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

Stafford review

CSP: Stafford Published: July 2023 Year of death: 2017 Extracted: 26 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 identifies systemic failures in recognising and responding to stalking and coercive control, including inadequate police incident classification, poor inter-agency information sharing, and insufficient risk assessment. It also highlights issues with mental health service engagement and the impact of misinformation on the victim's safety.

Home Office classifications

43 tags

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

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - panic attacks
  • Victim - post traumatic stress disorder (ptsd)
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - adjustment disorder
  • Perpetrator - suicidal thoughts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

26 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1

Addressed to Staffordshire Police

That Staffordshire Police should remind all Senior Officers and staff with responsibility for determining Right to Review applications of the importance of independence and transparency, and to consider the impact on this of any previous involvement with the individuals or case concerned when deciding who should undertake the review.

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

Recommendation 2

Addressed to Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board

That the Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should consider current arrangements for engaging GPs in the multi-agency response to domestic abuse and what developments may optimise the benefit of such engagement.

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

Recommendation 3

Addressed to Stafford Community Wellbeing Partnership

That the Stafford Community Wellbeing Partnership seek assurance from UHNM on the uptake and effectiveness of Emergency Department training in recognition of and response to patients with mental health problems, and that their arrangements for risk assessment and provision of access to mental health services are robust and being applied consistently.

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

Recommendation 4

Addressed to Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board

That the Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should promote professional awareness of available protective orders and the significance of these as indicators of risk.

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

Recommendation 20.1

Addressed to Staffordshire Women’s Aid

To work with partners and access funding to help find support for pets where women need to leave their homes to go into Refuge.

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

Recommendation 20.2

Addressed to Staffordshire Women’s Aid

For Staffordshire Women’s Aid to feel more confident in challenging decisions made by agencies – this will be addressed internally, and a new escalation policy will be developed.

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

Recommendation 20.3

Addressed to Staffordshire Women’s Aid

For Staffordshire Women’s Aid to increase its capacity to support victims through mental health problems via the one-year secondment with a mental health practitioner and an increasing partnership relationship with the mental health trust.

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

Recommendation 20.4

Addressed to Staffordshire Women’s Aid

For Staffordshire Women’s Aid to work with partners in exploring ways of better identifying signs of suicide and working together to respond to these risks.

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

Recommendation 20.5

Addressed to Staffordshire Women’s Aid

For Staffordshire Women’s Aid to clarify with other agencies the limits, as well as the benefits, of our counselling service.

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

Recommendation 20.6

Addressed to Staffordshire Women’s Aid | Partners

For partners to work together to better understand the continual abuse, such as that experienced by the victim, that can be perpetrated through social media and other such channels.

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

Recommendation 20.7

Addressed to Staffordshire Women’s Aid | Partners

For partners to work together to more quickly identify the continual presence and patterns of coercive control and to avoid seeing incidents as isolated.

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

Recommendation 21.1

Addressed to Staffordshire Police

Staffordshire Police Operating Model to include Local Policing Team Vulnerability Hub Roles and Responsibilities for the identification and management of risk with specific regard to existing Domestic Abuse Force Policy and Procedures.

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

Recommendation 21.2

Addressed to Staffordshire Police

Staffordshire Police to continue delivering Domestic Abuse training developed in Partnership with the University of Gloucester ensuring continued emphasis on the identification and investigation of Harassment and Stalking.

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

Recommendation 21.3

Addressed to Staffordshire Police

Staffordshire Police to continue their drive for improvement with the Standards and Quality of Investigation with specific regard to: - Reporting, Responding & Resolving.

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

Recommendation 21.4

Addressed to Staffordshire Police

The Independent Office for Police Conduct also made a recommendation which has been accepted by the organisation that: Staffordshire Police should deliver training as soon as is reasonably practicable to all call centre staff, staff who may from time to time handle calls and all staff who use CMS260 on effective cross-referencing of incidents and crimes and the importance of this and effective lateral research and systems checks.

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

Recommendation 22.1

Addressed to University Hospitals of North Midlands NHS Trust

Provide emergency portals at UHNM with training in Domestic Abuse and its links with Mental Health.

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

Recommendation 22.2

Addressed to University Hospitals of North Midlands NHS Trust

UHNM is currently undertaking a self – harm audit of which any lessons to be learnt will be addressed.

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

Recommendation 23.1

Addressed to Stafford Borough Council

The quality of the recording of information onto ECINs has been highlighted during the process of writing the IMR document. As such, Stafford Borough Council will be revising and reviewing the Terms of Reference for the Partnership Hub.

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

Recommendation 24.1

Addressed to Stafford and Surrounds CCG

Develop pathway for GP engagement by the wider Multi-Disciplinary Team for instances of domestic abuse.

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

Recommendation 24.2

Addressed to Stafford and Surrounds CCG

Standardise practice for each DHR that the perpetrator records are sought using the Independent Chair to request access on behalf of the Community Safety Partnership.

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

Recommendation 24.3

Addressed to Stafford and Surrounds CCG

GP training on control and coercion in terms of Domestic Violence and in its wider context to ensure they are aware of their duties to share concerns and understand the changes within the legislation.

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

Recommendation 25.1

Addressed to South Staffordshire and Shropshire NHS Foundation Trust

Ensure new referral pathways are actively promoted with all agencies. Done

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

Recommendation 25.2

Addressed to South Staffordshire and Shropshire NHS Foundation Trust

Reminder to be sent to all community staff to ensure they visit the “correspondence address” as noted on Rio.

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

Recommendation 26.1

Addressed to Victim Gateway

A further review of the services Domestic Abuse processes takes place and make any identified amendments to ensure that there is flexibility in decision making in relation to cases where there is a specialist provider involved.

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

Recommendation 26.2

Addressed to Victim Gateway

Revisit the referral pathways with all specialist domestic abuse services and come to an agreement on joint working cases.

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

Recommendation 27.1

Addressed to North Staffordshire Combined Healthcare NHS Trust

NSCHT Staff to continue to have access to Domestic Abuse awareness training to strengthen knowledge relating to non-molestation orders.

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