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

Central Bedfordshire review

CSP: Central Bedfordshire Published: July 2023 Year of death: 2018 Extracted: 36 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identified concerns regarding inter-agency communication, inconsistent risk assessment for domestic abuse (particularly for male victims and counter-allegations), and inadequate identification of vulnerability and alcohol use. Gaps in training and strategic coordination were also noted.

Home Office classifications

21 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - had been a victim of an abuser before
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - physical disability
  • Perpetrator - mental ill health
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

36 recommendations pulled from the report · 27 matched to organisations in the index

Recommendation 1

Addressed to Ministry of Justice

The Ministry of Justice to develop guidance for prisons in relation to their role in the DHR process, including the pro-active steps they should take to enable engagement with perpetrators.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.2

Addressed to Central Bedfordshire Council Adult Social Care

Case allocation and case closure sections within the operational policy will be updated by Integrated Services to reflect any revisions/improvements made within the system.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.3

Addressed to Central Bedfordshire Council Adult Social Care

When practitioner/ supervisor case closure discussions occur narrative, risk assessment and outcome will be recorded on the customer database. Team managers will highlight this expectation to all practitioners via individual team meetings to aid reflection and learning and ensure that practitioners are not reliant of systems and processes and are using mechanisms such as peer discussions, reflective practice, auditing and reflective case supervision and utilising available managerial support in their day to day practice.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.4

Addressed to Central Bedfordshire Council Adult Social Care

A corporate letter template will be drafted by Integrated Services and sanctioned for use when corresponding with the public around engagement/contact obstacles.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.5

Addressed to Central Bedfordshire Council Adult Social Care

The current customer database training will be reviewed by learning and development with practitioner involvement to ensure training modules are available to the workforce until the replacement system is in situ. Locality teams will identify system champions who can offer assistance to less experienced practitioners when required.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.6

Addressed to Central Bedfordshire Council Adult Social Care

The programme that is overseeing the procurement of a new electronic client database will ensure that robust training and operational guidance is available to the workforce prior to introduction of the new customer database system.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.7

Addressed to Central Bedfordshire Council Adult Social Care

Manager within Integrated Services will present this and other similar cases as a reflective case study so that team discussions can take place and assist in developing confidence and competence in this area of social work practice. The Practice surgeries and the Practice Forum will be used for further learning and to inform how we approach cases where there are indications of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.8

Addressed to Central Bedfordshire Council Adult Social Care

Policies and procedures relevant to safeguarding and domestic abuse will be highlighted to all practitioners via practice surgeries.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.9

Addressed to Central Bedfordshire Council Adult Social Care

To ensure all workers are equipped and supported to have conversations about domestic abuse it is recommended that the learning needs analysis captures and is agreed as a priority for this topic.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.10

Addressed to Central Bedfordshire Council Adult Social Care

All practitioners undertaking safeguarding activity to continue to have access via the domestic abuse partnership to a variety of domestic abuse training modules, including training relating to male victims.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.11

Addressed to Central Bedfordshire Council Adult Social Care

‘Research in Practice for Adults’ have been commissioned to deliver Safeguarding- Coercive and Controlling Behaviour training in March 2019. This subject was the ‘topic of the month’ in July 2018 following practitioner interest in additional learning in this area”.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.12

Addressed to Central Bedfordshire Council Adult Social Care

Where referrals are received from the Police relating to a domestic incident arrest and information and detail is sparse, the Safeguarding Team will make attempts to contact the PPU. The PPU will receive an email requesting urgent contact and further detail be shared with the safeguarding team and relevant locality team.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.13

Addressed to Central Bedfordshire Council Adult Social Care

The Head of safeguarding will review the Pan Bedfordshire Safeguarding Policies and Procedures by end of December 2018 and the Operational subgroup of the board will ratify the proposed changes.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.14

Addressed to Bedford Hospital NHS Trust

Continue with awareness raising through structured training, and team training events of Domestic Violence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.16

Addressed to Bedford Hospital NHS Trust

Aide Memoire being developed for nursing and medical professionals in regard to identifying signs of domestic violence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.17

Addressed to Luton & Dunstable University Hospital NHS Foundation Trust

The DHR findings will be shared with trust staff via departmental meetings and clinical governance

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.18

Addressed to Luton & Dunstable University Hospital NHS Foundation Trust

A summary of the findings of this investigation will be discussed within Children’s and Adults Safeguarding training sessions provided by the Trust”.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1.10.19

Addressed to West Street Surgery

Refresher Domestic Abuse training as incorporated in the Level 3 Safeguarding Training for all Clinical staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Central Bedfordshire Community Safety Partnership

The CSP to work with partners in the BDAP to agree a mechanism for collating and sharing findings and recommendations systematically from local DHRs.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Corporate Domestic Abuse Board

The Corporate Domestic Abuse Board to ensure that its review of CBC’s Domestic Abuse Strategy takes a gender informed approach, and that the revised strategy identifies the specific actions that will be taken, proportionally to need, to support male victims.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Central Bedfordshire Community Safety Partnership

The CSP should review existing strategic arrangements with local partners to ensure that these can support a robust multi-agency CCR locally.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Central Bedfordshire Council Children Services

CBC Children Services to ensure that the ‘get help’ section of the BDAP website is reviewed to make it more easily navigable.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Central Bedfordshire Community Safety Partnership | Commissioners

The CSP and the relevant commissioners to work with Victim Support and the Signpost Hub to develop shared policy, procedure and training for the identification, management and assessment of counter-allegations across domestic abuse services locally.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Corporate Domestic Abuse Board

The Corporate Domestic Abuse Board to ensure that its review of CBC’s Domestic Abuse Strategy identifies the specific actions that will be taken to support older victims.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Bedfordshire Police

Bedfordshire Police to ensure there is a consistent and robust process for the subversion all of domestic abuse incidents / crimes, with this supported by a training package that ensures that Police Officers and their supervisors are confident in the use of risk tools.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Bedfordshire Police

Bedfordshire Police to audit the timeframes for referrals made at periods of peak demands and identify mitigating actions to ensure prompt onward referral to partner agencies.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to Safeguarding Adults Board

The SAB to audit local referral pathways for adults who are victims of domestic abuse, and for whom there may be vulnerability or safeguarding concerns, to ensure these offer a robust response regardless of whether someone meets the level for statutory intervention.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to Bedfordshire Clinical Commissioning Group | Central Bedfordshire Council

Within the Better Care Fund Plan for Central Bedfordshire, the Bedfordshire CCG and CBC review funding for local HIDVA services to ensure that there is a consistent and equitable service offer.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 13

Addressed to Bedfordshire Clinical Commissioning Group

Bedfordshire CCG to work with GPs to monitor the impact of the changes to the discharge notifications from local hospitals and ensure that this GPs take follow up action if required.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 14

Addressed to Public Health Commissioners

Public Health Commissioners to develop a programme to raise awareness of best practice in relation to the identification and offer of brief advice by local services in relation to alcohol use

Verified wording from the published review · Original review (PDF) ↗

Recommendation 15

Addressed to Pan Bedfordshire Learning Academy

The Pan Bedfordshire Learning Academy to review the current training available in relation to male victims of domestic abuse and ensure that: (a) Key messages are integrated across all introductory training (b) Staff can access intermediary and advanced level training.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 16

Addressed to Pan Bedfordshire Learning Academy

The Pan Bedfordshire Learning Academy to ensure that domestic abuse training content addresses typologies of domestic violence and abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17

Addressed to Pan Bedfordshire Learning Academy

The Pan Bedfordshire Learning Academy to review the current training available locally and ensure it addresses the identification, management and assessment of counter-allegations. This should include integrating key messages across training content and also developing bespoke training content.

Verified wording from the published review · Original review (PDF) ↗