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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review identified challenges in engaging individuals with complex needs, including substance misuse, mental health issues, and childhood trauma, who experienced chaotic lifestyles and unstable accommodation. Opportunities for comprehensive assessment and follow-up on self-harm and domestic abuse were missed.

Extracted recommendations

20 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	CCG
1	All staff to implement the SG006A policy	Lancashire Care Foundation Trust
1	Following significant incidents relating to assault for consideration of vulnerable adults’ appropriateness of referral to support service users.	Discover Drug and Alcohol Recovery Service
1	Accurate recording of Mental Health referrals, assessment, and interventions.	Lancashire Teaching Hospital NHS Trust
1.1	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).	Chorley and South Ribble Community Safety Partnership
1.2	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.	Chorley and South Ribble Community Safety Partnership
2	Raise awareness regarding how dealing with incoming mail, referral processes and DNAs may need to be different for adults at risk.	CCG
2	Annual audit of compliance with recording routine enquiry on to the patient record on eCR	Lancashire Care Foundation Trust
2	Requirement for improvement in liaison with mental health services where Service user is engaging with both services.	Discover Drug and Alcohol Recovery Service
2	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.	Lancashire Teaching Hospital NHS Trust
2.1	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.	Chorley and South Ribble Community Safety Partnership
2.2	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.	Chorley and South Ribble Community Safety Partnership
2.3	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.	Lancashire Care Foundation NHS Trust
3	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.	Chorley and South Ribble Community Safety Partnership \| local safeguarding partnership
3	Medication and mail policies to be reviewed and case review completed regarding errors made with supervision from CCG safeguarding team.	Eaves Lane Surgery
3	The findings of the review will be disseminated to inform continued improvement of practice.	Lancashire Care Foundation Trust
3	Consider retention and discharge processes especially where service users are living in unsuitable accommodation.	Discover Drug and Alcohol Recovery Service
3	Consider police referrals and record patient’s consent	Lancashire Teaching Hospital NHS Trust
4	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.	Lancashire Children’s Services \| Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP)
5	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.	Community Safety Partnership
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗