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

Kent review

CSP: Kent Published: July 2023 Year of death: 2012 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 report identifies inadequate understanding and response to domestic abuse by health agencies, inconsistent information sharing, and failure to challenge self-reported substance misuse. Challenges with transient lifestyles and aliases hindered risk assessment, alongside insufficient safeguarding for children.

Extracted recommendations

11 recommendations pulled from the report

#	Recommendation	Addressed to
1	All agencies should review their domestic abuse policies, procedures, risk assessment tools and training with a particular emphasis on: • Ensuring, as far as possible and appropriate, a common approach and language is used; this will aid communication and inter-agency information sharing. Coupled with an increased use of multi- agency training it will also facilitate sharing of best practice. • Ensuring that apparently isolated or infrequent incidents are viewed in their wider context. • Building front line staff skills and confidence in using a range of appropriate questions when conducting risk assessments, particularly with people who appear reluctant to engage. • As part of this review they should also remind staff that it is not always advisable or appropriate to ask the partner of someone who is known or believed to be a victim of domestic abuse to contact them on the agency’s behalf and should ensure this is reflected in their procedures and training.	All agencies
10	The Children’s Safeguarding Board should formally review the various children’s safeguarding concerns raised in this report and agree an appropriate action plan.	Children’s Safeguarding Board
11	Kent Children’s Specialist Services should review the timing of and the quality of information used to make the decision to close the cases referred to them by Probation in respect of Aaron and of Katie’s unborn twins and, if necessary, amend policies and/or guidance and/or staff training.	Kent Children’s Specialist Services
2	Within health, there appeared to be a particularly worrying lack of awareness or understanding about domestic abuse. Whilst the individual trusts and Katie’s GP surgery have taken some steps to address this there is a need to ensure this is firmly bedded in and that other providers, particularly individual GP practices, take on board the learning from this review. It is therefore recommended that: • The adequacy and efficacy of the Kent Surgery’s Domestic Abuse Policy and training should be independently assessed and, if appropriate, remedial action taken. • The adequacy and efficacy of the EKHUFT’s Domestic Abuse Policy and training of A&E staff should be independently assessed and, if appropriate, remedial action taken. • CCGs should encourage GP surgeries to review their domestic abuse policies and training and, where necessary, to take positive action to improve their understanding and practice. In this context, the learning from this review suggests that it will be particularly important to ensure that staff, whether clinicians or not, • are aware of their role/responsibilities with regard to identifying domestic abuse • are aware of the key signs to be aware of with regard to domestic abuse • and that clinicians feel able to initiate conversations and routinely enquire about potential abuse. • It is further recommended that a rolling audit of domestic abuse policies, practice and training across GP surgeries in Kent and Medway be undertaken with a view to identifying where further work is needed. It appears that there is no body that is statutorily responsible for this and, consequently, no funding is available. It also appears that were such an audit to be carried out and were deficiencies to be found, there is no body with the power to do any more than encourage GP surgeries to improve their understanding and practice in relation to identifying, preventing and supporting victims of domestic abuse. Such encouragement is important, and in many cases may be all that is needed. Nevertheless, the apparent lack of robust monitoring and control measures in relation to domestic abuse policy and practice within the existing governance and contract monitoring arrangements for GPs in England and Wales is a significant concern. It is recommended the Home Office review with this their colleagues in the Department of Health.	Kent Surgery \| EKHUFT \| CCGs \| Home Office \| Department of Health
3	Agencies and service providers should routinely ask services users for information about how best to contact them. This information should be checked at every appointment and for service users known to be at particular risk of failing to attend (because, for example, of their transient lifestyle, substance misuse or mental health problems) more than one means of communication should usually be used.	Agencies and service providers
4	The delivery of Alcohol Identification and Brief Advice Training should be expanded to Health and Social Care Providers (e.g. Children and Families, Probation Service, Midwifery, etc.).	Health and Social Care Providers
5	A comprehensive risk assessment should be made available by Probation staff to substance misuse providers as soon as the initial referral is made.	Probation \| substance misuse providers
6	The membership and processes of the Central Referral Unit (CRU) should be reviewed to ensure that mental health and substance misuse issues are properly managed and providers consulted appropriately.	Central Referral Unit (CRU)
7	Referral pathways between Court Diversion/Custody Liaison Service and DIP should be formalised and agreed. In particular, it will be important to ensure that appropriate information protocols are in place to support the correct diagnosis and treatment of individual service users.	Court Diversion/Custody Liaison Service \| DIP
8	Whilst drug and alcohol services welcome self-referral on the basis that the patient needs to be motivated to change, some patients need help taking the first step. It is therefore recommended that, with the patient’s consent, health professionals should wherever possible directly refer to drug and alcohol services in preference to or alongside asking the patient to self-refer, and follow up these referrals to monitor patient compliance.	health professionals \| drug and alcohol services
9	Reference has been made to the variable quality of the IMRs. Several did not follow the template or adequately address the terms of reference. This was particularly a problem within health. It is recommended, therefore, that the revised training and standard letters/support materials be implemented and its impact evaluated so that report authors, and managers signing of the IMRs better understand and meet their statutory responsibilities with regard to domestic homicide reviews.	All agencies
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗