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
North Worcestershire review
CSP: North Worcestershire
Published: June 2023
Year of death: 2014
Extracted: 17 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 systemic failures in inter-agency information sharing and intelligence checks, particularly between police forces, leading to missed opportunities for risk assessment, safeguarding, and intervention regarding the perpetrator's escalating drug misuse and domestic abuse history across multiple relationships and locations.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Warwickshire Safeguarding Children Board (WSCB) is to seek assurance that: a) Children in Warwickshire seeking a school place are identified and an appropriate offer of a school place is made in a timely manner b) When children in Warwickshire are not in education relevant assessments are undertaken in relation to any identified vulnerabilities and appropriate arrangements are made to safeguard the child where required. | Warwickshire Safeguarding Children Board |
| 2 | West Midlands Police to confirm with North Worcestershire Community Safety Partnership within 6 months of the date of this report that information regarding the dissemination of the use of Domestic Violence Protection Notices and Orders has been completed for all officers within the force. | West Midlands Police |
| 3 | West Midlands Police and West Mercia Police examine their policies and procedures regarding action taken by officers at the reports of domestic abuse complaints, to ensure that all possible intelligence is gathered on the parties concerned and if necessary that intelligence is shared with other Police forces and agencies as deemed appropriate. | West Midlands Police | West Mercia Police |
| 4 | All agencies when working with substance misuse service users and other individuals that lead chaotic lifestyles, ensure appointments are co-ordinated resulting in joint interventions /meetings being better established. This will need a more structured approach to information sharing | All agencies |
| HEFT R1 | To ensure that the Trust Self-Harm Policy is followed: Relevant risk assessments are completed with RAID; Mental Health referrals to RAID is completed | Heart of England Foundation Trust |
| HEFT R2 | To review the ED adult assessment paperwork utilised when a mental health, substance misuse or domestic abuse issue is identified to ensure that the staff are prompted to: Undertake a complete social history including all household members, contact with children or other dependants; Consideration of safeguarding risk to children/ dependants; Document onward referrals e.,g., to substance misuse services | Heart of England Foundation Trust |
| HEFT R3 | To develop and deliver some ‘ on the job’ training for ED staff focussed around adult mental health and substance misuse presentations | Heart of England Foundation Trust |
| NPS R1 | Additional Domestic Abuse Checks guidance contained in this Domestic Abuse checklist for offender Managers. To review/record at Team Meeting and reviewed every 6 months by SPO. | National Probation Service |
| NPS R2 | All staff to be reminded that Home visits provide valuable information that would contribute to the management of offenders. Even when the offender is not assessed as High or Very High Risk of Serious Harm. | National Probation Service |
| SWFT R1 | South Warwickshire NHS Foundation Trust to promote the Health Visitor Domestic Violence and Abuse Training for all South Warwickshire NHS Foundation Trust Health Visitors to ensure that all windows of opportunity to offer support to victims of domestic abuse are not missed. | South Warwickshire NHS Foundation Trust |
| SWFT R2 | South Warwickshire NHS Foundation Trust to include a question in the record keeping audit tool about the significant adults in the child’s life being documented in the records and for the audit plan to ensure these recording standards are maintained in line with record keeping policies. | South Warwickshire NHS Foundation Trust |
| WMPolice R1 | Police call takers and dispatchers should be reminded to obtain as much detail as possible from a caller to enable increased intelligence research prior to arrival of attending officers. This will ultimately increase officer safety and awareness and more importantly the safety and welfare of any possible victims. | West Mercia Police |
| WMPolice R2 | Officers attending incidents such as these should be reminded to, ensure full intelligence research is carried out on the relevant nominals whilst they are in attendance. This will ensure welfare of all persons present, including the attending officers and provide police with a full intelligence picture. | West Mercia Police |
| WMPolice R3 | Staff responsible for closing police message logs for incidents should ensure all relevant information has been recorded on the same and actioned as necessary. | West Mercia Police |
| WMPolice R4 | Warwickshire and West Mercia Police to consider further training input for staff with regards the side affects of cocaine/drug use. | Warwickshire Police | West Mercia Police |
| WMP R1 | For actions to be identified Vulnerable Adult guide to be amended to address the issue of closure of logs to a standard that will allow searching via the FLINTS intelligence system to recover all incidents that involve a person. The guide currently states that all actions and signposting should be recorded on the OASIS Log, it should also state that before closure of the log that a PNC MUST be made via the integrated OASIS?PNC system | West Midlands Police |
| WMP R2 | The Vulnerable Adult Guide for Front Line Officers to have further examples provided regarding what is/is not a ‘vulnerable moment’ to prevent misinterpretation of what is and is not a ‘vulnerable moment’ to provide further clarity regarding adults who are repeatedly self-harming or suffering effects of drug induce paranoia, thus reducing the potential of missed opportunities to identify vulnerable adults and provide appropriate safeguarding, signposting and referrals. | West Midlands Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||