Summary AI-generated
Verify against the full report at the source link
The review identified inconsistent risk assessment, particularly regarding perpetrator suicide threats and stalking, and inadequate information sharing between agencies. Failures in police response to the victim's calls and breaches of bail conditions, alongside insufficient victim support like not providing a replacement mobile phone, were also key concerns.
Extracted recommendations
24 recommendations pulled from the report · 17 matched to organisations in the index
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership make use of this review as a case study to inform single and multi-agency training with a particular emphasis on understanding factors which increase the risk of homicide including threats of suicide by the perpetrator and attempts by the victim to end the relationship and the presence of stalking.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | NHS England | Dorset CCG | Dorset HealthCare NHS Trust
That Dorset Community Safety Partnership shares this DHR report with NHS England and Dorset CCG as commissioners and Dorset HealthCare NHS Trust as providers of the custody nurse service (formally known as the Criminal Justice and Liaison Service) so that they can consider the learning from this case in the further development of that service.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership obtain assurance that the Public Protection Notice (PPN) process enables a broader assessment to be carried out which includes the identification of any care and support needs the person may have.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That Dorset Community Safety Partnership obtains assurance that Dorset police make use of intelligence about a perpetrator’s previous behaviour in assessing the risk that perpetrator may present to a current victim.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That Dorset Community Safety Partnership obtain assurance from Dorset Police that they reassess risk to the victim at point at which a suspected domestic abuse perpetrator is granted bail.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership works with other relevant partnership boards to agree a standard process for sharing information about risk through the SCARF (now PPN) process.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership obtains assurance from partner agencies that they have systems in place to assure themselves that their staff comply with domestic abuse policies.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That the Dorset Community Safety Partnership seeks assurance from Dorset Police that the Niche system enables the police to effectively flag cases involving victims of domestic abuse.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That Dorset Community Safety Partnership obtain assurance from Dorset Police that they have fully complied with the IPCC recommendation that victims of domestic abuse are not left without an ability to make emergency calls.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That Dorset Community Safety Partnership obtain assurance from Dorset police that victims of domestic abuse are always promptly provided with information about alleged perpetrator bail conditions.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership | Dorset Police
That Dorset Community Safety Partnership obtain assurance from Dorset Police that any breach of pre-charge bail conditions by suspected perpetrators of domestic abuse will always be always dealt with effectively in order to safeguard victims.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership obtains assurance from all partner agencies that they fully incorporate a whole family approach to their domestic abuse policies.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership emphasises the responsibility of professionals for addressing domestic abuse concerns when the learning from this case is disseminated.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Community Safety Partnership
That Dorset Community Safety Partnership assess the adequacy of the support available to adults, young people and children affected by a domestic homicide of a family member or friend and raise any concerns with relevant agencies.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
NHS Dorset Clinical Commissioning Group
To continue to raise awareness of domestic abuse in primary care as per the Royal College of General Practitioners Guidance for General Practices- Responding to domestic abuse.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
To improve the Community Mental Health Team (CMHT) awareness of the support and advice available from the Safeguarding Adults team.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
Strengthen the record keeping practices to ensure all notes are validated in a timely fashion and safeguarding discussions are appropriately recorded.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
Criminal Justice Liaison and Diversion Service (CJLDS) to identify and record incident numbers to promote information sharing with the police.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
To explore the possibility of providing e-learning on Domestic Abuse for all staff members.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
Safeguarding Children’s level 3 training to be undertaken by all CMHT staff.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
CJLDS to review screening of vulnerable people associated to the patient on initial assessment and record discussion held with the police.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
CJLDS to review and screen court lists for victims of crime and ascertain whether they are open to DHC services.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset HealthCare University NHS Foundation Trust
To improve the CMHT awareness of the support and advice available from the Trauma Evaluation and Response Team (TEaR)
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dorset Police
Dorset Police to develop a flagging/review process for domestic abuse incidents featuring this threat which will prompt a review of the threat.
Verified wording from the published review · Original review (PDF) ↗