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: 77 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 concerns regarding intergenerational domestic abuse, the victim's vulnerability, self-harm, and substance misuse. It highlighted a fragmented multi-agency response, poor transition between child and adult services, and housing instability.

Home Office classifications

51 tags

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

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - neurodiverse condition diagnosis
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - school recommendations
  • DHR process - employer recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk 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

77 recommendations pulled from the report · 13 matched to organisations in the index

Recommendation R1

Addressed to Oxford Health NHS Foundation Trust

Domestic Abuse will always be discussed with the Named Nurse Safeguarding Children within CAMHS

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

Recommendation R2

Addressed to Oxford Health NHS Foundation Trust

Domestic Abuse will continue to form part of safeguarding training and supervision which all CAMHS staff are required to attend as part of their mandatory training

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

Recommendation R3

Addressed to Oxford Health NHS Foundation Trust

The use of the assessment triangle will be actively promoted as part of Safeguarding Children case discussion, training and supervision by CAMHS staff.

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

Recommendation R4

Addressed to 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.

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

Recommendation R5

Addressed to 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

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

Recommendation R6

Addressed to EWS

EWO’s are to be encouraged to undertake home visits in instances of poor or non engagement of family or young person

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

Recommendation R7

Addressed to Early Help

EWO’s to build into their practice on a routine basis completion and involvement in CAF process and TAC reviews.

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

Recommendation R11

Addressed to Wiltshire Council

All housing staff should attend annual safeguarding training – already actioned and in place.

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

Recommendation R12

Addressed to Wiltshire Council - Housing

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

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

Recommendation R13

Addressed to Wiltshire Council – Housing

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.

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

Recommendation R14

Addressed to Early Help

Early Help Team Leaders to ensure that supervision procedure is implemented and cases are discussed regularly including risk and vulnerability factors.

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

Recommendation R20

Addressed to Early Help | YOT | Housing | Social Care

YP homelessness protocol to be reviewed and rewritten to ensure that there are clear pathways for homeless young people.

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

Recommendation R21

Addressed to Early Help | YOT | Housing | Social Care

Document to ensure that agencies are clear about roles and responsibilities

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

Recommendation R22

Addressed to Early Help | YOT

Services to 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.

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

Recommendation R24

Addressed to YOT | Early Help | CAMHS

Professionals to consider what services can step up when young person reaches 18 but does not meet threshold for adult mental health services.

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

Recommendation R25

Addressed to Early Help | YOT

All staff to receive training on healthy relationships including co dependence, violent and manipulative relationships. An understanding of the complexities of working with young people within their relationships

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

Recommendation R27

Addressed to Early Help | YOT

Disseminate Swindon and Wiltshire Domestic abuse reduction strategy to be disseminated and implemented within Early Help Service.

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

Recommendation R28

Addressed to Kingdown School

There should be a ‘flag’ of some sort on a child’s electronic file so that staff are aware not to contact home.

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

Recommendation R29

Addressed to 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 and ensure the document is locked and marked as completed.

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

Recommendation R30

Addressed to 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

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

Recommendation R31

Addressed to 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.

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

Recommendation R32

Addressed to 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

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

Recommendation R33

Addressed to 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.

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

Recommendation R34

Addressed to 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.

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

Recommendation R35

Addressed to 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.

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

Recommendation R36

Addressed to 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.

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

Recommendation R37

Addressed to 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.

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

Recommendation R38

Addressed to National Probation Service-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.

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

Recommendation R39

Addressed to AWP Safeguarding Team

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

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

Recommendation R40

Addressed to Wiltshire Quality Director and Clinical Systems Manager.

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

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

Recommendation R41

Addressed to Wiltshire Quality Director

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.

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

Recommendation R42

Addressed to 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

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

Recommendation R46

Addressed to White Horse Surgery

Discuss with Dr Beale who is arranging the Mental Health orientated meeting and invite outside agencies for input

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

Recommendation R47

Addressed to Wilts CCG

Develop model adult safeguarding policy with clear reference to domestic violence which practices can adopt

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

Recommendation R50

Addressed to Wits CCG

Discuss development of icon specific to domestic violence/abuse to alert practice staff to presence of real/suspected domestic violence

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

Recommendation R51

Addressed to Children’s Social Care

The history and chronology of involvement should always be considered within assessments as a predictor of capacity to change and parenting capacity in general.

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

Recommendation R52

Addressed to 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.

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

Recommendation R53

Addressed to 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.

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

Recommendation R54

Addressed to Children’s Social Care

Children’s Social Care should refer vulnerable young people moving into adulthood to adult safeguarding/social care as routine practice

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

Recommendation R56

Addressed to 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.

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

Recommendation R57

Addressed to Wiltshire Police

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.

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

Recommendation R59

Addressed to Wiltshire Police

DAIT/MASH to identify potential victims of child sexual exploitation in domestic abuse cases and make a referral to the CSE team.

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

Recommendation R60

Addressed to Wiltshire Police

Develop a system in order that front line officers can easily identify serial victims and perpetrators when they attend domestic abuse incidents.

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

Recommendation R64

Addressed to Ambulance Service

To review internal process for sharing safeguarding information with external agencies other than Social Care.

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

Recommendation R67

Addressed to Wiltshire Substance Misuse Service

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

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

Recommendation R68

Addressed to Wiltshire Substance Misuse Service

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.

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

Recommendation R70

Addressed to BGSW CRC

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.

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

Recommendation R71

Addressed to BGSW CRC and NPS

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.

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

Recommendation R72

Addressed to BGSW CRC

Appropriate enforcement action to be undertaken and use of behaviour contracts to be considered by all Offender Manager’s within BGSW CRC.

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

Recommendation R74

Addressed to BGSW CRC

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.

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

Recommendation R75

Addressed to BGSW CRC and NPS

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.

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

Recommendation R76

Addressed to BGSW CRC

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.

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

Recommendation R77

Addressed to Curo Housing

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

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