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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

11 recommendations pulled from the report

#	Recommendation	Addressed to
1	That the Acute Mental Health Unit implement processes which ensure that patient assessments are shared with the patient’s GP.	Acute Mental Health Unit
10	Where appropriate that staff are informed of the need to update both electronic databases, i.e., Discovery System and RMS.	Gorwel
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.	Home Office
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.	Acute Mental Health Unit
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.	CMHT
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.	All GP Medical Practices
5	All GP Medical Practices to display appropriate domestic abuse information within the practice to raise awareness and to provide key information to patients.	All GP Medical Practices
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.	CMHT
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.	General Practice
8	Future revisions to the protocol to include general practitioners as consultees / representation as a member of the working group.	CMHT \| General Practice
9	Staff receive additional training regarding keeping detailed and accurate notes as regards contacts with clients.	Gorwel
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗