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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | 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). | Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board |
| 2 | 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. | Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board |
| 3 | 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. | Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board |
| 4 | 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. | Responsible Authorities Group |
| 5a | 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 | Stoke-on-Trent Safeguarding Children Board | (Staffordshire and Stoke-on-Trent) Child Sexual Abuse Forum |
| 5b | 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. | Stoke-on-Trent Safeguarding Children Board | (Staffordshire and Stoke-on-Trent) Child Sexual Abuse Forum |
| IPCC_R1 | 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. | Staffordshire Police |
| NPS_R15 | 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. | National Probation Service |
| SHA_R10 | 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. | Staffordshire Housing Association |
| SHA_R11 | 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. | Staffordshire Housing Association |
| SHA_R12 | 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. | Staffordshire Housing Association |
| SHA_R13 | 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. | Staffordshire Housing Association |
| SHA_R14 | 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. | Staffordshire Housing Association |
| SOTCC_R8 | 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. | Stoke-on-Trent City Council Early Intervention and Children’s Social Care |
| SOTCC_R9 | 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 | Stoke-on-Trent City Council Early Intervention and Children’s Social Care |
| StaffsPolice_R7 | 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. | Staffordshire Police |
| UHNM_R5 | Where a patient discloses Domestic Abuse the discharge letter to the GP will reflect the level of abuse and any actions taken. | University Hospitals of North Midlands NHS Trust |
| UHNM_R6 | 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. | University Hospitals of North Midlands NHS Trust |
| WMAS_R16 | 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. | West Midlands Ambulance Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||