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
Bridgend review
CSP: Bridgend
Published: July 2023
Year of death: 2013
Extracted: 20 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 identifies systemic failures in multi-agency risk assessment, information sharing, and domestic abuse awareness, leading to missed opportunities to safeguard the victim and her children. Concerns include the perpetrator's manipulation of services and inadequate support for the victim from health and social care.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Bridgend Community Safety Partnership to ensure Western Bay Adult and Safeguarding Boards commission a multi-agency partnership to develop strategy to ensure the implementation of the NICE Guidance 2014 and the new Domestic Abuse and Sexual Violence (Wales) Bill. | Bridgend Community Safety Partnership |
| 2 | Bridgend Community Safety Partnership to ensure that all GPs are complying with the General Practitioners Guidance on Domestic Violence issued in 2011 and that within six months from the date this report is accepted by the Bridgend CSP Board, each GP surgery confirms with the Bridgend Community Safety Partnership that the guidance had been adhered to and training for all medical and none medical staff is underway. | Bridgend Community Safety Partnership |
| 3 | DASG (Bridgend Domestic Abuse Steering Group) to ensure all agencies review and agree a personal Information Sharing Protocol (ISP - WASPI) which includes the competition of risk assessments. | DASG (Bridgend Domestic Abuse Steering Group) |
| 4 | Bridgend Community Safety Partnership considers organising a ‘Learning Event’ involving practitioners involved in this case once the Overview report has been presented and accepted by the Community Safety Partnership Board, in order that the recommendations and learning from this review can be disseminated. | Bridgend Community Safety Partnership |
| ABMU MH 1 | All qualified mental health professionals providing one to one interventions should have training in formal violence risk assessment | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 2 | There will be domestic violence pathways in place for service users, involving staff being able to ask about domestic violence and act to sign post people to appropriate services or alert appropriate safeguarding bodies. | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 3 | For service users presenting with serious mental ill health and domestic violence, specialist forensic mental health consultation will be available to staff | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 4 | The risk assessment tool for mental health will contain a section on children and their safeguarding needs | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 5 | Domestic violence perpetrators will be signposted to appropriate services for help in regards to reducing domestic violence risk will be contained in healthcare records and risk assessment plans. | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 6 | Service users with personality disorder will be identified and their needs reflected in care and treatment plans. A bid for funding for the development of specialist personality disorder services will be submitted to Welsh Government. | Abertawe Bro Morgannwg University Health Board |
| ABMU MH 7 | Care and treatment plans will include details of prescribing and changes in prescription will be recorded in patients’ healthcare records | Abertawe Bro Morgannwg University Health Board |
| Probation 1 | For the OM to ensure the timely completion of OASys assessments that is reviewed and updated in line with Professional Judgement. | Wales Probation Service |
| Probation 2 | To improve the quality of each OASys assessment completed is of sufficient quality, containing all relevant information required. | Wales Probation Service |
| Probation 3 | To improve the frequency and quality of recording on DELIUS. | Wales Probation Service |
| Probation 4 | To refresh Offender Managers within SNB LDU understanding of Professional Judgment principles. | Wales Probation Service |
| Safeguarding 1 | Closure Document required ensuring Management Oversight prior to case closure. | Bridgend County Borough Council Social Care Workforce Development Team |
| Safeguarding 2 | Social Work assessments to be informed by historical and current information from family members, agencies / professionals. | Bridgend County Borough Council Social Care Workforce Development Team |
| Safeguarding 3 | Children must be spoken to alone for the purposes of Assessment and protection. | Bridgend County Borough Council Social Care Workforce Development Team |
| Safeguarding 4 | Completion of a Risk Assessment when recommended | Bridgend County Borough Council Social Care Workforce Development Team |
| Wellbeing 1 | Establish a multi-agency forum to discuss complex and high risk individuals (that do not meet MAPPA criteria) | Bridgend County Borough Council Adult Services Wellbeing |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||