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
Liverpool review
CSP: Liverpool
Published: June 2023
Year of death: 2018
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 highlights systemic failures in multi-agency working, particularly regarding Adult Social Care's response to domestic abuse referrals and safeguarding concerns. It notes a lack of consistent risk assessment, inadequate information sharing, and missed opportunities for evidence-led prosecutions and coordinated support for the victim and perpetrator's complex needs.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 8.1.1 | Officers and staff involved in dealing with domestic abuse should be reminded of the need for adherence to the positive action approach towards domestic abuse and the need to consider Evidence Led Prosecutions in cases where victims do not support a prosecution. Consideration of such prosecutions should become standard Police and CPS practice for cases of repeat incidents where the victim refuses to support prosecution. | Merseyside Police | CPS |
| 8.2.1 | There should be a mandatory process to ensure that further action is taken in cases where there have been numerous VPNs received from the police. This process should be supported by policy, procedure and guidance which actively promotes professional challenge of any tendency towards tolerating domestic abuse within families and relationships where there are complex and multiple needs, such as misuse of alcohol and mental health problems. | Adult Social Care |
| 8.2.2 | Adult Social Care should explore ways in which case record systems and processes could provide better linking and tracking of information between the case records of high-risk domestic abuse perpetrators and those of their victims. | Adult Social Care |
| 8.2.3 | Staff should be reminded that all information pertaining to adult safeguarding enquiries - including decisions to trigger or not to trigger a Section 42 enquiry - must be recorded on the enquiry document on Liquid Logic. ASC decision makers should be made aware that a decision by the domestic abuse victim not to support criminal action is not a valid rationale for not triggering Section 42 enquiries. On the contrary, it may well be an indicating factor that Section 42 enquiries should take place. | Adult Social Care |
| 8.5.1 | Improve actions following parental / adult child assessment. | Royal Liverpool and Broadgreen University Hospitals NHS Trust |
| 8.5.2 | To review the process in place for patients who are repeat attenders with mental health issues. | Royal Liverpool and Broadgreen University Hospitals NHS Trust |
| 8.6.1 | Clinical records to be reviewed regarding domestic violence alerts and a system to be introduced to trigger further action in domestic abuse cases. Review organisational training needs, to identify targeted training for domestic abuse where required. | Mersey Care NHS Foundation Trust |
| 8.8.1 | Highlighting of known domestic abuse within GP records | GP Practice |
| 8.8.2 | Emphasizing the importance of professional curiosity. | GP Practice |
| 8.8.3 | Record keeping | GP Practice |
| 8.9.1 | All staff to complete Safeguarding Adults training | Merseyside Community Rehabilitation Company |
| 8.9.2 | All frontline staff to understand neurodiversity and develop strategies to work with difference. | Merseyside Community Rehabilitation Company |
| 8.9.3 | Risk Assessment and sentence planning to involve all relevant agencies and workers. | Merseyside Community Rehabilitation Company |
| 9.1.1 | Commissioners of housing support services should ensure that all service contracts include a requirement for staff and managers to receive regularly updated training on domestic abuse. This training should include work on risk assessment and risk management approaches with perpetrators and with victims of abuse. It should also include raising awareness and understanding of local multi-agency policy and procedure and the role and function of MARAC. This recommendation should be particularly highlighted and followed up for action, with the specific supported housing provider which featured in this DHR. | Commissioners of housing support services | Supported Housing Service |
| 9.2.1 | The CitySafe Board should arrange a review of MARAC processes, and related multi-agency procedures and guidance on domestic abuse, with the aim of: • Establishing clear operational guidance and procedures which recognise thresholds for instigating multi-agency strategy meetings and action plans. Thresholds to include specifying of the number of repeat incidents which should trigger a strategy meeting. • Updating all partners on multi-agency policy and procedure and guidance on domestic abuse • Increasing awareness and understanding of common themes and practices in relation to domestic abuse, safeguarding adults and working with people who are vulnerable and have complex and multiple needs. • Highlighting that agencies working in silos represents a major barrier to services, for people with multiple and complex needs who are victims and / or perpetrators of domestic abuse. • Supporting all agencies to review their training needs and plan future training programmes. | CitySafe Board |
| 9.3.1 | There should be a multi-agency review of terminologies used in policies, procedure, notification and referral systems around adult safeguarding and domestic abuse. The aim should be to ensure that all partners work to common definitions and expectations of actions to follow, in relation of terms such as: • Referral • Notification • Vulnerable Person Notification • Safeguarding Referral • Safeguarding Alert | Multi-agency |
| 9.4.1 | There should be a one-day multi-agency Learning Event to share all of the learning from LDHR 15. | Multi-agency |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||