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
Leicester review
CSP: Leicester
Published: July 2023
Extracted: 39 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 a lack of a 'whole family approach' in care provision, ineffective management of the perpetrator's mental health and care plans, and insufficient recognition and response to safeguarding and domestic abuse concerns affecting the victim and their family.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Reiteration of the importance of linking and creating relationships to inform practitioners of who is involved with Customer Service Centre staff, locality teams and county wide teams. Training in progress. | Leicestershire Adult Social Care |
| 1 | It is recommended that care plans are co-produced with the patient, and this is monitored at a team level in accordance with the Record Keeping and Care Planning Policy and the outcomes are reported to the Trust Quality systems every three months. This should be in place within three months. | Leicestershire Partnership NHS Trust |
| 1 | Reminder to all clinicians about checking medication instructions from outpatient appointments with repeat prescriptions. Investigate any discrepancies. | GP Practice |
| 1 | The first recommendation is designed to improve knowledge and practice when NHS and police staff overlap and when operational manners and procedures challenge patients. We urge the Trust and the police to discuss together (for example, in a workshop or a series of seminars focused on best practice) how they might consider developing knowledge, understanding and improve practice when patients need to be taken to the Health Based Place of Safety (HBPOS) under S.136 of the Mental Health Act and/or who are already detained under Section of the Mental Health Act and need help to be returned to hospital. | Leicestershire Partnership NHS Trust | Leicestershire Police |
| 1 | All Health agencies to ensure that staff are cognisant that non-concordance with medication should be considered a trigger for a re-assessment of the risk the patient is to themselves and also to others within the environment the patient is located. | All Health agencies |
| 10 | It is recommended that there should be an effective system in place between inpatient and community service settings to ensure that medication response and dosage is correct and responsive to the patient’s needs. This system should be implemented within two months and monitored at the operational level. | Leicestershire Partnership NHS Trust |
| 11 | It is recommended that a ‘whole family’ approach is taken to the involvement of family and carers in the delivery of care to patients with severe mental illness and assessment and engagement of their needs and the rationale for these decisions is documented, and this is monitored through the Trust quality systems every three months. | Leicestershire Partnership NHS Trust |
| 12 | It is recommended that staff recognise the safeguarding needs of patients and parents of patients in the caring role. | Leicestershire Partnership NHS Trust |
| 13 | It is recommended that observation levels and changes to observation levels are documented accurately. | Leicestershire Partnership NHS Trust |
| 14 | It is recommended that any change of regime in the administration of depot medication be discussed and agreed with the responsible Consultant. | Leicestershire Partnership NHS Trust |
| 15 | It is recommended that clinical staff consider the significant changes in a patient’s life and the impact or potential impact they may have on the patient’s mental state. | Leicestershire Partnership NHS Trust |
| 2 | The Approved Mental Health Practitioner (AMHP) report was amended to prompt consideration of onward referrals. If a referral is not made, then the reason for this should be recorded in the case notes. | Leicestershire Adult Social Care |
| 2 | It is recommended that systems are put in place at a team level to monitor that all patients have a Care Plan as per the Record Keeping and Care Planning and assurance should be provided to the Trust Quality systems every three months. This should be in place with immediate action. | Leicestershire Partnership NHS Trust |
| 2 | Make individual risk assessments for patients who do not attend for Shared Care Agreement (SCA) drug physical check and document decisions about continuing to prescribe. Inform secondary care team (if still involved in the patient’s care) of the assessment and decision. | GP Practice |
| 2 | The second recommendation concerns the need for Trust clinical teams and leaders to improve learning, awareness, motivation and responsiveness to safeguarding practice. Whilst safeguarding staff, policy and systems exist in the Trust, operational routine practice is not currently embedded. We recommend that the Trust should take action and demonstrate metrics as well as qualitative feedback after six months. | Leicestershire Partnership NHS Trust |
| 2 | Leicestershire Partnership NHS Trust to use the opportunity of the transformation programme to instil into training and awareness of all staff the need for adherence to the requirements of the Care Programme Approach to assess the risks involved in managing patients who have been detained for treatment and are being discharged paying specific attention to: The family’s wishes and concerns, The patient’s concordance with medication, The effects of non-concordance of medication may have on the family and others in the household, To consider the ‘whole family approach’ | Leicestershire Partnership NHS Trust |
| 3 | The importance of the whole family approach to be emphasised with Adult Social Care staff and possibly training / Continuing Professional Development (CPD) opportunity to be offered. | Leicestershire Adult Social Care |
| 3 | It is recommended that risk assessments are monitored at a team level in accordance with the Clinical Risk and Management policy and the outcomes are reported to the Trust Quality systems every three months. | Leicestershire Partnership NHS Trust |
| 3 | For patients who DNA/decline their Primary Care Annual Mental Health Review, the secondary care team, if still involved, should be informed. | GP Practice |
| 3 | The third recommendation concerns the impact of the community transformation. Our team recommends that the Trust should show how basic care processes (e.g., care planning, risk assessment, and access to outpatient appointments, etc.) are being delivered during the transformation. Our team urges particular special attention to the quality and content of risk assessment, an area of concern in the perpetrator’s case. | Leicestershire Partnership NHS Trust |
| 3 | When dealing with multi-generational families, all agencies must consider the ‘whole family’ approach and how they react and respond to each other within the family settings and how an individual’s physical or mental health and circumstances may impact on other members of the family present. This issue should be embedded in training within each agency | All agencies |
| 4 | Training for Carers in progress building on the Core Carers training to include the learning from case studies and onward referrals. | Leicestershire Adult Social Care |
| 4 | It is recommended that CPA reviews and process should meet the standards of the Clinical Risk Assessment and Management policy and that this should be monitored at a team and strategic level through the Trust Quality systems every three months. | Leicestershire Partnership NHS Trust |
| 4 | Mental Health register reviewed by the registered GP. | GP Practice |
| 4 | The fourth recommendation is for the NHS England team to re-visit the Trust after six months. The aim is to examine reports and data relating to the above recommendations and discuss with the independent team. | NHS England |
| 5 | Where Health and Social Care are working with people in the same household, they should communicate to share relevant information and document when this has occurred. | Leicestershire Adult Social Care |
| 5 | It is recommended that a process is agreed to provide access to the Care Plan in the electronic patient record when they are temporarily not in use, such as an episode of inpatient care. This system should ensure that the full records are available for use in practice, and this should be implemented within three months and monitored through the information management and technology systems in the Trust. | Leicestershire Partnership NHS Trust |
| 5 | Review the coding issue where the exception code was being used incorrectly for patients who in remission and for patients who should have been removed from the register because their diagnosis was not appropriate for the Mental Health (MH) register. | GP Practice |
| 6 | Continuous embedding or recording in LAS (Adult Social Care recording system) using the RAAN2 method of recording which prompts analysis to take place and reasons given for actions. | Leicestershire Adult Social Care |
| 6 | It is recommended that caseloads of the multi-professional Community Mental Health Teams be assessed for acuity and limits set to ensure that the clinicians have the capacity to deliver the services to the required standards. This should be achieved within three months, and monitoring systems put in place to enable escalation if caseloads should breach the numbers. | Leicestershire Partnership NHS Trust |
| 6 | Registered GP reviewed notes of all patients on MH register to resolve coding problem. All remaining patients to receive further invitation to attend surgery or to have a home visit, from their own GP, tailoring the offer to best enable them to access care. | GP Practice |
| 7 | Leicestershire Adult Social Care should review the appropriateness of desk top reviews of Section 117 cases where the person is not in receipt of services. This appears to currently be an administrative exercise with no contact or benefit to the service user. Consideration should be given to where face to face reviews are indicated. | Leicestershire Adult Social Care |
| 7 | It is recommended that there is a review of the systems and processes of the medical provision in outpatients, to deliver a service which provides appointments to patients when required. This process should commence within two months and report through the performance management systems to the Board of Directors. | Leicestershire Partnership NHS Trust |
| 7 | To take an opportunistic approach so that patients due a Mental Health review who contact the surgery on another matter are offered an opportunity to book at a convenient time. | GP Practice |
| 8 | Discussion with AMHP manager to improve consistent use of paperwork and timely inputting of assessment onto LAS. | Leicestershire Adult Social Care |
| 8 | It is recommended that a ‘whole family’ approach is taken to deliver care when more than one clinical service is involved, to provide a systematic approach which includes risk assessment and the mitigation of risks. This should be in place within six months and monitored through the Caldicott systems of the Trust every three months. | Leicestershire Partnership NHS Trust |
| 8 | The Practice to focus on Carer identification as the patient concerned was known to be a Carer but was not formally added to the Practice Carer’s Register. | GP Practice |
| 9 | Leicestershire Adult Social Care will ensure that Occupational Therapists (OTs) are being reminded about the wider picture and potential safeguarding issues through the redeveloped ASC Safeguarding Core training. Lead Practitioners / Principal OT will also ensure that the key messages of learning from this DHR are specifically fed back to the OT Teams. | Leicestershire Adult Social Care |
| 9 | It is recommended that, where there are vulnerable adults living and caring for patients with serious mental illness, safeguarding adult advice should be accessed and, if necessary, an assessment and review performed and documented. Identification of patients in this situation should be made within three months and monitored through Trust safeguarding systems. | Leicestershire Partnership NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||