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 report highlights systemic failures in multi-agency risk assessment, information sharing, and support for the victim, who experienced long-term domestic abuse, the perpetrator's alcohol misuse, and mental health issues. Agencies missed opportunities to intervene effectively.

Extracted recommendations

20 recommendations pulled from the report

#	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
1	For the OM to ensure the timely completion of OASys assessments that is reviewed and updated in line with Professional Judgement.	Probation
1	Establish a multi-agency forum to discuss complex and high risk individuals (that do not meet MAPPA criteria)	Adult Services Wellbeing
1	Closure Document ICS required ensuring Management Team Oversight prior to case closure.	Safeguarding (Children’s Services)
1	All qualified mental health professionals providing one to one interventions should have training in formal violence risk assessment	ABMU Mental Health
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
2	To improve the quality of each OASys assessment completed is of sufficient quality, containing all relevant information required.	Probation
2	Social Work assessments to be informed by historical and current information from family members, agencies / professionals.	Safeguarding (Children’s Services)
2	There will be domestic violence pathways in place for service users, involving staff being able to ask about and act to sign post people to appropriate services or alert appropriate safeguarding bodies.	ABMU Mental Health
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)
3	To improve the frequency and quality of recording on DELIUS.	Probation
3	Children must be spoken to alone for the purposes of Assessment and protection.	Safeguarding (Children’s Services)
3	For service users presenting with serious mental ill health and domestic violence, specialist forensic mental health consultation will be available to staff	ABMU Mental Health
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
4	To refresh Offender Managers within SNB LDU understanding of Professional Judgment principles.	Probation
4	Completion of a Risk Assessment when recommended	Safeguarding (Children’s Services)
4	The risk assessment tool for mental health will contain a section on children and their safeguarding needs	ABMU Mental Health
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.	ABMU Mental Health
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.	ABMU Mental Health
7	Care and treatment plans will include details of prescribing and changes in prescription will be recorded in patients’ healthcare records and care and treatment plans.	ABMU Mental Health
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗