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

Cornwall review

CSP: Cornwall Published: July 2023 Year of death: 2017 Extracted: 14 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 fragmented multi-agency responses to the victim's complex needs, including substance misuse, mental health issues, and childhood trauma. There was a failure to holistically identify and address domestic abuse risks, often masked by other vulnerabilities, compounded by poor information sharing and engagement challenges.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
1	We recommend that professionals across Cornwall be updated in their training in relation to domestic abuse and violence to ensure thorough and up to date knowledge. They should also be encouraged and supported to use routine enquiry when appropriate. Particular focus should be given to third sector and independent organisations locally including Cosgarne Hall and Addaction.	Safer Cornwall
2	Training/information should be offered at the beginning of each DHR to support agencies in the completion of IMRs. The CSP should ensure the standard SLA with DHR chairs is updated to reflect this.	Cornwall Community Safety Partnership
3	Family members should be an integral part of DHRs. Family members should be involved at the earliest opportunity and support should be provided to ensure they can remain key stakeholders throughout the process. The CSP should ensure Chairs adhere to the DHR Statutory Guidance to ensure this is the case for all future DHRs.	Cornwall Community Safety Partnership
4	We recommend that a process be developed by the CCG, the NHS Trusts, the police and adult social care, and other relevant organisations, to examine the process for information exchange between them, with specific focus on how best to do so when working with transient or homeless people.	NHS Kernow Clinical Commissioning Group \| Cornwall Partnership NHS Foundation Trust \| Devon and Cornwall Police \| Cornwall Council Adult Social Care
5	We recommend the development of a multi-agency approach to working with people, particularly couples, experiencing multiple vulnerabilities. The continued delivery of the DAAT/DASV joint working protocol and dual Diagnosis Strategy and complex needs strategy should be prioritised, rolled out and embedded. This should include the need for services to engage in assertive outreach to engage with those with multiple vulnerabilities. As part of the Complex Needs Strategy we recommend that work be undertaken to improve the understanding of Adverse Childhood Experiences and the development of effective trauma pathways in Cornwall.	Safer Cornwall
6	Adult Safeguarding to reissue guidance about how to make Adult Safeguarding referrals, i.e. can be made via email.	Cornwall Council Adult Social Care
Cosgarne Hall IMR 1	A dedicated database specifically aimed at transient couples or perpetrators that are accessed by professional agencies who provide accommodation, to collate information on domestic abuse victims allowing relevant professionals to extract the required up to date information for their offered service which could determine trends and highlight risk escalation.	Cosgarne Hall
CPFT IMR 1	Services must record a brief summary of any clinical discussion held in the MDT using the SBARD tool (Situation, Background, Assessment, Recommendation, and Decision). This to be recorded as a minimum in the patient’s clinical record, live in the MDT to avoid loss of information. The Nurse Consultants for each area to measure compliance and quality of information recorded.	Cornwall Partnership NHS Foundation Trust
Primary Care IMR 1	A Domestic Violence Policy should be in place in the GP surgery	The GP Surgery (Cornwall)
Primary Care IMR 2	Domestic violence awareness / training should be arranged for staff.	The GP Surgery (Cornwall)
Primary Care IMR 3	The Children’s Safeguarding policy is dated 8.10.2014 and contains clear information that it will be reviewed annually. This is overdue.	The GP Surgery (Cornwall)
Primary Care IMR 4	Consideration of any enhancement to medical notes/information transfer where individuals are known to be homeless/in supported lodgings.	The GP Surgery (Cornwall)
Primary Care IMR 5	There are regular Multi-agency MH hub meetings held at the GP Practice, which recently have been less well attended by MH. Patients to be discussed at meetings should be known in advance to ensure maximum efficiency of practitioner’s time, and outline reports sent, if attendance is not possible.	The GP Surgery (Cornwall)
Primary Care IMR 6	To continue to raise awareness and provide training for professionals regarding support and advice for children who experience physical or sexual violence in order to minimise the impact it has on their long-term health and emotional wellbeing outcomes.	The GP Surgery (Cornwall)
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗