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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | 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. | Ministry of Justice |
| 10 | The SAB to develop guidance on raising concerns about abuse and neglect. | Safeguarding Adults Board |
| 11 | 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. | Safeguarding Adults Board |
| 1.10.10 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.11 | ‘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”. | Central Bedfordshire Council Adult Social Care |
| 1.10.12 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.13 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.14 | Continue with awareness raising through structured training, and team training events of Domestic Violence. | Bedford Hospital NHS Trust |
| 1.10.15 | Development of an e-learning package. | Bedford Hospital NHS Trust |
| 1.10.16 | Aide Memoire being developed for nursing and medical professionals in regard to identifying signs of domestic violence. | Bedford Hospital NHS Trust |
| 1.10.17 | The DHR findings will be shared with trust staff via departmental meetings and clinical governance | Luton & Dunstable University Hospital NHS Foundation Trust |
| 1.10.18 | A summary of the findings of this investigation will be discussed within Children’s and Adults Safeguarding training sessions provided by the Trust”. | Luton & Dunstable University Hospital NHS Foundation Trust |
| 1.10.19 | Refresher Domestic Abuse training as incorporated in the Level 3 Safeguarding Training for all Clinical staff. | West Street Surgery |
| 1.10.2 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.20 | Review Mental Health/Counselling Pathway. | West Street Surgery |
| 1.10.3 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.4 | A corporate letter template will be drafted by Integrated Services and sanctioned for use when corresponding with the public around engagement/contact obstacles. | Central Bedfordshire Council Adult Social Care |
| 1.10.5 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.6 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.7 | 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. | Central Bedfordshire Council Adult Social Care |
| 1.10.8 | Policies and procedures relevant to safeguarding and domestic abuse will be highlighted to all practitioners via practice surgeries. | Central Bedfordshire Council Adult Social Care |
| 1.10.9 | 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. | Central Bedfordshire Council Adult Social Care |
| 12 | 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. | Bedfordshire Clinical Commissioning Group | Central Bedfordshire Council |
| 13 | 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. | Bedfordshire Clinical Commissioning Group |
| 14 | 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 | Public Health Commissioners |
| 15 | 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. | Pan Bedfordshire Learning Academy |
| 16 | The Pan Bedfordshire Learning Academy to ensure that domestic abuse training content addresses typologies of domestic violence and abuse. | Pan Bedfordshire Learning Academy |
| 17 | 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. | Pan Bedfordshire Learning Academy |
| 2 | The CSP to work with partners in the BDAP to agree a mechanism for collating and sharing findings and recommendations systematically from local DHRs. | Central Bedfordshire Community Safety Partnership |
| 3 | 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. | Corporate Domestic Abuse Board |
| 4 | The CSP should review existing strategic arrangements with local partners to ensure that these can support a robust multi-agency CCR locally. | Central Bedfordshire Community Safety Partnership |
| 5 | CBC Children Services to ensure that the ‘get help’ section of the BDAP website is reviewed to make it more easily navigable. | Central Bedfordshire Council Children Services |
| 6 | 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. | Central Bedfordshire Community Safety Partnership | Commissioners |
| 7 | 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. | Corporate Domestic Abuse Board |
| 8 | 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. | Bedfordshire Police |
| 9 | 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. | Bedfordshire Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||