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
Aylesbury Vale review
CSP: Aylesbury Vale
Published: June 2023
Year of death: 2017
Extracted: 18 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 lessons regarding the need for improved risk assessments, professional curiosity, and information sharing across agencies, particularly concerning vulnerable individuals with substance misuse issues and chaotic lifestyles. It also highlighted the importance of robust case-note recording and regular policy reviews.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 10 (AVCCG) | To increase awareness of the Adult Safeguarding Threshold Document to all staff working in General Practice, that was launched this year by Buckinghamshire Adult Safeguarding Board. | Aylesbury Vale Clinical Commissioning Group |
| 11 (SMART) | Continued focus on risk management within SMART Buckinghamshire, follow up peer audit and management audit to take place within the next 3 months. | SMART Buckinghamshire |
| 12 (SMART) | Continued focus on case notes; audits to be carried out in the next 3 months based on the SMART practice standard. | SMART Buckinghamshire |
| 14 (SCAS) | SCAS to internally share the learning from this incident, particularly in respect to the missed opportunity of completing a safeguarding referral when presenting circumstances indicate that a person is vulnerable or at risk. | South Central Ambulance Service NHS Trust |
| 15 (AWA) | The Outreach Centre Manager to consider developing a check list of activities that should be carried out or followed up for each referral. It needs to be borne in mind that each client is an individual and as such the nature of the work varies from client to client. | Aylesbury Women’s Aid |
| 16 (AWA) | The Outreach Centre Manager to carryout spot checks on random case files on a regular basis. This will enable consistency and conformity of the service provided by the IDVA team. | Aylesbury Women’s Aid |
| 17 (AWA) | The Leadership Team, with input from all workers, to explore innovative ways of engaging with clients who are challenging to engage with. | Aylesbury Women’s Aid |
| 1 (TVP) | The Pre-Release Risk Assessment (PRRA) section concerning issues raised in custody to be altered from being a statement to being clear questions which are required to be addressed. | Thames Valley Police |
| 2 (TVP) | NICHE MINERVA working Group to be asked to consider the following: Removing the generic 'YES/NO' option as to whether any areas of concern were identified for the PRRA so that each point has to be considered individually when the PRRA is being completed. Adding a 'tick box' for when a DASH form was refused to enable these cases to be easily identifiable. | Thames Valley Police |
| 3 (TVP) | In early 2018 a quality assurance audit should be conducted to ensure the improvement in risk assessment, safeguarding and data recording expected as a result of the implementation of the SaVE training, improved risk assessment utilising THOR in conjunction with the Contact Management Model and changes to DASH form and IRB DASH check processes has been achieved. | Thames Valley Police |
| 4 (TVP) | When DASH is refused, and the grading is standard for the third time the victim should be re-visited by a police officer to try to encourage them to engage with the process and complete a full and accurate risk assessment. | Thames Valley Police |
| 5 (TVP) | When it is known that a child is in care (Looked After Child- LAC) this should be made immediately clear to any personnel that are accessing that child's record on NICHE that this is the case. This can be completed using the existing Child Protection Flag and the remarks section can be used to highlight the status. | Thames Valley Police |
| 6 (TVP) | Written Guidance on the closure of domestic incidents where victims refused to engage that is utilised by Contact Management should be incorporated in to the domestic abuse operational guidance. | Thames Valley Police |
| 7 (TVP) | When a child protection plan is in place a sig flag should be utilised on Command & Control and placed on all addresses at which the child stays or visits regularly (both parents' addresses if they live separately and other caregivers) to immediately notify that this may be a concern irrespective of what the incident is and who is involved. | Thames Valley Police |
| 8 (AVCCG) | General Practitioners to be reminded to flag an adult at risk within the GP computer records as recommended as good practice by Care Quality Commission (CQC) | Aylesbury Vale Clinical Commissioning Group |
| 9 (AVCCG) | To encourage within General Practice professional curiosity when enquiring about possible Domestic Violence, and to ask questions specifically around unusual or suspicious injuries. To be aware of the risks of gender bias, when assessing patients with unexplained injuries. | Aylesbury Vale Clinical Commissioning Group |
| Panel National Recom | The Home Office is recommended to review and learn lessons from Police Forces in respect to the service offered by Family Liaison Officers following a major incident when the family of the victim and the perpetrator are the same. This should include consideration being given to the support offered to both the families of the victim and the perpetrator. This review should cover the period immediately after the incident, including support at the scene, through to the period up to trial. | Home Office |
| Panel Recommendation | The representative for Thames Valley Police, on the national working group considering the Pre-Release Risk Assessment computerised process, raises the issue identified about the limiting questions currently contained within the computerised process; and offers suggestions to improve the process. (See Recommendation 1 (TVP) | Thames Valley Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||