Summary AI-generated
Verify against the full report at the source link
The review identified that both the victim and perpetrator had complex needs, including substance misuse, mental health issues, and childhood trauma, which contributed to chaotic lifestyles and inconsistent engagement with services. Opportunities were missed to assess their vulnerabilities under the Care Act and to explore domestic abuse more deeply, exacerbated by unsuitable housing conditions.
Extracted recommendations
20 recommendations pulled from the report · 6 matched to organisations in the index
Addressed to
CCG
Raise awareness regarding self-neglect and the identification and coding of adults at risk. Challenge the attitudes that drug users can sometimes be seen as “difficult” rather than vulnerable.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Care Foundation Trust
All staff to implement the SG006A policy
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Discover Drug and Alcohol Recovery Service
Following significant incidents relating to assault for consideration of vulnerable adults’ referral to support service users.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Teaching Hospitals NHS Trust
Accurate recording of Mental Health referrals, assessment, and interventions.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Chorley and South Ribble Community Safety Partnership
Chorley and South Ribble Community Safety Partnership (CSP) should be assured that the learning from this review is incorporated into the work currently being undertaken to ensure compliance with regulations to improve the conditions for residents accommodated in homes of multiple occupancy (HMOs).
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Chorley and South Ribble Community Safety Partnership
The Chorley and South Ribble CSP should review the success of providing drug and alcohol support services in HMOs and explore whether this type of provision can be provided in the future.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
CCG
Raise awareness regarding how dealing with incoming mail, referral processes and DNAs may need to be different for adults at risk.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Care Foundation Trust
Annual audit of compliance with recording routine enquiry on to the patient record on eCR
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Discover Drug and Alcohol Recovery Service
Requirement for improvement in liaison with mental health services where Service user is engaging with both services.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Teaching Hospitals NHS Trust
LTHTR to provide telephone numbers to the patient such as the Crisis Team and/ or the Samaritans and thus record that this has been completed.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Chorley and South Ribble Community Safety Partnership
The Chorley and South Ribble CSP should receive assurance that the requirements of the Care Act 2014 in relation to the assessment of people with complex care and support needs are understood by agencies and are being implemented.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Chorley and South Ribble Community Safety Partnership
The Chorley and South Ribble CSP should receive assurance that specialist substance misuse services are able to link into appropriate care and support services across the partnership area.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Care Foundation NHS Trust
The Lancashire Care Foundation NHS Trust (LCFT – now known as the Lancashire and South Cumbria NHS Foundation NHS Trust) should provide assurance to the Community Safety Partnership that clinical guidance in relation to the management of self-harm and suicide is followed in primary and secondary care.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Chorley and South Ribble Community Safety Partnership | local safeguarding partnership
The Chorley and South Ribble CSP should work with the local safeguarding partnership to ensure that developing awareness of childhood trauma and its impact in adult life is understood and that models of good practice are adopted in local services.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Eaves Lane Surgery
Medication and mail policies to be reviewed and case review completed regarding errors made.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Care Foundation Trust
The findings of the review will be disseminated to inform continued improvement of practice.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Discover Drug and Alcohol Recovery Service
Consider retention and discharge processes especially where service users are living in unsuitable accommodation.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Teaching Hospitals NHS Trust
Consider police referrals and record patient’s consent
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Lancashire Children’s Services | Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership
Lancashire Children’s Services and the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) should use learning from this review to develop practice in relation to supporting vulnerable parents when children are removed from their care.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Community Safety Partnership
The Community Safety Partnership should be assured that the local response to domestic abuse includes sufficient training and support to professionals across all agencies that enables the application of professional curiosity in relation to all aspects of domestic abuse and the ability to identify, assess and refer to specialist services.
Verified wording from the published review · Original review (PDF) ↗