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

Chorley and South Ribble review

CSP: Chorley and South Ribble Published: July 2023 Year of death: 2017 Extracted: 20 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

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.

Home Office classifications

26 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

20 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

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) ↗

Recommendation 1

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) ↗

Recommendation 1

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) ↗

Recommendation 1.1

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) ↗

Recommendation 1.2

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 2.1

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) ↗

Recommendation 2.2

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) ↗

Recommendation 2.3

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 4

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) ↗

Recommendation 5

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) ↗