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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | 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. | Staffordshire Police |
| 2 | 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. | Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board |
| 20.1 | To work with partners and access funding to help find support for pets where women need to leave their homes to go into Refuge. | Staffordshire Women’s Aid |
| 20.2 | 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. | Staffordshire Women’s Aid |
| 20.3 | 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. | Staffordshire Women’s Aid |
| 20.4 | 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. | Staffordshire Women’s Aid |
| 20.5 | For Staffordshire Women’s Aid to clarify with other agencies the limits, as well as the benefits, of our counselling service. | Staffordshire Women’s Aid |
| 20.6 | 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. | Staffordshire Women’s Aid | Partners |
| 20.7 | For partners to work together to more quickly identify the continual presence and patterns of coercive control and to avoid seeing incidents as isolated. | Staffordshire Women’s Aid | Partners |
| 21.1 | 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. | Staffordshire Police |
| 21.2 | 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. | Staffordshire Police |
| 21.3 | Staffordshire Police to continue their drive for improvement with the Standards and Quality of Investigation with specific regard to: - Reporting, Responding & Resolving. | Staffordshire Police |
| 21.4 | 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. | Staffordshire Police |
| 22.1 | Provide emergency portals at UHNM with training in Domestic Abuse and its links with Mental Health. | University Hospitals of North Midlands NHS Trust |
| 22.2 | UHNM is currently undertaking a self – harm audit of which any lessons to be learnt will be addressed. | University Hospitals of North Midlands NHS Trust |
| 23.1 | 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. | Stafford Borough Council |
| 24.1 | Develop pathway for GP engagement by the wider Multi-Disciplinary Team for instances of domestic abuse. | Stafford and Surrounds CCG |
| 24.2 | 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. | Stafford and Surrounds CCG |
| 24.3 | 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. | Stafford and Surrounds CCG |
| 25.1 | Ensure new referral pathways are actively promoted with all agencies. Done | South Staffordshire and Shropshire NHS Foundation Trust |
| 25.2 | Reminder to be sent to all community staff to ensure they visit the “correspondence address” as noted on Rio. | South Staffordshire and Shropshire NHS Foundation Trust |
| 26.1 | 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. | Victim Gateway |
| 26.2 | Revisit the referral pathways with all specialist domestic abuse services and come to an agreement on joint working cases. | Victim Gateway |
| 27.1 | NSCHT Staff to continue to have access to Domestic Abuse awareness training to strengthen knowledge relating to non-molestation orders. | North Staffordshire Combined Healthcare NHS Trust |
| 3 | 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. | Stafford Community Wellbeing Partnership |
| 4 | 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. | Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||