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
Exeter review
CSP: Exeter
Published: June 2023
Year of death: 2018
Extracted: 9 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 identifies systemic failures in inter-agency collaboration, risk assessment, and the application of domestic abuse frameworks. Despite both the victim and the perpetrator having complex needs and agency support, the risk of homicide was not effectively mitigated, partly due to their disengagement.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| R1 | Improve arrangements for the co-ordination across agencies of services for clients with complex needs, including those who, overall, have a high level of need or risk but may not meet individual service thresholds. (#355-#359, #361) | Safer Devon Partnership | Devon Partnership NHS Trust | Devon County Council | Devon & Cornwall Police | Exeter City Council |
| R2 | Improve communication and joint working arrangements between Devon Partnership NHS Trust and local drug and alcohol treatment providers for mental health patients with substance misuse problems. (#360) | Devon Partnership NHS Trust | Together Drug & Alcohol Services |
| R3 | Review the nature and level of public agency commissioning of accommodation and associated support services for vulnerable adults in Devon to ensure appropriate facilities are available to meet needs safely at a choice of locations. (#364-#365) | Devon County Council | Devon Partnership NHS Trust |
| R4 | Improve the handling of adult safeguarding referrals where there are difficulties obtaining consent to refer or where the referrer has serious concerns about the response. (#362-#363) | Devon County Council |
| R5 | Ensure that staff working directly with clients in all agencies providing or commissioning care or support for vulnerable people receive training, appropriate to their role and in line with the 2018 Inter Collegiate Guidance, on adult safeguarding including domestic and sexual violence and abuse. (#367-#369) | Devon Partnership NHS Trust | Devon County Council | Exeter City Council | Devon & Cornwall Police | Caraston Hall | Hollywell Housing Trust | Home Group | Rethink Mental Illness | Together Drug & Alcohol Services |
| R6 | In managing structural and personnel changes, seek minimal effect on continuity of care for mental health clients, including liaison with other agencies involved with them. (#370) | Devon Partnership NHS Trust |
| R7 | Review the way in which Devon and Cornwall Police record, investigate and present evidence to the Crown Prosecution Service regarding assaults involving strangulation. (#348-#349) | Devon & Cornwall Police |
| R8 | In evaluating the Devon Partnership NHS Trust pilot of a community forensic team, take account of the views of partner agencies on how the team collaborates with their services. (#371-#372) | Devon Partnership NHS Trust |
| R9 | Ensure there are arrangements by which staff at any level in agencies working with individuals who pose risks are alert to the potential use of multi-agency frameworks for managing them and can access information and advice on their use. (#368) | Devon Partnership NHS Trust | Devon County Council | Exeter City Council | Devon & Cornwall Police | Caraston Hall | Hollywell Housing Trust | Home Group | Rethink Mental Illness | Together Drug & Alcohol Services |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||