Recommendation 1
That the Acute Mental Health Unit implement processes which ensure that patient assessments are shared with the patient’s GP.
Verified wording from the published review · Original review (PDF) ↗
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
Gwynedd review
CSP: Gwynedd
Published: June 2023
Year of death: 2017
Extracted: 11 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
Original review (PDF) ↗
Source: Home Office DHR Library
Summary AI-generated
The review highlights significant gaps in information sharing between mental health services and primary care, leading to missed opportunities to identify and respond to long-standing domestic abuse and coercive control. It also identifies issues with agency protocols, recording practices, and supporting victims who retract statements.
Home Office classifications
43 tags
Source-supplied classifications used by the Home Office to catalogue this review.
- Victim - mental ill health
- Victim - depression
- Victim - had been a victim of an abuser before
- Victim - immigration involvement
- Children - living with victim (including adult children)
- Child - primary address same as victim
- Perpetrator - case heard in court
- Perpetrator - issued life sentence
- Perpetrator - alcohol misuse
- Perpetrator - mental ill health
- Perpetrator - anxiety
- Perpetrator - psychosis
- Perpetrator - suicidal thoughts
- Perpetrator - suicide attempts
- Perpetrator - known to agencies as a domestic abuse perpetrator
- Perpetrator - known to police as a domestic abuse perpetrator
- Perpetrator - known to social services as a domestic abuse perpetrator
- Perpetrator - known to mental health services as a domestic abuse perpetrator
- Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
- Perpetrator - known to others as a domestic abuse perpetrator
- Perpetrator - known to family as a domestic abuse perpetrator
- Perpetrator - attended drug and alcohol services
- Perpetrator - supervised by mental health services
- Perpetrator - died by suicide
- Perpetrator - immigration involvement
- Aggravating factors - separation
- Aggravating factors - coercive or controlling behaviour
- Aggravating factors - psychological or emotional abuse
- Aggravating factors - physical abuse
- DHR process - family contributed to dhr
- DHR process - family consulted about terms of reference
- DHR process - family supported by expert specialist advocate
- DHR process - family received draft report
- DHR process - health services recommendations
- DHR process - idva or other domestic abuse support service recommendations
- DHR process - technology systems recommendation themes
- DHR process - identification of risk recommendation themes
- DHR process - training recommendation themes
- DHR process - policy recommendation themes
- DHR process - multi agency working recommendation themes
- DHR process - record keeping recommendation themes
- DHR process - awareness raising recommendation themes
- DHR process - other recommendation themes
Extracted recommendations
Recommendation 2
That the Acute Mental Health Unit cease using fax machines as a primary means of relaying sensitive and confidential information and instead utilise secure email systems which can password protect confidential information, which can provide a clear audit trail, and which can utilise a send receipt option as a means of confirming that the intended recipient has received the assessment.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 3
That CMHT review the way in which the electronic database is used regarding assigning a patient to a consultant and regarding ensuring that a patient’s details are properly closed on the system in a timely manner.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 4
All GP Medical Practices to provide frontline staff with appropriate information and training to be able to identify signs of domestic abuse and be able to signpost individuals to an appropriate support/advisory service.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 5
All GP Medical Practices to display appropriate domestic abuse information within the practice to raise awareness and to provide key information to patients.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 6
CMHT to take into consideration available information they may also hold on an individual that may or may not be known to general practice when considering GP referrals.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 7
General Practice to understand the mechanisms used by CMHT to assess GP referrals to them in the knowledge of the protocol and key sections.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 8
Future revisions to the protocol to include general practitioners as consultees / representation as a member of the working group.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 9
Staff receive additional training regarding keeping detailed and accurate notes as regards contacts with clients.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 10
Where appropriate that staff are informed of the need to update both electronic databases, i.e., Discovery System and RMS.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 11
The Panel recommend that the Home Office give consideration to extending the scope of DHR’s to include a statutory obligation on major UK employers to engage with the DHR process.
Verified wording from the published review · Original review (PDF) ↗