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
Northampton review
CSP: Northampton
Published: July 2023
Year of death: 2016
Extracted: 35 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 recognising and responding to the victim's vulnerability and the domestic abuse dynamics within the relationship. Agencies struggled with multi-agency coordination, precise mental capacity assessments, and timely provision of support, exacerbated by the individuals' inconsistent engagement and alcohol misuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Agencies making reference to a person’s mental capacity should be precise as to what decisions the person can and cannot be deemed to have capacity to make especially where the person’s safeguarding is involved. | All agencies |
| 1 | All parties who are entitled to, receive a copy of this report. | Northampton County Council |
| 1 | Northamptonshire Police undertakes an awareness raising approach supported by relevant training for key roles to remind all staff the importance of submitting Form SA1 where appropriate including its operation within Niche. | Northamptonshire Police |
| 1 | Housing Officers and Support Workers to be given specialist training/awareness raising to consider “could this situation be domestic abuse?” in any situations of alleged abuse/violence. | Northampton Partnership Housing |
| 1 | For NCC Public Health and CCG commissioner to review the potential for current Drug and Alcohol pathways and consider how this is better integrated with Mental Health Services for future service delivery including options for full alignment and integration. | NCC Public Health | CCG commissioner |
| 1 | The Trust should re-launch the multi-agency Adults At Risk (ARM) process in order to support those individuals for whom access to services is a challenge. | Northampton General Hospital |
| 1 | The individual staff members involved in the attendances for the victim and the perpetrator where there were missed opportunities to refer the patients to reflect on their practice. | East Midlands Ambulance Service |
| 10 | The Department to strengthen their processes to ensure that the DHR process is enabled to take place uninterrupted in a fair and transparent manner. | Northampton County Council |
| 10 | New procedure to be created when concern cards are received that the Housing Officer arranges a meeting/discussion with the person who submitted the card to ensure they have a full understanding of the situation. | Northampton Partnership Housing |
| 11 | Procedure/guidance to be created for Housing Officers that when they receive information from a third party that someone is at risk they urge the person to contact other services such as social services and the police as other services may hold information they do not and direct dialogue with other services could extract further relevant information. | Northampton Partnership Housing |
| 12 | A process for the recording and storing of letters to be devised and implemented. | Northampton Partnership Housing |
| 2 | Cancellation of appointments by known vulnerable people should not be accepted on face value and should be checked and confirmed, especially when a family member is expressing concerns regarding the behaviour and demeanour of the vulnerable person. | All agencies |
| 2 | The department to standardise supervision arrangements and embed the Supervision Policy to ensure that team meetings take place. | Northampton County Council |
| 2 | Northamptonshire Police develops a model to identify, problem solve and actively manage investigations where the victim(s) are vulnerable and reluctant to engage with the police beyond the initial report. | Northamptonshire Police |
| 2 | Support Officer DC to be asked about the lack of notes for this case and provided with required training. Support Manager to reiterate to wider team and provide training on the importance of following procedure putting notes on to say they are the support worker and recording notes and actions. | Northampton Partnership Housing |
| 2 | The Trust should work in collaboration with the police to develop a clear protocol to support the effective safety planning of those who leave hospital where concerns for their welfare remain. | Northampton General Hospital |
| 2 | A communication piece will be shared in the EMAS E-News reminding staff of the importance of recognising Domestic Violence and Abuse (DVA) and offering victims referrals to supportive services. It will be highlighted that this needs to be documented. | East Midlands Ambulance Service |
| 3 | All agencies should be aware of the need to consider calling for a multi-agency meeting with regard to those known vulnerable people who are regularly calling for assistance from a variety of agencies in circumstances when the calls are unnecessary or inappropriate. | All agencies |
| 3 | The Department to roll out training to ensure that the Care Act and local guidance/policy have been embedded into local arrangements and day to day practice. | Northampton County Council |
| 3 | Housing Officers and Support Officers to receive guidance/training on the importance of sharing intelligence and information. | Northampton Partnership Housing |
| 3 | There is a level 2 safeguarding workbook containing information on DVA to be provided to all staff during February 2017. From April 2017 all staff will be required to complete an eLearning package and assessment around safeguarding and DVA. This will be used as a training needs analysis and themes will be pulled from this domestic homicide review and used in the assessment during 2017-2018. | East Midlands Ambulance Service |
| 4 | Northampton Partnership Homes should be aware of the need to make referrals to the police and /or social services where evidence of criminality is observed by NPH personnel in the course of their duty and should always be mindful that a safeguarding opportunity may be missed if such a referral is not made. | Northampton Partnership Homes |
| 4 | The Department to devise and implement an Audit Framework that seeks to ensure that each tier of staff including management carry out frequent audits including peer audits. | Northampton County Council |
| 4 | Procedure to be created for the call centre so when they take a call from someone saying they are at risk or unsafe in their property that all Team Leaders are emailed with the details, that the call is put through to the duty officer if available and if not that a call back is logged for the Housing Officer. This will ensure that the decision making doesn’t sit with one person in terms of outcome. | Northampton Partnership Housing |
| 5 | Where issues of funding for accommodation arises Adult Social Services should take a leading role in the coordination of efforts to secure funding, which should be completed as soon as possible and not prolong a person’s vulnerability in delaying the decision making process. | Adult Social Services |
| 5 | The Department to implement a mechanism to highlight cases that have been open to Adult Social Care for extended periods of time in order to trigger a holistic review of arrangements. | Northampton County Council |
| 5 | An investigation will be undertaken regards Support Worker VJ for not taking the appropriate action when the victim called to say he was unsafe in September 2015. The resulting action taken will depend on whether through the DHR it can be ascertained had the Support Worker called the police, whether a move would have been sought. | Northampton Partnership Housing |
| 6 | The Department to carry out an internal investigation into the management of The Pending List. | Northampton County Council |
| 6 | Procedure to be created for when someone contacts the Housing Officer to say they are unsafe or at risk e.g. must always take action- taking information and checking with the police and to record outcome on IBS. Training to be delivered to Housing Officers once procedure created. | Northampton Partnership Housing |
| 7 | The Department to review the process used to categorise Pending List cases and ensure that staff are equipped and trained to effectively carry out an assessment of risk. | Northampton County Council |
| 7 | Create a procedure that in all cases where someone claims they are in danger or at risk or a third party makes the claim on their behalf, that they are referred to the serious case panel for consideration. | Northampton Partnership Housing |
| 8 | The NSAB to ensure that their arrangements and assurance seeking mechanisms are robust and fit for purpose. There should be an effective Learning and Improvement Framework in place that is equipped to expose and indicate any potential and /or current risk. | NSAB |
| 8 | NPH to provide training and increase awareness to Housing Officers that tenants can make homeless applications to other local authorities if at risk with support. | Northampton Partnership Housing |
| 9 | The NSAB to ensure and oversee the timely review and ratification of Policy Documents. The Department to consider rolling out training for staff to support staff awareness of NSAB, the interface between the Board and Local Arrangements, the role of the Board and how practitioners can act as a crucial source of information to the Board and the strategic decision making process. | NSAB | Northampton County Council |
| 9 | Liaise with Contact Centre managers to ensure that when there is concerning information taken this is shared with Housing Officers. | Northampton Partnership Housing |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||