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 WorcestershirePublished: June 2023Year of death: 2014Extracted: 17 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
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.
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
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
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.
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.
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.
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
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.
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.
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.
Staff responsible for closing police message logs for incidents should ensure all relevant information has been recorded on the same and actioned as necessary.