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
Stoke-on-Trent review
CSP: Stoke-on-Trent
Published: July 2023
Year of death: 2020
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 report identifies systemic failures in recognising and assessing high-risk domestic abuse, stalking, and harassment, particularly concerning information sharing between agencies and understanding victim vulnerability. There were missed opportunities for perpetrator intervention and inadequate consideration of the child's lived experience.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Stoke-on-Trent Community Safety Partnership should, through the Domestic Abuse Commissioning and Development Board in Stoke-on-Trent and Staffordshire, request assurances from Staffordshire Police as the lead accountable body for MARAC in the area as to whether the policies and procedures are sufficiently clear for ensuring the MARAC routinely considers the applicability of the DVDS. | Stoke-on-Trent Community Safety Partnership |
| 2 | The respective Directors of Children’s Services should ensure that policy and procedures include a reference to the DVDS and the role of children’s services to enquire about the applicability of the DVDS. | Local Authorities |
| 3 | The Director of Children’s Services in Stoke-on-Trent should ensure that policy, guidance and professional development on conducting enquiries and assessments include specific reference to the importance of considering any history of domestic abuse especially when men move into households with children. | Director of Children’s Services in Stoke-on-Trent |
| 4 | Staffordshire Police should consider how learning in respect of the disclosures made to emergency call handling staff is accessed and considered in DASH assessments. | Staffordshire Police |
| 5 | Staffordshire Police should consider whether any further measures are required to improve the identification and targeting of higher risk perpetrators of domestic abuse and the development of risk assessment planning when DVPOs are breached. | Staffordshire Police |
| 6a | The training provided for staff in children’s social care services includes recognition of higher risk indicators and action to be taken. | Stoke-on-Trent Community Safety Partnership |
| 6b | That local strategies for developing multi-agency domestic abuse risk assessment include the identification of characteristics and behavioural clusters or markers of high-risk domestic abuse and the importance of exploring relationship history. | Stoke-on-Trent Community Safety Partnership |
| 6c | Training to primary and secondary health care professionals on the links between domestic abuse, poor mental health and substance misuse and implications for practice and risk assessment. | Stoke-on-Trent Community Safety Partnership |
| 7 | The Safer Derbyshire community safety partnership should consider whether the DHR has identified any learning that is additional to the DHRs previously completed in the county. | Safer Derbyshire community safety partnership |
| Derbyshire County Co | Local Authorities transferring cases should provide robust information at the onset of a request to transfer a case to ensure robust safeguarding decision making is achieved for children. Escalation processes should be invoked where information is not received or is inadequate for safeguarding children. | Derbyshire County Council Children’s Services |
| Derbyshire County Co | Cases should not be approved for closure without ensuring that partner / third sector agencies involved in the case have been consulted to ensure planned activities have been achieved or are in progress sufficiently that safeguards for the child will not be detrimentally affected by the closure. | Derbyshire County Council Children’s Services |
| Derbyshire County Co | If allocated workers are absent for more than 3 weeks a case support plan including cover arrangements should be drawn up by managers. | Derbyshire County Council Children’s Services |
| National policy 1 | The issue of accessing personal data held by general practitioners in the context of DHRs and reliance on consent rather than the legal obligation to be involved and contribute to the review and the substantial public interest to prevent domestic homicide. | Government |
| National Probation S | The National Probation Service to consider more formally the need to assess the risk of harm posed to perpetrators of domestic abuse, by their partners, where partners are repeat victims of abusive behaviours and, in particular, have additional vulnerabilities such as alcohol dependence, substance misuse needs or mental health needs. | National Probation Service |
| National Probation S | Where service users have a significant history of domestic abuse/intimate partner violence, regardless of the index offence of the current sentence, that suitability for BBR (or equivalent Accredited Programme) is assessed and the outcome is recorded in the OASys Risk Management Plan. | National Probation Service |
| National Probation S | Reinforce the message that SARA is to be reviewed when OASys is reviewed for relevant domestic abuse perpetrator cases, or a Professional Judgement entry to be included in nDelius to explain why it is appropriate not to review SARA. | National Probation Service |
| National Probation S | Where service users have a demonstrated capacity for violence, consider risk both to and from others in a comprehensive manner. | National Probation Service |
| National Probation S | OASys to be reviewed to support significant events including a changed assessment of the risk of harm. | National Probation Service |
| North Staffordshire | All staff to record the rationale for decisions made to raise or not raise safeguarding concerns directly with Children’s Social Care. | North Staffordshire Combined Healthcare NHS Trust |
| Stoke-on-Trent Child | Training about completing assessments and application of Threshold to be given to Early Help workers | Stoke-on-Trent Children and Young People’s Service |
| Stoke-on-Trent Child | Early Help workers to be provided with support to develop child-focused thinking and recording | Stoke-on-Trent Children and Young People’s Service |
| Stoke-on-Trent Child | Research materials in respect of the ‘Toxic Trio’ to be provided to those completing assessments and used within analysis. | Stoke-on-Trent Children and Young People’s Service |
| Stoke-on-Trent Child | Children’s social care services to ensure that consideration is given to contacting GPs when a CIN assessment is being completed where the consent of parent or carers with parental responsibility has been given. | Stoke-on-Trent Children and Young People’s Service |
| Stoke-on-Trent Child | A “seven-minute” briefing will be rolled out to inform of the Lessons Learned from this review to both Children’s Social Care and Early Help. | Stoke-on-Trent Children and Young People’s Service |
| Stoke-on-Trent Clini | Assessment of risk of harm during mental health consultations needs to consider the risk of harm to others as well as to one’s self. It is recommended that the enquiry and recording of such becomes an embedded practice in primary care. | Stoke-on-Trent Clinical Commissioning Group (CCG) |
| Stoke-on-Trent Clini | Practices ensure that robust protocols are in place to appropriately code the records of children and families subject to safeguarding processes as per RCGP guidance. | Stoke-on-Trent Clinical Commissioning Group (CCG) |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||