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

South Cambridgeshire review

CSP: South Cambridgeshire Published: July 2023 Year of death: 2018 Extracted: 12 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

Agencies missed opportunities to identify and respond to coercive control and domestic abuse, often attributing the victim's vulnerabilities and missed appointments to her alcohol misuse rather than exploring potential manipulation by the perpetrator. There was a lack of professional curiosity and integrated multi-agency working.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
1	Consider running reports through Systm1 on patients that have failed to attend more than 3 appointments in 3 months and contrast this to any identified vulnerabilities to compile a report and take appropriate actions.	GP Practices
10	To publish and disseminate the Home-Link scheme and lettings policy to partner agencies, together with the referral mechanism for the Residents at Risk group and the Problem-Solving Group.	South Cambridgeshire District Council
11	All agencies to review there on line applications forms to make sure that they are in an easy to read format and/or that there is a reference for adults with additional needs, i.e. dyslexia, signposting them to where they can gain the additional support required to complete the relevant forms.	All agencies
12	A vulnerability scoring system is to be looked at to provide consistency among GP practices in relation to the assessment of their most vulnerable patients for inclusion onto MDT discussions. At the moment ‘vulnerability’ is multifactorial and will vary hugely in nuance and severity between individual patients (incorporating physical illness factors, presence or absence of learning disability, drugs / alcohol factors, severity of mental illness, social inclusion, risk of coercion / control). There are currently no formal ‘vulnerability’ scorings systems available. Patients with a particular known risk factor (e.g. Alcohol misuse) could then be asked a list of screening questions to determine their ‘vulnerability score’ and whether a more formal discussion at an MDT might be beneficial.	National Recommendation
2	Follow up of persistent non-attenders or those considered at risk, not just by text as currently occurs, but also by phone. Consider telephone follow ups on vulnerable patients such as the victim when they do not attend their appointments. This is currently the recommended protocol when children do not attend their appointments.	GP Practices
3	Vulnerable patients should be booked in directly by the clinician at the end of the appointment, rather than being sent to book a routine appointment at reception. A ‘task to self’ could then be scheduled by the clinician booking the appointment to check attendance.	GP Practices
4	Domestic abuse training to be provided and attended by the GP Practice, including all the GPs, Registered Practitioners and Administrators with patient facing contact. The training is to include coercive and controlling behaviour within a relationship and the importance of GP’s seeing patients on their own where they are able to give them the space and opportunity to identify any issues or concerns.	GP Practices
5	Inclusion’s domestic abuse policy is to be updated to include coercion and control. Their domestic abuse training is also to be updated to provide their staff with a clear understanding of what coercion and control is and the impact this has on individuals. The impact of drug and alcohol dependency and people with complex needs is to be highlighted, looking at how these needs can be manipulated by partners or husbands as a means to control. The training is to include this DHR as a case study to reinforce the need for professionals to ask questions of their clients surrounding potential abuse.	Inclusion
6	This review is to be highlighted in training within the Ambulance service regarding instances of possible strangulation and the necessity of reporting these to the police.	East of England Ambulance Service
7	The Cambridgeshire and Peterborough Safeguarding Adults Board to review their training package surrounding self-neglect under the Care Act 2014 to include those with complex needs, including alcohol and drug misuse and the impact that these addictions have on their decision making abilities. This is to include decision making and ‘lifestyle choices’ and fluctuating capacity. To also review their MARM processes to include adults with alcohol dependency issues.	The Cambridgeshire and Peterborough Safeguarding Adults Board
8	To consider reviewing and updating the Violence against Women and Girls Strategic needs assessment 2017, to identify issues surrounding alcohol and drug dependency and the impact on victims and to develop multi agency practices and training. The training should look at a whole systems approach in relation to adults with complex needs, including alcohol and/or drug dependency and the impact that these needs have on the adults vulnerability and how these needs can be manipulated by partners and husbands within relationships.	Cambridgeshire and Peterborough Strategic Domestic Abuse and Sexual Violence Board
9	The Board should promote guidance available to friends, family or colleagues of someone they suspect is in an abusive or unhealthy relationship on how they could help them in an informed, supportive and non-judgmental way to identify possible options and solutions.	Cambridgeshire and Peterborough Strategic Domestic Abuse and Sexual Violence Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗