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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review highlights systemic failures in inter-agency information sharing, particularly between police forces, leading to missed opportunities for intervention regarding the perpetrator's drug misuse and domestic abuse history. Inadequate risk assessment, management of harassment complaints, and coordination of services for individuals with chaotic lifestyles were also identified.

Home Office classifications

33 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - pregnancy
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

17 recommendations pulled from the report · 15 matched to organisations in the index

Recommendation DHR 1

Addressed to Warwickshire Safeguarding Children Board (WSCB)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation DHR 2

Addressed to West Midlands Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation DHR 3

Addressed to West Midlands Police | West Mercia Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation DHR 4

Addressed to All agencies

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation HEFT IMR 1

Addressed to Heart of England Foundation Trust

To ensure that the Trust Self-Harm Policy is followed: Relevant risk assessments are completed with RAID; Mental Health referrals to RAID is completed

Verified wording from the published review · Original review (PDF) ↗

Recommendation HEFT IMR 2

Addressed to Heart of England Foundation Trust

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation HEFT IMR 3

Addressed to Heart of England Foundation Trust

To develop and deliver some ‘ on the job’ training for ED staff focussed around adult mental health and substance misuse presentations

Verified wording from the published review · Original review (PDF) ↗

Recommendation NPS IMR 1

Addressed to National Probation Service

Additional Domestic Abuse Checks should be requested by Offender Managers when significant new concerns are identified.

Verified wording from the published review · Original review (PDF) ↗

Recommendation NPS IMR 2

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWFT IMR 1

Addressed to South Warwickshire NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWFT IMR 2

Addressed to South Warwickshire NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMP IMR 1

Addressed to West Midlands Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMP IMR 2

Addressed to West Midlands Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMPercia IMR 1

Addressed to West Mercia Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMPercia IMR 2

Addressed to West Mercia Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMPercia IMR 3

Addressed to West Mercia Police

Staff responsible for closing police message logs for incidents should ensure all relevant information has been recorded on the same and actioned as necessary.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMPercia IMR 4

Addressed to Warwickshire Police | West Mercia Police

Warwickshire and West Mercia Police to consider further training input for staff with regards the side affects of cocaine/drug use.

Verified wording from the published review · Original review (PDF) ↗