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
Nuneaton and Bedworth review
CSP: Nuneaton and Bedworth
Published: June 2023
Year of death: 2012
Extracted: 54 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
Agencies failed to consistently identify and assess domestic abuse risks, share critical information, and enforce protective measures, particularly regarding repeat incidents and perpetrator history. Training gaps and MARAC process limitations contributed to missed opportunities for intervention.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| R1 | To review the investigative decision-making process relating to ‘high risk’ domestic abuse incidents, to ensure that the appropriate level of skill and type of resources and supervision is allocated to each specific domestic abuse investigation. | Warwickshire Police |
| R10 | Refuge to ensure that any change of operational practice from the service specification to be documented in writing and is treated as a formal appendix to the contract and to the specification signed by both Refuge and the commissioning body. | Refuge |
| R11 | There should be mandatory, comprehensive training in domestic violence including in risk assessment for all police officers and staff of Warwickshire police. | Warwickshire Police |
| R12 | That Warwickshire police ensure that they take positive action to: arrest perpetrators of all alleged crimes relating to domestic violence when the opportunity arises; collect evidence including at initial call-out to increase chance of prosecution; detain perpetrators – when possible and at every opportunity – to increase safety of victims | Warwickshire Police |
| R13 | That Warwickshire Police take action to consistently enforce bail conditions and deny bail conditions to those who have a proven track record of breaching/ disregarding bail/ injunctions/ community punishment orders. | Warwickshire Police |
| R14 | That the Community Safety Partnership works with the Safer Warwickshire Partnership Board to put in place clear, written policies for all agencies in the county explaining when and how to refer to specialist domestic violence support services e.g. Refuge (for accommodation services) and Stonham Home Group (the organisation now running IDVA and outreach services in the county) to ensure vulnerable victims do not fall through the cracks. | Community Safety Partnership | Safer Warwickshire Partnership Board |
| R15 | That clear SMART action points are included in MARAC minutes following all MARAC meetings to prevent ambiguity. | MARAC |
| R16 | However, the panel identified that a process needs to be put into place to ensure that feedback is requested and given on the outcome of referrals, especially if no contact can be made or support is declined, so that alternative options can be explored. | Warwickshire Domestic Violence Support Services |
| R17 | When information in relation to correspondence is added to the electronic records a note of the date the information is received must be made in the record. | Medical Centre |
| R18 | Flagging system for Domestic Abuse history to be introduced onto Electronic record system | Medical Centre |
| R19 | Software producer for the GP practice IT system to be consulted to identify if an update to the electronic records system can be made to enable the system to make automatic links of registered patients by address | Software producer for the GP practice IT system |
| R2 | A review of the police Referrals & Assessment Unit (RAU) has taken place, and has identified the need for better levels of supervision and processes to facilitate more efficient management of caseloads of staff: Further work is already underway to develop a policy that identifies acceptable levels of inputting backlogs dependant on risk level, and that includes a mechanism for reporting when the levels are exceeded. A new process has already been introduced to actively manage and triage any backlog to identify any case that relates to either a pre-existing or subsequent ‘high risk’ incident. A business case to introduce a new structure within the RAU with dedicated supervisory roles has been accepted as part of the new joint policing arrangements between Warwickshire Police and West Mercia Police. These posts will be in place by December 2013. | Warwickshire Police |
| R20 | Safeguarding and Domestic Abuse training to be completed by all staff at the Medical Centre, including awareness of MARAC process. | Medical Centre |
| R21 | Medical Centre to introduce a system to ensure that unreadable & unclear correspondence received is requested in a legible format from the agency sending correspondence and to escalate concerns if a pattern or theme is spotted with an agency. | Medical Centre |
| R22 | Procedures must be tightened up across agencies to reduce delays in sending correspondence to GPs especially related to a serious incident such as attempted suicide. | All agencies |
| R23 | That there is clarity for the respective agencies of follow up arrangements following an attempted suicide and less reliance on the patient to make contact for follow-up. | All agencies |
| R24 | That the CWPT serious incident review considers whether the assessment of the victim being identified as low risk at the time of the attempted suicide was the correct level of risk. | Coventry & Warwickshire Partnership NHS Trust |
| R25 | That information from the MARAC process is shared with GP practices along with the new CAADA Guidance for GPs. | MARAC | GP practices |
| R26 | To ensure that reduced staffing services over Christmas and New Year or other holiday periods do not negatively impact upon communication to other health and social care agencies. | All health and social care agencies |
| R27 | To ensure and reinforce that Children’s Teams follow the existing guidance in respect of referrals where children may be at risk of significant harm and the protocol for Domestic Abuse referrals in a timely manner. | Warwickshire Children’s Services |
| R28 | Where domestic abuse is disclosed to Children’s Services an appropriate member of the team should undertake a domestic abuse risk assessment with the victim or refer to a specialist domestic abuse service for a risk assessment on their behalf, as per the Warwickshire MARAC Operating Protocol | Warwickshire Children’s Services |
| R29 | That officers/agencies investigating or reporting domestic abuse incidents are reminded of the importance of recording the full names and home addresses of any children witnessing domestic abuse – this is especially important when they are visiting a parent and are not residing at their usual home address. | All officers/agencies investigating or reporting domestic abuse incidents |
| R3 | The learning points from this IMR and the DHR as a whole to be shared with all police officers and staff using DASH to ensure that the risk assessments are applied with consideration of all available information. | Warwickshire Police |
| R30 | The actions, set out below, that have been agreed in relation to the Serious Further Offence (SFO) investigation already conducted, have been implemented within the agreed timescales: Previous convictions must be used to inform every Pre-Sentence Report risk screening or their absence should be noted and corrected as soon as possible: All court duty staff to be reminded of this core practice expectation; Advice to be taken from Human Resources regarding capability or disciplinary action regarding the conduct of Officer 1; Area Office Administrators to review court administrative practice to ensure pre cons are collected and passed to UPW immediately post sentence; Unpaid Work operational managers (UPW OMs) to be reminded that pre cons must be checked before risk screenings are signed. Also that in signing risk screenings they are confirming they are satisfied themselves that the information is accurate. Potential for inconsistency and inappropriate judgements in relation to enforcement when offender reporting illness or death of significant others: Unpaid Work manager has circulated guidance to all operational managers on decision making in relation to this issue. | Warwickshire Probation Trust |
| R31 | In this case sufficient information should have been available to enable the Probation Trust to identify a domestic abuse risk; to make an appropriate proposal to the court and to manage the case based on that knowledge. This did not happen because the officer did not follow agreed procedure and the risk screening incorrectly stated there was no history of domestic abuse. This emphasises the importance of inter-agency checks at the commencement of Probation supervision and, in particular checks with the Police Public Protection Team. Approximately 65% of Probation Trust commencements in Warwickshire have domestic incident call out information recorded on the Police records. Approximately 35% have a history recorded in the last 12 months. The average number of previous call outs per identified case is 3.9. The administration of the checks against police records on commencement is carried out by a post holder funded by the Community Safety Partnership on an annual basis. The funding does not include cover for sick leave, annual leave etc. or resourcing for Unpaid Work commencements. The administration of checks in advance of sentence at court is carried out by liaison between Police and Probation staff in the justice centres if there are indications of risk identified through risk screening. It is therefore recommended that: Police, Probation and CPS to consider prioritising resource allocation to the information exchange process; That the Court Service/sentencers tolerate adjournments for this to take place where it is recommended by the Probation Court Duty Officer. | Warwickshire Probation Trust | Police | CPS | Court Service |
| R32 | That information provided by friends and family is shared with the Offender Manager who is preparing post-sentence assessments as this will be of significant help in developing the perpetrator’s profile | Warwickshire Probation Trust |
| R33 | South Warwickshire NHS Foundation Trust Review all recommendations from the DHR and complete on action plan relating to the recommendations as appropriate. | South Warwickshire NHS Foundation Trust |
| R34 | WMAS to continue to raise awareness on Domestic violence and the need to report any concerns through the safeguarding process. | West Midlands Ambulance Service |
| R35 | To improve communication between services to highlight potential at risk individuals and families so these cases can possibly be picked up using early warning signs. | West Midlands Ambulance Service |
| R36 | To raise the profile of domestic abuse in both adult and child safeguarding training sessions. (The Panel is of the view that there needs to be separate training on domestic abuse and that is is not sufficient to only link it with safeguarding training). | George Eliot Hospital |
| R37 | To target front line staff in A&E with specific domestic abuse training to enable them to identify people at risk and initiate appropriate supportive and protective actions. | George Eliot Hospital |
| R38 | To develop and implement a Domestic Abuse Policy in collaboration with partner organisations. | George Eliot Hospital |
| R39 | To engage with the Warwickshire Against Domestic Abuse Campaign to explore ways of improving detection of abuse and support for victims of abuse. | George Eliot Hospital |
| R4 | The MARAC Steering Group to be invited to develop a robust process for identification of MARAC repeat cases from other agencies along with subsequent MARAC referral, as part of the MARAC Improvement Plan. | MARAC Steering Group |
| R40 | To ensure that the profile of domestic abuse is not only raised under the umbrella of both child and adult protection, but in its own right | George Eliot Hospital |
| R41 | Public awareness campaign e.g. production of information leaflets / posters which can be distributed throughout agencies. | All agencies |
| R42 | To develop and ensure implementation of an induction programme for new MARAC agencies and representatives to support them in understanding their roles and the requirements of MARAC agencies. | MARAC Steering Group |
| R43 | To complete the revision of the MARAC Operating Protocol to ensure that it is compliant with the CAADA checklist. | MARAC Steering Group |
| R44 | To complete the MARAC Information Sharing Protocol to ensure that it is compliant with the CAADA checklist. | MARAC Steering Group |
| R45 | To improve and re-format the MARAC minutes template to ensure that it includes: Whether the victim is aware of the referral; The contribution of each agency; Detail of the discussion of the case; The rationale of why actions were agreed or not pursued; The risks identified, how these risks will be addressed, by whom and by when; Identification of the support agency for the victim | MARAC Steering Group |
| R46 | To clearly define the role of the IDVA in relation to the MARAC, including the requirement to contact the victim prior to the meeting and to ensure that there is clarity about ongoing contact | MARAC Steering Group |
| R47 | The MARAC Steering Group should make a formal decision regarding the flagging of files, and inform all agencies of the outcome | MARAC Steering Group |
| R48 | Remind all agencies of their responsibilities relating to attendance, including sending deputies and/or written notes in the absence of the usual representative. | MARAC Steering Group |
| R49 | In view of the high number of cases referred to the North MARAC, to split the monthly meeting into 2 (if less than 20 cases referred, the second meeting can be cancelled). | MARAC Steering Group |
| R5 | CWPT to establish a clear requirement for ‘client facing’ staff, particularly those undertaking assessment, to complete training regarding Domestic Violence and Abuse (DVA) awareness that is proportionate and relevant to their role. This needs to include understanding of indicators of domestic abuse from the perspective of perpetrators and / or victims, the impact upon victims, particularly children, knowledge around specific assessment tools such as DASH, support services available and professional responsibilities. | Coventry & Warwickshire Partnership NHS Trust |
| R50 | MARAC Steering Group to complete a feasibility study as to whether a multi-agency web-based database for MARAC cases (e.g. Paloma’s MODUS database) would be beneficial. | MARAC Steering Group |
| R51 | To implement all the additional recommendations of the CAADA Quality Assurance Report that are not covered above. | MARAC Steering Group |
| R52 | To develop and implement multi-agency training on the use of DASH to assess risks and ensure that risk assessments are in line with CAADA guidelines, specifically in relation to the use of professional judgement in cases where the victim is unable or reluctant to fully disclose information that might highlight the risks more clearly | All agencies |
| R53 | To improve processes to ensure that all repeat incidents are referred to MARAC | All agencies |
| R54 | To explore the options for developing risk assessments of the risks posed by perpetrators, and linked to this, the identification of serial abusers | All agencies |
| R6 | To review the current safeguarding sessions delivered within induction to all staff, to ensure that it explicitly highlights domestic abuse issues and signposts to specialist advice and support available both within and external to the Trust. | Coventry & Warwickshire Partnership NHS Trust |
| R7 | To review administrative procedures and support within community mental health services to ensure that correspondence to other agencies is completed within an appropriate timescale. | Coventry & Warwickshire Partnership NHS Trust |
| R8 | To consider how information around domestic abuse is communicated between, and responded to, by the different health agencies within the context of deliberate self-harm and other mental health assessments within A & E. | All health agencies |
| R9 | That all health agencies need to provide leadership at a senior level to develop a culture whereby domestic abuse is recognised and acted upon at all levels in the organisation. | All health agencies |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||