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

Middlesbrough review

CSP: Middlesbrough Published: July 2023 Year of death: 2016 Extracted: 34 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 highlights systemic failures in multi-agency coordination, information sharing, and risk management for a vulnerable victim with complex needs. Key concerns include the ineffective response to coercive control and adolescent-to-parent violence, and the lack of assertive engagement strategies for victims disengaging from services.

Extracted recommendations

34 recommendations pulled from the report

#	Recommendation	Addressed to
19.1	Middlesbrough Community Safety Partnership should consider the feasibility of developing a coordinated case management approach to the care of vulnerable service users, who engage in risky behaviours, with full consideration of MARAC and other safeguarding processes.	Middlesbrough Community Safety Partnership
19.10	All staff of NPS Cleveland to be issued with a reminder of enforcement processes from the Head of Area in respect of Court Orders and Prison Licences and the need to seek approval from a manager if they wish to depart from the process in an attempt to achieve improved compliance.	National Probation Service
19.11	All staff of NPS Cleveland to be notified by the Head of Area that they must bring cases assessed as posing a medium risk of causing serious harm in the context of domestic violence to a manager for discussion when new information is received and/or when they are to re-assess the level of risk of causing serious harm.	National Probation Service
19.12	All staff of NPS Cleveland to be issued with guidance from the Head of Area about the need to pass information about possible new offences and breaches of Court Orders and Prison Licences to Cleveland Police Intelligence Hub.	National Probation Service
19.13	All staff of NPS Cleveland to be re-issued with guidance from the Head of Area as to when referrals to MARAC, MAPPA and Adult Safeguarding should be made.	National Probation Service
19.14	The development of a management of domestic abuse policy	South Tees Hospital NHS Foundation Trust
19.15	To audit A&E staff response to disclosures of domestic abuse	South Tees Hospital NHS Foundation Trust
19.16	GPs to input into the frequent attenders at Emergency Departments.	South Tees Clinical Commissioning Group
19.17	GPs to input into case management of patients with severe chronic dependence on alcohol.	South Tees Clinical Commissioning Group
19.18	Provide staff training around DASH Risk Identification Checklist and MARAC process	Middlesbrough Recovering Together
19.19	Ensure quality standards for case note recording and assessments are being met.	Middlesbrough Recovering Together
19.2	The Middlesbrough Community Safety Partnership should put in place processes by which it can gain assurance that: 1. MARAC actions are meaningful and contribute to the safety of the victim. 2. Agencies are held to account for the delivery of agreed actions. 3. Safety planning for victims of domestic abuse when offenders come towards the end of a sentence imposed by the criminal justice system can be made an integral part of the domestic abuse community response, for example by being incorporated into MARAC.	Middlesbrough Community Safety Partnership
19.20	Provide risk identification and management training for all members of staff in HILT team.	Middlesbrough Recovering Together
19.21	Ensure community teams are following up none attendance via the Did not Attend policy.	Middlesbrough Recovering Together
19.22	To raise the profile of Domestic Abuse in TEWV services through training to equip practitioners with information and tools on best practice when addressing concerns related to domestic abuse. This should cover topics such as the Toxic Trio and the Safe Lives DASH (Domestic Abuse, Stalking and Harassment and Honour Based violence) 2009) risk assessment.	Tees Esk and Wear Valleys NHS Foundation Trust
19.23	To provide information and guidance for information sharing with other agencies when it is vital in the best interests of people who are experiencing domestic abuse. This should include when confidentiality and consent issues arise to reduce the impact of further risk of abuse or harm.	Tees Esk and Wear Valleys NHS Foundation Trust
19.24	To have a clear escalation process when risks of domestic abuse are identified which identifies where support can be accessed that is inclusive of the MARAC arrangements.	Tees Esk and Wear Valleys NHS Foundation Trust
19.25	The Trust to adopt a more effective approach for practitioners to readily access information required for their assessments where MARAC alerts have been placed on the system.	Tees Esk and Wear Valleys NHS Foundation Trust
19.26	To have a recognised tool in the Trust electronic notes that capture safeguarding concerns, the consideration given to the risk and the justifications for decision making. This should take into account a person’s capacity to understand and serve a purpose for formulating a decision for safeguarding.	Tees Esk and Wear Valleys NHS Foundation Trust
19.27	Staff should attend domestic abuse refresher training to ensure they have up to date knowledge and understanding of the issues relating to domestic violence.	Adult Social Care
19.28	All staff should attend Care Act 2014 refresher training to ensure they are fully up to date with their duties and responsibilities under this legislation.	Adult Social Care
19.29	Staff should attend refresher training on safeguarding and the referral criteria to ensure they are up to date with current practice and procedures.	Adult Social Care
19.3	The Middlesbrough Community Safety Partnership should consider adopting an appropriate evidence based model for supporting victims of domestic abuse with complex needs [mental health/substance misuse], such as the Alcohol Concern Blue Light Project methodology and training materials.	Middlesbrough Community Safety Partnership
19.30	Female victims of domestic abuse should be given the opportunity to be interviewed/assessed by a female social worker.	Adult Social Care
19.31	When individuals are signposted to other agencies there should be effective systems in place to ensure timely feedback/follow up on outcomes.	Adult Social Care
19.32	Social work staff require in house comprehensive initial and refresher training on recording skills to ensure a full recording of events is completed for every contact.	Adult Social Care
19.33	In house training on information sharing should be provided to all staff.	Adult Social Care
19.34	Cases that involve repeat contacts in respect of vulnerable/at risk individuals but currently do not progress from the Adult Access point require an agreed threshold point where the case requires allocation to a relevant social work team for a more in-depth assessment of the situation.	Adult Social Care
19.4	Middlesbrough Community Safety Partnership should circulate the Home Office Information booklet on Adolescent to Parent Violence and Abuse [APVA] to partner agencies and seek assurances they have pathways in place that ensure the appropriate response is delivered when APVA is recognised. Partner agencies should circulate the information to their staff and ensure it is included on new and refresher training.	Middlesbrough Community Safety Partnership
19.5	The Middlesbrough Community Safety Partnership should seek assurance from commissioners that access to historic records is considered as part of the continuity arrangements when commissioning new services.	Middlesbrough Community Safety Partnership
19.6	PC *******is spoken to and debriefed around actions when attending the incident on 11th December 2013	Cleveland Police
19.7	The Probation Service Individual Management Review should be shared with the probation officer and the three managers responsible for supervision during the period of the perpetrator’s contact with the Probation Service so that its findings can influence and improve future practice relating to risk assessment, enforcement and seeking guidance from a manager.	National Probation Service
19.8	The probation officer’s present manager to conduct a “deep dive” assessment of ten of the cases which the probation officer managed at Middlesbrough Probation Office to seek assurance about enforcement and risk assessment practice and the extent of case referral to a manager for advice.	National Probation Service
19.9	All staff of NPS Cleveland to be issued with a reminder from the Head of Area that all contacts and telephone calls must be recorded on Delius within 24 hours.	National Probation Service
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗