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

Somerset review

CSP: Somerset Published: June 2023 Year of death: 2017 Extracted: 37 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 identified inconsistent use of DASH risk assessments and MARAC referrals, a lack of professional curiosity, and poor multi-agency information sharing. Challenges in supporting individuals with co-occurring mental health, substance misuse, and domestic abuse issues were also noted, alongside concerns about risk assessment downgrading.

Extracted recommendations

37 recommendations pulled from the report

#	Recommendation	Addressed to
1	All panel members to review their own response and activities with regards to the 3 themes. I.e. Risk Assessing, Multi Agency Engagement and Mental Health	Safer Somerset Partnership’s Domestic Abuse Board
10	LSCB to review their approach to Child Protection Conferences to ensure that the learning, from this review, regarding trigger points for escalated risk of Domestic Abuse in the family environment are recognised and acted upon.	Somerset Safeguarding Children Partnership
11	The Home Office Quality Assurance panel should direct police forces across the country to confirm that a Mental Health pathway of referral exists, allowing officers to refer those exhibiting symptoms to a framework of support including statutory, volunteer and charities service providers.	Home Office
12	All self-harm matters should be considered for vulnerability assessment and followed up with a referral to MASH if appropriate	Safer Somerset Partnership’s Domestic Abuse Board
13	Somerset Local Safeguarding Children Board to improve knowledge amongst Children’s Services professionals of the available support for parents whose children have or are going through the process of formal adoption.	Somerset Safeguarding Children Partnership
14	ASC to improve management of high risk perpetrators to increase the safety of high risk victims	Avon and Somerset Constabulary
15	ASC to ensure management of DA offenders is in accordance with best practice	Avon and Somerset Constabulary
16	Compliance by officers of policy to refer domestic abuse cases to Lighthouse Safeguarding Unit (LSU) to be reviewed	Avon and Somerset Constabulary
17	Probation Officers to ensure they are aware of the definition of a ‘significant event’ linked to reoffending and harm	BGSW CRC
18	Probation Officers to ensure that risk management prioritise victim safety	BGSW CRC
19	Ensure that information provided by service user is checked with partner agencies	BGSW CRC
2	Embed the principles of the ACPO DASH Risk Assessment process throughout all CSP agencies.	Safer Somerset Partnership’s Domestic Abuse Board
20	Encourage those who work within GP practices to ask Domestic Abuse screening/safety questions	Clinical Commissioning Group
21	Access policy and children’s DNA policy to be revised to clearly describe process for maternity users.	Musgrove Hospital
22	Improve staff awareness of domestic abuse within organisation	Sedgemoor District Council
23	Publicise help/support available for all forms of domestic violence within organisation	Sedgemoor District Council
24	Devise a robust approach to risk assessment and management	Sedgemoor District Council
25	Professionals are confident about sharing information and making informed decisions about actions	Sedgemoor District Council
26	Ensure that the decision not to accept any referral (for voluntary perpetrator programme) is shared with key partners	SIDAS Barnardo’s
27	Ensure timely closure of client files	SIDAS Barnardo’s
28	Caseworkers to Intensify and record all methods of attempts to engage both client and other professionals during 1st month following allocation	SIDAS Livewest
29	CW to update other professionals and record in case notes this has happened following significant event during client engagement.	SIDAS Livewest
3	Review the systems, policies and procedures that ensure the completion of DASH Risk Assessments and ensure that MARAC referrals are completed when required	Safer Somerset Partnership’s Domestic Abuse Board
30	Effective Information sharing	SCC Adult Social Care
31	Disseminate learning from DHR across Adult Social Care	SCC Adult Social Care
32	Improve confidence of professionals in accessing all relevant support for clients	SCC Adult Social Care
33	SCC Adult Social Care to review, alongside the SSAB Manager, engagement with future DHR and the cross over between other review mechanisms	SCC Adult Social Care
34	Ensure completion of DASH Risk Assessments when ‘in-custody’ DA victims disclose abuse, and refer as appropriate	Avon and Somerset Police
35	CAAS to consult with police officers once a prisoner presents as a domestic abuse victim. Discuss risk management plan and confirm actions required	Somerset Partnership NHS FT
36	All frontline community mental health service professionals are aware of the ‘Hidden Harm’ protocol, and use it	Somerset Partnership NHS FT
37	Ensure compliance with the statutory child protection process obligations	Somerset Partnership NHS Foundation Trust
4	Develop a culture of ‘Professional Curiosity’ of frontline practitioners through on-going training and internal publicity	Safer Somerset Partnership’s Domestic Abuse Board
5	Encourage those who work within GP practices to ask Domestic Abuse screening/safety questions	Safer Somerset Partnership’s Domestic Abuse Board
6	The development of a robust quality assurance process for managing risk reports within the Lighthouse/Police Safeguarding Unit.	Avon and Somerset Police
7	The down grading of all DASH Risk assessments must be reviewed and agreed by those supervising frontline practitioners.	Safer Somerset Partnership’s Domestic Abuse Board
8	All CSP practitioners and line managers to receive training regarding risk management in domestic abuse cases and subsequent information sharing	Somerset County Council \| Safer Somerset Partnership
9	The South West Ambulance Service should enhance their training programme to encourage frontline practitioners to demonstrate more professional curiosity when receiving disclosures of domestic abuse from patients and their families	Southwest Ambulance Service NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗