community awareness, were also noted.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Reinforce the need for professionals to proactively consider Care Needs, Safeguarding and Mental Capacity in their deliberations in respect of abusive relationships. | Safer Somerset Partnership |
| 10 | To address the learning and development opportunities provided by the review. | Safer Somerset Partnership |
| 2 | Improve the effectiveness of information sharing across the partnership. | Safer Somerset Partnership |
| 3 | Empower professionals to recognize, respond and report Domestic Abuse, encouraging professional curiosity through an ‘open mind’ and ‘investigative mindset’. | Safer Somerset Partnership |
| 4 | Reinforce the need for effective use of the DASH risk assessment tool | Safer Somerset Partnership |
| 5 | Strengthen professionals understanding of the effect on risk of victims who suffer from substance misuse and mental health issues. | Safer Somerset Partnership |
| 6 | To strengthen the Partnership approach to Domestic Abuse risk management. Including a review of the local Marac, ensuring GP involvement, policies in respect of repeat occurrences and enhancing the application of tactical options to combat multiple risks, including suicidal ideation. | Safer Somerset Partnership | Somerset Clinical Commissioning Group |
| 7 | To systemise the approach to vulnerable adults who don’t meet the threshold for MARAC and/or Safeguarding when dealing with complex individuals who present multiple vulnerability factors, taking into account guidance in respect of “What to do if it’s not Safeguarding”, the “Missing and Vulnerable to Exploitation Panel” and in so doing determine the role of ‘One Teams’. | Safer Somerset Partnership |
| 8 | To address the potential barriers identified in this review to victims of Domestic Abuse face in seeking support from agencies. This includes training to reduce gender bias by professionals. | Safer Somerset Partnership |
| 9 | To raise awareness across the ‘Safety Net’ of community organisations of where to seek support in respect of Domestic Abuse. | Safer Somerset Partnership |
| 9.1.2 | Guidance on ‘Situational violence’ to be added to current DA procedural guidance; to include information on screening techniques (February 2018) | Avon and Somerset Police |
| 9.1.3 | The Force should take further steps to raise awareness of male victims of DA and also make officers aware of their own possible unconscious biases in circumstances involving male victims. The force should also undertake checking and testing to see whether male victims of DA are currently receiving expected standards of service by the Force. (April 2018) | Avon and Somerset Police |
| 9.2.1 | Enhanced Information sharing by auditing referral routes and ensuring Social Care Representation at MARAC | Somerset County Council Adult Social Care |
| 9.2.2 | Disseminate learning from DHR across Adult Social Care. | Somerset County Council Adult Social Care |
| 9.2.3 | Understand the availability of domestic abuse support resources for males in Somerset and disseminate this to Safeguarding and locality teams | Somerset County Council Adult Social Care |
| 9.4.1 | Ensure that staff complete fuller case notes to fully demonstrate the action they are taking and why. | Somerset Integrated Domestic Abuse Service (Live West) |
| 9.5.1 | When CMHT’s receive referrals from SDAS, to contact referrer to discuss whether joint assessment with SDAS could be offered. | Somerset Partnership NHS Foundation Trust |
| 9.5.2 | During Court Assessment and Advice Service (CAAS) assessment when it becomes apparent that there is a victim of domestic abuse perpetrated by the client they are assessing, for CAAS to check with Police that the victim (who CAAS would not have contact with) has had an ACPO DASH completed and been referred to domestic abuse support services as applicable. | Somerset Partnership NHS Foundation Trust |
| 9.5.3 | Reiterate to CAAS in all instances where domestic abuse is suspected during CAAS assessment/contact, and/or Minor Injuries Unit (MIU) contact, staff to offer to undertake DASH with patient if patient is suspected victim of domestic abuse. If DASH declined by patient, CAAS/MIU to give contact details for domestic abuse support services. | Somerset Partnership NHS Foundation Trust |
| 9.5.4 | Encourage all staff working in acute settings to be familiar with the Dual Diagnosis Policy and to attend Dual Diagnosis training as applicable. | Somerset Partnership NHS Foundation Trust |
| 9.6.1 | SDAS staff to consider using the DASH form as a risk assessment tool as well as a referral tool and to explain to clients that completion of a DASH form does not have to automatically trigger a referral into SIDAS but can be used simply to indicate risk level and for further discussion with the client. | Somerset Drug and Alcohol Service (SDAS) |
| 9.8.1 | Reiterate message within Emergency Department (ED) regarding substance misuse as indicator of increase risk of vulnerability alongside recognising victims of domestic abuse in male patients and following correct processes associated with this. | Taunton and Somerset NHS Foundation Trust |
| 9.8.2 | Re-emphasize need for professional curiosity particularly when patient flagged as domestic abuse victim and presents with assault injuries to ED. | Taunton and Somerset NHS Foundation Trust |
| 9.8.3 | Think family approach to be embedded in ED and safeguarding training across TST, professional curiosity when aggressive behaviour demonstrated and flag on system re MARAC. | Taunton and Somerset NHS Foundation Trust |
| 9.8.4 | Review how MARAC related information is recorded by safeguarding service on MAXIMS /EPRO to be most useful / available to staff to access. | Taunton and Somerset NHS Foundation Trust |
| 9.9.1 | Diary sheets will be reviewed in conjunction with other diary sheets/ incidents to enable a holistic view of the case. | Yarlington Housing |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||