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 Ribble review
CSP: South Ribble
Published: July 2023
Year of death: 2019
Extracted: 11 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 found that agencies primarily focused on the victim's complex health and social care needs, often attributing alleged abuse to carer breakdown. Direct action to address domestic abuse allegations was lacking, with insufficient multi-agency coordination and specialist input.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 17.1.1 | Agencies contributing to the review should provide South Ribble Community Safety Partnership with evidence that their staff have been provided with information in relation to the link between domestic abuse and suicide risk. | Agencies contributing to the review |
| 17.1.2 | Agencies contributing to the review should provide South Ribble Community Safety Partnership with detailed information on their plans to train staff in the coercion and control elements of domestic abuse. | Agencies contributing to the review |
| 17.1.3 | The learning from this review should be shared with Lancashire Safeguarding Adult Board. | Lancashire Safeguarding Adult Board |
| ASC.1 | Adult Social Care should review its policy and processes in relation to cases where domestic abuse is disclosed and produce a new pathway and guidance for staff dealing with such cases. The introduction of the new pathway should be supported by case audit to ensure that appropriate progress in implementing the pathway is maintained. | Adult Social Care |
| CCG.1 | Robust use of Carer’s Register and “Think Family” approach. Practices to be reminded about the importance of coding of medical records to clearly identify vulnerabilities. Coding of records will be undertaken in a staged approach with priority patients coded. | CCG |
| CCG.2 | Domestic abuse enquiry, use of professional curiosity. Routine enquiry about domestic abuse, in a safe environment to be carried out by clinicians in primary care as per NICE Guidance PH50. Utilise key messages from a recent DHR to avoid duplication of efforts. | CCG |
| CCG.3 | Management of complex cases and use of multi-disciplinary meetings. Access to case supervision from GP Lead/ CCG / LSCFT safeguarding professionals. LSCFT Safeguarding team requested to provide presentation update to primary care teams regarding their role. | CCG |
| CCG.4 | Guidance for non-attendance where vulnerability is a feature. Utilise key messages and learning from previous DHR Adult E. | CCG |
| CCG.5 | Safety of practitioners when lone working. Use of Flag or Special Alerts in medical records to be embedded across primary care to identify risk factors. Circulation of lone working policy to remind practices regarding safety of practitioners and information sharing. | CCG |
| CCG.6 | Effective responses to communication and information sharing between Primary Care and gtd via use of special patient notes. Primary Care and gtd to work together to ensure that gtd have access to all relevant information where appropriate to support information sharing and response to safeguarding and domestic abuse. | CCG |
| VS.1 | Victim Support will review its policy and processes to ensure that where appropriate a referrer is notified when a victim declines support. | Victim Support |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||