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
Leeds review
CSP: Leeds
Published: June 2023
Year of death: 2014
Extracted: 49 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 understanding coercive control, underestimating risk during separation, and inadequate risk assessments by multiple agencies. It highlights issues with unclear referral processes and delayed access to specialist domestic violence services for the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1.1 | All statutory agencies will ensure that they have policies and procedures in place for responding to domestic abuse including explicitly addressing coercive control. | All statutory agencies |
| 1.2 | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Leeds Partnership will ensure that all member agencies develop plans for skilling up workers to understand coercive control. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Leeds Partnership |
| 1.3 | All statutory agencies will ensure that they provide information about coercive control on their websites and other material about domestic abuse aimed at the public. | All statutory agencies |
| 1.4 | Safer Leeds will request that the West Yorkshire Domestic Violence Sub Group consider conducting a public awareness campaign about domestic abuse, including coercive control. | Safer Leeds Partnership |
| 2.1 | Safer Leeds will map current services for managing domestic abuse perpetrators across all statutory agencies involved in the Safer Leeds partnership including ensuring that: agencies outside the criminal justice system recognise that they have a responsibility to manage perpetrators; the needs of victims are considered by agencies working with perpetrators. | Safer Leeds Partnership |
| 2.2 | Safer Leeds will consider raising the impact on domestic abuse victim of legal aid changes through the Leeds Domestic Violence & Abuse Board. | Safer Leeds Partnership |
| 2.3 | All statutory health agencies in Leeds will develop a plan for implementing the NICE guidance on domestic abuse, including responding to perpetrators. | All statutory health agencies in Leeds |
| 3.1 | Leeds & York Partnership Foundation Trust, Leeds Adult Social Care, Leeds Women’s Aid and West Yorkshire Police will ensure that all staff understand when a DASH risk assessment should be conducted and will ensure that staff are either trained to do a DASH assessment or are aware of the referral pathways to follow to ensure a DASH assessment is done. | Leeds & York Partnership Foundation Trust | Leeds Adult Social Care | Leeds Women’s Aid | West Yorkshire Police |
| 3.2 | Leeds & York Partnership Foundation Trust and Leeds Adult Social Care will ensure that where domestic abuse is a known issue, the victim will be offered a DASH risk assessment, where possible, either directly or through referral to another agency. | Leeds & York Partnership Foundation Trust | Leeds Adult Social Care |
| 3.3 | LYPFT will increase the number of front-line practitioners able to conduct such an assessment. | Leeds & York Partnership Foundation Trust |
| 3.4 | Leeds Adult Social Care will ensure that domestic abuse is explicitly addressed within the recommendations section where it is a known issue within a Mental Health Act Assessment. | Leeds Adult Social Care |
| 3.5 | West Yorkshire Police will ensure that DASH risk assessments are carried out for all confirmed reported domestic incidents. | West Yorkshire Police |
| 4.1 | Leeds Adult Social Care will ensure that the safety of the victim and any children or adults at risk within the household is explicitly considered within the Mental Health Act Assessment where domestic abuse is a known issue. | Leeds Adult Social Care |
| 4.2 | Leeds & York Partnership Foundation Trust will ensure that the safety of the victim and any children or adults at risk within the household is explicitly considered as part of discharge planning where domestic abuse is a known issue. | Leeds & York Partnership Foundation Trust |
| 4.3 | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Leeds Partnership will review the support available to help victims assess their own risk and plan for their safety. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Leeds Partnership |
| 4.4 | The Chair of the Community Safety Partnership shall write to Resolution, the Solicitors Regulation Authority and the Law Society in order to invite the relevant organisations to raise awareness amongst their members as to the definition of domestic abuse and the potential consequences of controlling and coercive behaviour in domestic abuse situations, particularly in the light of the recent changes to the criminal, legislative definition | Chair of the Community Safety Partnership |
| 5.1 | Leeds Adult Social Care will ensure that actions to address domestic abuse are included within the recommendations section of a Mental Health Act Assessment where domestic abuse is a known issue. | Leeds Adult Social Care |
| 5.2 | Leeds & York Partnership Foundation Trust will ensure that all relevant key issues from the Mental Health Act Assessment are highlighted on the electronic records of patients and addressed within the period of detention. | Leeds & York Partnership Foundation Trust |
| LASCR1 | To consider how immediate recommendations discussed by the Approved Mental Health Professional and the section 12 Doctor are shared and recorded with the ward staff to ensure there is appropriate follow up. | Leeds Adult Social Care |
| LASCR2a | For the Approved Mental Health Professional Assessment template to be reviewed: in the ‘Assessment Conclusion’ section to have mandatory boxes to confirm if referrals are needed for Children’s Social Services, Adult Social Care, Adult Safeguarding and MARAC for the service user and anyone impacted/at risk from the service user. | Leeds Adult Social Care |
| LASCR2b | to have a section which has to be signed by the Mental Health Duty Team Manager to confirm they have read the assessment and to record any additional risk factors and recommendations which they think need addressing. | Leeds Adult Social Care |
| LASCR2c | For the AMPH to alert the duty manager if any specific recommendations would need signing off by the duty manager. | Leeds Adult Social Care |
| LASCR3 | The new recording system which will be used by Adult Social Care (CIS) to link recommendations identified within the AMHP assessment with evidence that actions have been completed. | Leeds Adult Social Care |
| LASCR4 | For the AMHP training programme and continual professional development training to include specific reference to risks for others who may be affected by the mental health service user. To include reference to children’s services and safeguarding, adults safeguarding and domestic violence, including the MARAC process | Leeds Adult Social Care |
| LASCR5 | For the Leeds Safeguarding Partnership Website to have more explicit information for members of the public about alternative sources of help regarding domestic violence. | Leeds Adult Social Care |
| LASCR6 | For the mandatory safeguarding training for Leeds Adult Social Care staff to include written information about MARAC and links about organisations that could help victims of domestic violence who may be experiencing lower level risks of domestic violence and may not meet the criteria for MARAC. | Leeds Adult Social Care |
| LASCR7 | For Adult Social Care and the Adult Safeguarding Board to be explicitly referred to within Leeds City Council’s Domestic Violence and Abuse Scrutiny Board’s recommendations. | Leeds Adult Social Care | Adult Safeguarding Board |
| LASCR8 | For Senior Adult Social Care Staff to consider developing a Domestic Violence policy/guidelines in relation to service users and their families. | Leeds Adult Social Care |
| LCCG1 | Provide feedback to GP Practice | Leeds Clinical Commissioning Group |
| LCCG2 | Clinicians in Primary Care assessing mental health presentations are advised to routinely assess and record: risk to self, risk to others, perceived risk from others | Leeds Clinical Commissioning Group |
| LCCG3 | GP practices are advised to ensure that, where staff recognise risks to self/others or risk from others information is recorded, shared and accessible to clinical colleagues and other practice staff who need to be aware of these issues. | Leeds Clinical Commissioning Group |
| LCH1 | To implement core questions of routine and selective enquiry into domestic violence into the assessment undertaken by CAMHS practitioners. | Leeds Community Healthcare |
| LCH2 | To implement a SNS review of acting on information shared with the service from A&E departments. | Leeds Community Healthcare |
| LDVS1 | Review of the Referral Form for LDVS support services used by all referring sources. Specific focus on enhancing the information obtained from the client and/or referring agent with specific questions relating to actual and perception of risk and the welfare of children & young people in the home. | Leeds Domestic Violence Service |
| LDVS2 | LDVS Lead and Service Managers include ‘Changes to Policies, Procedures and Protocols’ as a standard agenda item at all LDVS Management meetings. Review and Revision actions and outcomes to be monitored in meeting minutes. This will help to ensure all LDVS partners aware of revisions and to highlight those which are due for review. | Leeds Domestic Violence Service |
| LDVS3 | Introduction of a referral alert monitoring system within LDVS Outreach. This will ensure contact is attempted with all clients referred for support within the prescribed timescale to improve client outcomes and enable potential problems in meeting this performance measure to be identified and escalated to Senior Management in a timely manner. | Leeds Domestic Violence Service |
| LTHT1 | To consider developing training needs analysis on domestic violence issues, prioritising this review of current arrangements and pathways in high volume patient areas. | Leeds Teaching Hospitals Trust |
| LTHT2 | To explore how relevant clinical information held by mental health services such as mental health assessments and risk assessments can be communicated to and recorded by LTHT. | Leeds Teaching Hospitals Trust |
| LTHT3 | The domestic violence task and finish group to consider whether current safeguarding policies can be reviewed and strengthened or alternatively whether a stand-alone domestic violence policy is required. | Leeds Teaching Hospitals Trust |
| LWA1 | LWA to prepare a more detailed Protocol for the Drop-In service which codifies and explicitly states appropriate processes and actions to be implemented depending on a range of presenting client circumstances, including notes and record keeping. | Leeds Women’s Aid |
| LWA2 | LWA Risk Assessment protocol for drop-in and telephone services to be revised which codifies and explicitly states appropriate processes and actions to be implemented relating to risk assessment. | Leeds Women’s Aid |
| LYPFT1 | Where a patient is being discharged from hospital clear information should be shared with the community service | Leeds & York Partnership Foundation Trust |
| LYPFT2 | In patient wards should have clear contact information for community services | Leeds & York Partnership Foundation Trust |
| LYPFT3 | The Trust policy for 7 day follow up should be reviewed to include any locally agreed standards | Leeds & York Partnership Foundation Trust |
| LYPFT4 | Where carers are involved, ward staff should ensure that they are invited to key clinical meetings to ensure their involvement. | Leeds & York Partnership Foundation Trust |
| LYPFT5 | Where a child is involved in a case such as this a referral should be made to the child safeguarding team in their own right. | Leeds & York Partnership Foundation Trust |
| WYP1 | That West Yorkshire Police review its training in respective of domestic abuse to ensure that concepts of coercion and control are fully embedded and officers recognise behaviours which meet the Force definition and follow procedures accordingly. | West Yorkshire Police |
| WYP2 | That West Yorkshire Police remind Safeguarding Unit staff of the importance of formally recording third party concerns that a victim is subject to abuse. | West Yorkshire Police |
| YAS1 | Within 3 months YAS will put a bulletin in Operational Update to remind staff of the impact on children and young people witnessing or affected by Deliberate Self-Harm/Para-suicide or suicide. The age & relationship of the child or young person must be documented and a referral to Children’s Social Care must be made. | Yorkshire Ambulance Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||