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

Stoke-on-Trent review

CSP: Stoke-on-Trent Published: July 2023 Year of death: 2015 Extracted: 19 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 identified systemic failures in multi-agency responses to domestic abuse, including inadequate risk assessment, poor information sharing, and missed opportunities to intervene with the victim and the perpetrator. Agencies struggled to safeguard the victim who did not seek or support professional intervention, and to recognise and respond to child sexual exploitation risks.

Home Office classifications

27 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - post traumatic stress disorder (ptsd)
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - technology systems 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

19 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

Addressed to Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board

The Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should seek assurances that agencies supporting victims of domestic abuse are fully utilising existing tools and powers to support victims of domestic abuse, including Domestic Violence Protection Notices/Orders and the “right to know” under the Domestic Violence Disclosure Scheme (Clare’s Law).

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

Recommendation 2

Addressed to Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board

Upon the enactment of the current Domestic Abuse Bill into law, the Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should widely promote the provisions of the new Act, and should seek assurances that agencies supporting victims of domestic abuse have in place plans to fully utilise the new tools and powers within the Act.

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

Recommendation 3

Addressed to Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board

The Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should ensure that all domestic abuse support service providers across Stoke-on-Trent and Staffordshire are made aware of this review and its findings, and seek assurances from the providers that their case closure policy is robust and in line with national guidance.

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

Recommendation 4

Addressed to Responsible Authorities Group

The Responsible Authorities Group request that the implementation of the recommendations from the review of MARAC effectiveness be taken forward across the force area, and that the local approach for Stoke-on-Trent be developed, agreed and implemented as a matter of urgency, in consultation with the Responsible Authorities Group.

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

Recommendation 5a

Addressed to Stoke-on-Trent Safeguarding Children Board | (Staffordshire and Stoke-on-Trent) Child Sexual Abuse Forum

seek reassurance from partners that their processes and training provision enable all staff to effectively identify and respond to children at risk of Child Sexual Exploitation, and

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

Recommendation 5b

Addressed to Stoke-on-Trent Safeguarding Children Board | (Staffordshire and Stoke-on-Trent) Child Sexual Abuse Forum

reinforce the message that young people do not become any less vulnerable to exploitation as they approach adulthood and that at any age they should not be viewed as consenting to their own exploitation.

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

Recommendation IPCC_R1

Addressed to Staffordshire Police

That in conjunction with upgrades to their IT system, Staffordshire Police considers operating a process in the Control Room to proactively audit un-resourced incidents and to demonstrate that, where a response has been delayed beyond the target time limit, the incident has been regularly reviewed by a supervisor.

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

Recommendation NPS_R15

Addressed to National Probation Service

Where there are known issues of domestic violence and agency involvement there should always be an explicit victim protection plan in order to ensure all possible preventatives steps have been taken to avoid future harm.

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

Recommendation SHA_R10

Addressed to Staffordshire Housing Association

Domestic abuse awareness training and practical guidance on how to deal with such issues is delivered for all customer facing staff within Staffordshire Housing Association.

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

Recommendation SHA_R11

Addressed to Staffordshire Housing Association

Staffordshire Housing Association to review its ASB and Domestic Abuse policies and consider if clearer guidance can be provided if it is believed that domestic violence or abuse is a cause of the ASB issue reported. Consider should also be given whether an information exchange request should be submitted for all reports of violence or domestic abuse. SHA will consider if reports of violence or domestic abuse, and whether domestic abuse should be reported to Arch’s domestic abuse services.

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

Recommendation SHA_R12

Addressed to Staffordshire Housing Association

Ensure that Staffordshire Housing Association`s ASB recording systems are able to easily recognise infrequent, but repeat incidents of ASB to ensure that appropriate action is taken.

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

Recommendation SHA_R13

Addressed to Staffordshire Housing Association

Staffordshire Housing Association to consider agreeing a process when domestic abuse is reported via a third party who wishes to remain anonymous, and in cases where the victim and perpetrator do not report the issue, engage with services or consent for action to be taken.

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

Recommendation SHA_R14

Addressed to Staffordshire Housing Association

Staffordshire Housing Association to improve information sharing across the group, specifically with Arch domestic abuse services, in situations where services are dealing with the same customers who may be at risk.

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

Recommendation SOTCC_R8

Addressed to Stoke-on-Trent City Council Early Intervention and Children’s Social Care

Briefing to SRT to ensure that all referrals relating to CSE are considered in relation to risk and vulnerability and are not to be determined by age. This is to ensure that all children are offered the opportunity to engage in services to make them safer.

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

Recommendation SOTCC_R9

Addressed to Stoke-on-Trent City Council Early Intervention and Children’s Social Care

Disseminate message through CSE training that a child is a child until they are 18 years and should be offered an assessment as this may provide a smooth transition into accessing services for adults

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

Recommendation StaffsPolice_R7

Addressed to Staffordshire Police

Staffordshire Police to utilise location markers for all the known residential addresses for each person in relationships giving cause for concern of Domestic Violence / Abuse.

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

Recommendation UHNM_R5

Addressed to University Hospitals of North Midlands NHS Trust

Where a patient discloses Domestic Abuse the discharge letter to the GP will reflect the level of abuse and any actions taken.

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

Recommendation UHNM_R6

Addressed to University Hospitals of North Midlands NHS Trust

UHNM to review, with the Principal Officer for MASH, the process for the sharing of patient details with external agencies when the patient does not consent.

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

Recommendation WMAS_R16

Addressed to West Midlands Ambulance Service

West Midlands Ambulance Service Safeguarding Manager to request review of case by Emergency Operations Centre Clinical Manager to review and audit original call and also a review of information sharing with other emergency services where West Midlands Ambulance Service have been the sole agency to receive the call - findings from this to be fed back to safeguarding manager.

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