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.

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

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

40 tags

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

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - depression
  • Victim - psychosis
  • Victim - suicidal thoughts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - present at homicide (including adult children)
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy 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

34 recommendations pulled from the report · 24 matched to organisations in the index

Recommendation 19.1

Addressed to Middlesbrough Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.2

Addressed to Middlesbrough Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.3

Addressed to Middlesbrough Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.4

Addressed to Middlesbrough Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.5

Addressed to Middlesbrough Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.6

Addressed to Cleveland Police

PC *******is spoken to and debriefed around actions when attending the incident on 11th December 2013

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.7

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.8

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.9

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.10

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.11

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.12

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.13

Addressed to National Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.17

Addressed to South Tees Clinical Commissioning Group

GPs to input into case management of patients with severe chronic dependence on alcohol.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.20

Addressed to Middlesbrough Recovering Together

Provide risk identification and management training for all members of staff in HILT team.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.21

Addressed to Middlesbrough Recovering Together

Ensure community teams are following up none attendance via the Did not Attend policy.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.22

Addressed to Tees Esk and Wear Valleys NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.23

Addressed to Tees Esk and Wear Valleys NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.24

Addressed to Tees Esk and Wear Valleys NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.25

Addressed to Tees Esk and Wear Valleys NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.26

Addressed to Tees Esk and Wear Valleys NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.27

Addressed to Adult Social Care

Staff should attend domestic abuse refresher training to ensure they have up to date knowledge and understanding of the issues relating to domestic violence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.28

Addressed to Adult Social Care

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.29

Addressed to Adult Social Care

Staff should attend refresher training on safeguarding and the referral criteria to ensure they are up to date with current practice and procedures.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.30

Addressed to Adult Social Care

Female victims of domestic abuse should be given the opportunity to be interviewed/assessed by a female social worker.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.31

Addressed to Adult Social Care

When individuals are signposted to other agencies there should be effective systems in place to ensure timely feedback/follow up on outcomes.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.32

Addressed to Adult Social Care

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19.34

Addressed to Adult Social Care

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.

Verified wording from the published review · Original review (PDF) ↗