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
Wiltshire review
CSP: Wiltshire
Published: July 2023
Extracted: 76 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 highlights systemic failures in identifying and responding to domestic abuse, particularly concerning the victim's childhood exposure, vulnerability, and the age gap in her relationship. It notes poor inter-agency communication, inadequate risk assessment, and inconsistent support for her complex needs including mental health, housing, and substance misuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| • | All CAMHS staff will recognise that domestic abuse experienced by young people is a Safeguarding issue. This includes the effect of perpetrators using power and control after a relationship has allegedly ended. | Oxford Health NHS Foundation Trust |
| • | CAMHS clinicians should routinely use the assessment triangle to aid the understanding of the needs of young people with complex issues. | Oxford Health NHS Foundation Trust |
| • | The NNSC in CAMHS will explore training for all CAMHS clinicians about domestic abuse in young people can be delivered. | Oxford Health NHS Foundation Trust |
| • | The NNSC for CAMHS in Wiltshire will explore with the Service Managers and Team Managers the use of timescales in supervision to determine when an issue needs to be escalated to avoid drift | Oxford Health NHS Foundation Trust |
| • | Cases of this nature should evidence actual or attempted visits to the family home. | Wiltshire Council Education Welfare Service |
| • | EWO’s are required to utilise the Common Assessment Framework approach to all cases where there is evidence of poor engagement and vulnerabilities in families. | Wiltshire Council Early Help |
| • | EWO’s to use a variety of methods to engage young people and their families, including working with/alongside schools | Wiltshire Council Education Welfare Service |
| • | EWO’s to ensure appropriate consideration and discussion with schools regarding referral to MASH | Wiltshire Council Early Help |
| • | Cases to remain within the legal system where this has commenced | Wiltshire Council Early Help |
| • | Clear management oversight in NEET PA cases | Wiltshire Council Early Help |
| • | NEET PA cases to have an assessment and action plan | Wiltshire Council Early Help |
| • | Case recording are need to identify what this means and analytical rather than descriptive | Wiltshire Council Early Help | Youth Offending Team |
| • | Pathway for homeless young people needs to be clear | Wiltshire Council Early Help | Youth Offending Team | Wiltshire Council Housing Options | Wiltshire Council Children’s Social Care |
| • | CAF / TAC approach to all young people needs to be more joined up with a single lead to ensure that actions are followed through and monitored. Information needs to be appropriately shared but in complex cases with many professionals we need to ensure that information is acted up and appropriate referrals are made to move things forward. | Wiltshire Council Early Help | Youth Offending Team | Child and Adolescent Mental Health Services |
| • | Better coordination at the point of turning 18. This would enable a smoother transition to adulthood and ensure that things to do get missed. | Youth Offending Team | Wiltshire Council Early Help | Child and Adolescent Mental Health Services |
| • | Improve professionals understanding of complex personal relationships and the impact of this on individuals. | Wiltshire Council Early Help | Youth Offending Team | Multi Agency Risk Assessment Conference MARAC |
| • | Disseminate Swindon and Wiltshire Domestic abuse reduction strategy to be disseminated and implemented within Early Help Service. | Wiltshire Council Early Help | Youth Offending Team |
| • | All Offender Managers should complete an Initial Sentence Plan in a timely manner and in accordance with National Policy- within 10 working days of sentence and ensure the document is locked and marked as completed. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | All Offender Managers should undertake an OASys review following a significant event to review the risk of serious harm | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | All facilitators of programmes should ensure that every programme session attended by an offender should be documented via Ndelius. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | All interventions following sentence should be started promptly in order for offence focused work to be undertaken to start reducing the risk of serious harm and risk of re-offending | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | Any areas that have been identified as linked to risk of serious harm or re-offending for an offender should be prioritized within supervision sessions. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | The National Probation Service will remind Offender Managers of the importance of undertaking home visits, especially when there are concerns about domestic abuse. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | Line managers should be actively involved in the management of cases, particularly when there are concerns in regards to domestic abuse and this should be clearly recorded via Ndelius. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | The National Probation Service will ensure that Offender Managers have a clear understanding of the MARAC referral process via team meetings, staff development hours and individual supervision. | National Probation Service-MARAC Lead |
| • | The National Probation Service will continue to promote the importance of building strong working relationships with external agencies through individual supervision, staff development hours, team meetings and any relevant training events. | National Probation Services-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | The National Probation Service will work closely with the Community Rehabilitation Company to discuss report proposals where relevant and necessary. | National Probation Services-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | All interventions following sentence should be started promptly in order for offence focused work to be undertaken to start reducing the risk of serious harm and risk of re-offending | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | All Offender Managers should complete an Initial Sentence Plan in a timely manner and in accordance with National Policy- within 10 working days of sentence. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | Any areas that have been identified as linked to risk of serious harm or re-offending for an offender should be prioritised within supervision sessions. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | The National Probation Service will continue to promote the importance of building strong working relationships with external agencies through individual supervision, staff development hours, team meetings and any relevant training events. | National Probation Services-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | The National Probation Service will work closely with the Community Rehabilitation Company to discuss report proposals where relevant and necessary. | National Probation Services-Middle Managers-Gloucestershire and Wiltshire LDU |
| • | Ensure all SOPs within AWP contain explicit reference to Domestic Abuse and Safeguarding and the actions required. By AWP Safeguarding Team by 31 July 2016 | AWP Safeguarding team |
| • | For the team managing the RiO template documents to formally consider producing a new standard “Discharge to GP” editable letter in RiO that references a “Crisis and Contingency-type” plan. By AWP Clinical Systems Manager by 30 June 2016 | Wiltshire Quality Director and Clinical Systems Manager. |
| • | For staff to be advised to use the term “signposted” rather than “referred” when discussing the outcome of discussions about Turning Point and LIFT /IAPT which require the service user to be proactive to access such services. By Service Managers by 31 May 2016. | Wiltshire Quality Director |
| • | For AWP staff to be reminded that Ourspace contains a Domestic Abuse Library containing resources for identifying and managing the risk of domestic abuse. By Service Managers by 31 May 2016 | Wiltshire Quality Director |
| • | The history and chronology of involvement should always be considered within assessments as a predictor of capacity to change and parenting capacity in general. | Children’s Social Care |
| • | Joint assessments with housing should be undertaken whenever a child/young person is at risk of homelessness. During such assessments, the wider needs of the child/young person should be considered and the homeless issue should not overshadow any other concerns highlighted. | Children’s Social Care |
| • | Young people who are in domestically abusive relationships and are subject to physical harm should be considered under our child protection procedures. | Children’s Social Care |
| • | Children’s Social Care should refer vulnerable young people moving into adulthood to adult safeguarding/social care as routine practice | Children’s Social Care |
| • | Action is taken in relation to the individual social workers practice. | Children’s Social Care |
| • | The Child Sexual Exploitation (CSE) Tool to be considered when working with vulnerable young people particularly where this is an age gap in a relationship. This identifies risk factors, protective factors and level of risk. | Children’s Social Care |
| • | Training programme for all relevant clinical staff | Royal United Hospital, Bath |
| • | Continue funding for IDVA project at the RUH | Wiltshire Clinical Commissioning Group |
| • | Risk assessment and process in priority areas as above | Royal United Hospital, Bath |
| • | Safeguarding | South Western Ambulance Service NHS Trust |
| • | Identify a lead person in the service to attend regular probation meetings to discuss the clients placed on orders with their respective probation case manager/offender manager | Wiltshire Substance Misuse Services |
| • | Meeting with probation Service to review treatment options and policy of faltering engagement with a view of managing non-compliant clients and revoking court orders. | Wiltshire Substance Misuse Services |
| • | Domestic Abuse Training for Recovery Worker arranged for 01/06/15 | Wiltshire Substance Misuse Services |
| • | Recommendation for an independent review to be undertaken for the DACC. | Wiltshire Domestic Abuse Conference Call (DACC) |
| 1 | From the 01/01/2016 Horizon, the witness care unit at Wiltshire Police telephone victims of domestic abuse that have been identified as standard risk of harm, and signpost them to appropriate support agencies as required. | Wiltshire Police |
| 2 | Training of front line officers on the new coercive and controlling behaviour law | Wiltshire police |
| 3. | DAIT/MASH to identify potential victims of child sexual exploitation in domestic abuse cases and make a referral to the CSE team. | Wiltshire police |
| 4. | Develop a system in order that front line officers can easily identify serial victims and perpetrators when they attend domestic abuse incidents. | Wiltshire Police |
| Add domestic violenc | Add domestic violence to agenda for Local Education Group meeting | White Horse Surgery |
| All BGSW CRC staff ( | All BGSW CRC staff (when Court appearances are known) to continue to discuss cases with the NPS at the pre-sentence stage. NPS to also be pro-active in discussing current cases. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company | National Probation Service |
| All BGSW CRC staff t | All BGSW CRC staff to continue to build and develop effective working relationships with other agencies. What’s agreed and put in place to clearly be recorded on the case recording system. Offender Manager’s to inform their Line Manager’s if they are dissatisfied with the response/involvement from a specific agency. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| All Housing Options | All Housing Options staff should ensure that any client who discloses Domestic Abuse should ensure a DASH Risk Assessment is completed to assess the risk. | Wiltshire Council Housing Options |
| All housing staff sh | All housing staff should attend annual safeguarding training – already actioned and in place. | Wiltshire Council |
| All staff to attend | All staff to attend Domestic Abuse training and made aware of the agencies that they can refer families too as well as an understanding of the MARAC process | Wiltshire Council Housing Options |
| Appropriate enforcem | Appropriate enforcement action to be undertaken and use of behaviour contracts to be considered by all Offender Manager’s within BGSW CRC. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| BGSW CRC staff will | BGSW CRC staff will ensure all requirements are started in a timely manner (or sequenced as appropriate). In addition, staff will continue to monitor key issues and undertake structured work to address the areas identified in the Risk Management and Sentence Plan. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| BGSW CRC to consider | BGSW CRC to consider the timing of cases being re-allocated. A 3-way to be prioritised if a re-allocation can not be avoided. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| BGSW CRC to consiste | BGSW CRC to consistently provide intervention and support for female service users. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| BGSW CRC to continue | BGSW CRC to continue to effectively manage domestic abuse cases through adhering to the Operating Model guidelines; reflective supervision being prioritised and continuing to work in close liaison with other agencies. | Bristol Gloucester Swindon and Wiltshire Community Rehabilitation Company |
| Closer working with | Closer working with Social Services | The Avenue Surgery |
| Closer working with | Closer working with representatives of Splitz Support services to develop appropriate policies | The Avenue Surgery |
| Develop robust train | Develop robust training log | The Avenue Surgery |
| Develop systematic w | Develop systematic way of flagging suspected victims of domestic violence/abuse in clinical GP systems | Wits CCG |
| Improve attendance f | Improve attendance from Drug and Alcohol Services and Mental Health Services | Wiltshire Multi Agency Risk Assessment Conference (MARAC) |
| In circumstances whe | In circumstances where a tenant is identified as a victim of domestic abuse, and is already known to be in receipt of DA Specialist Support a discussion will be had with that specialise DA agency to determine who is the lead professional co-ordinating support to the individual/family | Curo Housing |
| Raise profile of dom | Raise profile of domestic violence/abuse and Share the learning from this domestic homicide review across practices | Wilts CCG |
| Review safeguarding | Review safeguarding adults policy with respect to domestic violence | Wilts CCG |
| Social Care practice | Social Care practice improvements Developed Implemented 2013 - completed | Children’s Social Care |
| Support for MARAC to | Support for MARAC to be placed on a statutory footing | Wiltshire Multi Agency Risk Assessment Conference (MARAC) |
| There there is a kno | In the notes leads to add the wording such as ‘do not ring home’ or ‘please see Head of House before making contact with parents would suffice. | Kingdown School |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||