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
Bristol review
CSP: Bristol
Published: June 2023
Year of death: 2015
Extracted: 50 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 a lack of inter-agency information sharing, insufficient understanding of the victim's complex family dynamics and vulnerabilities, and missed opportunities to identify and respond to coercive control and domestic abuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Relevant agencies within this Review to report to Safer Bristol and Bristol Safeguarding Children Board on how they ask children and young people about being seen alone; what policies, procedures, training and considerations there are in relation to this; and if any improvements are identified, for these to be acted upon and the learning shared. | Safer Bristol | Bristol Safeguarding Children Board |
| 2 | Department of Health to draw on the learning from this Review to support General Practices nationally on identifying as early as possible when new patients registering with the practice are connected with existing patients. | Department of Health |
| 3 | Clinical Commissioning Group to communicate with all health agencies in Bristol the expectation that children up to the age of 16 will be assessed for Gillick Competency using Fraser Guidelines at every appropriate interaction, and that this will be recorded in their notes. With particular emphasis on appointments with children concerning contraception and sexual health. | Clinical Commissioning Group |
| 4 | All agencies (through Safer Bristol Partnership and Bristol Safeguarding Children’s Board) to report on how they now ensure that full account is taken of a child/young person’s history, household and wider family/friend networks, including practitioners’ use of professional curiosity, and how identified issues and needs are addressed. With specific reference to the recognition and inclusion of fathers and wider family and friend networks in work with children and young people. | Safer Bristol Partnership | Bristol Safeguarding Children’s Board |
| 5 | All agencies not already reporting on this through section 11 audits to report (through Safer Bristol Partnership and Bristol Safeguarding Children’s Board) on how they integrate and prioritise the views of the children and young people they are working with, within a ‘whole family’ approach. | Safer Bristol Partnership | Bristol Safeguarding Children’s Board |
| 6 | All agencies to report (through Safer Bristol Partnership and Bristol Safeguarding Children’s Board) on how they monitor record keeping by staff to ensure it is consistently and robustly done. | Safer Bristol Partnership | Bristol Safeguarding Children’s Board |
| 7 | The Domestic Abuse and Sexual Violence Strategy Group to address how the widest possible network of agencies can access up to date information on domestic abuse, pathways for referral, best practice and any training available. To report on this to the Safer Bristol Partnership. | Domestic Abuse and Sexual Violence Strategy Group | Safer Bristol Partnership |
| 8 | All agencies to report (through Safer Bristol Partnership and Bristol Safeguarding Children’s Board) on the domestic abuse training they deliver internally, or access externally, and how this addresses the identification of and response to coercive and controlling behaviours, and where this is not adequately done, for changes to be made to those training programmes. | Safer Bristol Partnership | Bristol Safeguarding Children’s Board |
| 9 | Safer Bristol Partnership and Bristol Safeguarding Children’s Board to review domestic abuse training currently delivered through the partnerships to ensure that it adequately covers the identification of and response to coercive and controlling behaviours, both in relation to support for victims and appropriate and safe challenge to perpetrators (for those agencies for which this is within their remit). Also to ensure that any domestic abuse training that is developed in the future covers this. | Safer Bristol Partnership | Bristol Safeguarding Children’s Board |
| Action for Children | The Operational Director of Children’s Services, Children’s Services Manager and a member of the Practice Improvement service should review a number of current case files to be satisfied about standards of safeguarding and recording. | Action for Children |
| Action for Children | The Children’s Services Manager should ensure that further case files are selected for review on a quarterly basis in 2015-16 from this service in order to ensure that any improvements noted have been made and sustained. | Action for Children |
| Action for Children | In light of the above and other information, the Operational Director of Children’s Services and Children’s Services Manager should investigate the workload levels for practitioner staff and report on this and any action needed to the UK Director for Children’s services (West) and ensure that the Head of Safeguarding is made aware of the finding in case this might have wider relevance to other similar services elsewhere. | Action for Children |
| Action for Children | Training should be provided to all practitioners and supervisors on the implications of safeguarding vulnerable teenagers. This should be based on case materials or case studies so we can check whether there is an over-concentration on adults and/or over-optimism/de-sensitisation in the service and should also review expectations and judgments about required levels of hygiene and cleanliness in households. | Action for Children |
| Bristol City Council | Ensure that fathers are actively involved in social care assessments and ongoing work. | Bristol City Council Children’s Social Care Services |
| Bristol City Council | Ensure all family members living with children or having significant levels of contact are identified at an early stage of assessment. | Bristol City Council Children’s Social Care Services |
| Bristol City Council | Improve standards of practice for Care Leavers. | Bristol City Council Children’s Social Care Services |
| Bristol City Council | Consideration to be given to specific training for Leaving Care Personal Advisers around some the complexities of working with Care Leavers, including a focus on how past experiences of trauma and abuse can impact on their choices as they move into adulthood, and how best they can support them with this. | Bristol City Council Children’s Social Care Services |
| Bristol City Council | Pre-birth assessments of the expected babies of Care Leavers should be carried out in a timely way and should be holistic. | Bristol City Council Children’s Social Care Services |
| Bristol City Council | Early Help should challenge case closure by commissioned services or external Lead Professionals when a full assessment of all the risk factors included in the referral have not been explored. There are systems in place whereby this could be actioned from immediate effect. | Bristol City Council Children’s Early Help Services |
| Bristol City Council | Early Help should contact agencies that have been referred to provide support to children and families to ensure that the referral has been accepted and to provide information about the timescales involved for the support being provided. | Bristol City Council Children’s Early Help Services |
| Bristol City Council | Early Help should ensure that agencies are aware that should concerns re-emerge that a new referral can and should be made. | Bristol City Council Children’s Early Help Services |
| Bristol Hospital Edu | Review its referral form to ensure that it reflects the Assessment of Need for Children and their Families triangle namely: the child’s developmental needs; parenting capacity to meet their needs and environmental factors that impact on the child and their family (which includes family history and functioning). | Bristol Hospital Education Service |
| Bristol Hospital Edu | Staff supporting children and young people should have access to relevant information, a pen picture of issues which staff should be aware of and monitor. How information is shared within the service should be reviewed, if staff are not aware of risk factors or specific issues then they are not able to respond effectively. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Adopt a team around the child or family approach to ensure that all professionals, disciplines and agencies involved with the child and their family share relevant information and are part of the support package via a formal referral meeting involving relevant agencies. | Bristol Hospital Education Service |
| Bristol Hospital Edu | All agencies, including mainstream schools, should submit a written report at the first review and updates of their involvement between reviews and most importantly attend reviews. If agencies do not attend there should be a requirement that they submit a report and if they regularly miss reviews this should be challenged and escalated where necessary by Hospital Education within their organisation. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Student reviews should be conducted against a standard agenda format that includes updates, progress in relation to education and social/emotional targets, next steps and importantly address any safeguarding issues. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Put in place recording standards that ensures staff record antecedents, behaviour and consequences when reporting incidents and that all recording is contextual and informative. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Maintain chronologies that are reviewed regularly by management and before any student review. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Records held electronically should be audited to ensure compliance with the agreed recording standards. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Staff to be aware of the BSCB escalation procedure it they are unhappy with the outcome of referrals made to either First Response or Early Help. In respect of other agencies there are similar processes in place to raise concerns. | Bristol Hospital Education Service |
| Bristol Hospital Edu | In relation to safeguarding CPD this should be reviewed to ensure that staff receive an annual update in relation to safeguarding, access training in relation to attachment, blended families, the importance of effective information sharing, the significance of historical information, working within the CAF framework, the BSCB threshold document, disguised compliance and adopting professional curiosity. | Bristol Hospital Education Service |
| Bristol Hospital Edu | There should be regular 1:1 supervision of all staff working with children and young people to ensure that the welfare of the child is paramount and their voice heard. In addition, the 1:1’s should have a set agenda whereby staff reflect on their involvement with parents, children and young people and other professionals, the fundamental question being are we being effective? Are we meeting the needs of the child or young person? If not what do we need to do? | Bristol Hospital Education Service |
| Bristol Hospital Edu | The management committee should consider how it ensures safeguarding governance is embedded and delivered as required under Working Together to Safeguard Children and Keeping Children Safe in Education. | Bristol Hospital Education Service |
| Bristol Hospital Edu | Education training providers have the same statutory responsibilities under Working Together to Safeguard Children and Keeping Children Safe in Education. As such recommendations made in respect of Hospital Education also apply to training providers and commissioners should ensure that they meet statutory requirements. | Education training providers | commissioners |
| CAMHS a | Clear risk assessment documentation should be recorded and easily accessible in the CAMHS records – this is already in place after the introduction of electronic records. | Child and Adolescent Mental Health Services, Avon and Wiltshire Mental Health Partnership NHS Trust |
| CAMHS b | Consider whether there should be a standardised way of asking about domestic violence and recording this is in CAMHS records and risk assessments. This needs to be done in a meaningful way with families at an appropriate time and not as a simple ‘tick box exercise’. The Review Panel member will take this forward with the safeguarding leads. | Child and Adolescent Mental Health Services, Avon and Wiltshire Mental Health Partnership NHS Trust |
| CAMHS c | Following an episode of specialist work within CAMHS such as family therapy, a written summary should be produced and disseminated appropriately. | Child and Adolescent Mental Health Services, Avon and Wiltshire Mental Health Partnership NHS Trust |
| CAMHS d | This case highlights the interface between CAMHS and other agencies. Multi agency meetings should have a clear remit, with goals and action points for each agency. Minutes of meetings should be produced and disseminated with a review date. within the appropriate framework such as SAF, Child in Need, a lead professional should be identified. | Child and Adolescent Mental Health Services, Avon and Wiltshire Mental Health Partnership NHS Trust |
| CAMHS e | CAMHS records should have a clear and up to date risk assessment outlining risk in a holistic manner, not just focusing on mental health and risk of harm to self. I will take this forward with my safeguarding colleagues so we can produce a service wide approach to assessing and documenting risk. | Child and Adolescent Mental Health Services, Avon and Wiltshire Mental Health Partnership NHS Trust |
| Creative Youth Netwo | Make contact with the agency /service you have referred the young person to see how they are progressing in their new offer. | Creative Youth Network |
| Creative Youth Netwo | All staff trained in signs of danger and coercive control. | Creative Youth Network |
| Creative Youth Netwo | Ensure that going forward that staff meet face to face with a young person to finish a one-to-one intervention rather than finishing via a text. | Creative Youth Network |
| Places for People Li | Amendment to Assessment and Support Planning Procedure to ensure Managers take responsibility for appropriate case management. | Places for People Living+ |
| Places for People Li | Training to be delivered to all front-line staff on record keeping. | Places for People Living+ |
| Places for People Li | Review Safeguarding Training. | Places for People Living+ |
| Places for People Li | Amendment to Assessment and Support Planning procedure. To specify all cases must be closed on ecco (case management system) and good practice to inform in writing/email key stakeholders (Social Workers, Health Visitors etc). Report developed to identify cases with no recorded action for 30 days. | Places for People Living+ |
| Places for People Li | Amendment to Assessment and Support Planning Procedure. To cover increasing disengagement – how this should be identified, actions and tools available to use to address concerns (Support Philosophy tools, Retention Plans etc). | Places for People Living+ |
| Places for People Li | Current Safeguarding Training covers coercive control/abuse. Coercive Control is also included in Domestic Abuse Training. Recommend Domestic Abuse Training for all Managers covering customers and staff. | Places for People Living+ |
| University Hospitals | The IMR has highlighted that staff in the Emergency Department at the BRI did not complete a ‘Cause for Concern’ form when the victim attended intoxicated. Although not directly related to this Review, Nursing and Medical staff will be reminded that when any young person aged 16 and 17 year olds attends the department intoxicated a ‘Cause for Concern’ form needs to be completed. This action will be addressed through the existing fortnightly ‘Cause for Concern’ meeting. Oversight of this action will be through the existing Trust governance process, including through the Child Protection Operational Group. | University Hospitals Bristol NHS Foundation Trust |
| University Hospitals | When the perpetrator delivered her baby at St. Michael’s Hospital there was not a social report available for staff to follow. UHB now has a dedicated person within the safeguarding team who is responsible for contacting allocated social workers to ensure social reports are in place when a baby is delivered. | University Hospitals Bristol NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||