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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| R1 | Domestic Abuse will always be discussed with the Named Nurse Safeguarding Children within CAMHS | Oxford Health NHS Foundation Trust |
| R10 | Ensure additional oversight of case progression | Early Help |
| R11 | All housing staff should attend annual safeguarding training – already actioned and in place. | Wiltshire Council |
| R12 | 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 |
| R13 | 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 |
| R14 | Early Help Team Leaders to ensure that supervision procedure is implemented and cases are discussed regularly including risk and vulnerability factors. | Early Help |
| R15 | Records to be made on IYSS re: supervision discussion | Early Help |
| R16 | Implement NEET assessment and planning tool. | Early Help |
| R17 | Ensure tool includes identification of DV issues | Early Help |
| R18 | Guidance to go out to staff on case recording – rather than describe what has happened | Early Help | YOT |
| R19 | Quality of case recording to be reviewed and scrutinized regularly through supervision | Early Help | YOT |
| R2 | 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 | Oxford Health NHS Foundation Trust |
| R20 | YP homelessness protocol to be reviewed and rewritten to ensure that there are clear pathways for homeless young people. | Early Help | YOT | Housing | Social Care |
| R21 | Document to ensure that agencies are clear about roles and responsibilities | Early Help | YOT | Housing | Social Care |
| R22 | 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. | Early Help | YOT |
| R23 | YOT to improve transition arrangements with Probation | YOT | Early Help | CAMHS |
| R24 | Professionals to consider what services can step up when young person reaches 18 but does not meet threshold for adult mental health services. | YOT | Early Help | CAMHS |
| R25 | 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 | Early Help | YOT |
| R26 | Raised awareness in Early Help about domestic abuse and impact on young people | Early Help | YOT |
| R27 | Disseminate Swindon and Wiltshire Domestic abuse reduction strategy to be disseminated and implemented within Early Help Service. | Early Help | YOT |
| R28 | There should be a ‘flag’ of some sort on a child’s electronic file so that staff are aware not to contact home. | Kingdown School |
| R29 | 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 |
| R3 | The use of the assessment triangle will be actively promoted as part of Safeguarding Children case discussion, training and supervision by CAMHS staff. | Oxford Health NHS Foundation Trust |
| R30 | 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 |
| R31 | 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 |
| R32 | 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 |
| R33 | 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 |
| R34 | 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 |
| R35 | 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 |
| R36 | 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-Middle Managers-Gloucestershire and Wiltshire LDU |
| R37 | 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 Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| R38 | The National Probation Service will work closely with the Community Rehabilitation Company to discuss report proposals where relevant and necessary. | National Probation Service-Middle Managers-Gloucestershire and Wiltshire LDU |
| R39 | 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 |
| R4 | 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 |
| R40 | 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. |
| R41 | 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 |
| R42 | 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 |
| R43 | Meet with Social Services local lead Paul Hunter | The Avenue Surgery |
| R44 | Instigate recently purchased Training Tracker software | The Avenue Surgery |
| R45 | Meet with representatives of Splitz to develop appropriate policies | The Avenue Surgery |
| R46 | Discuss with Dr Beale who is arranging the Mental Health orientated meeting and invite outside agencies for input | White Horse Surgery |
| R47 | Develop model adult safeguarding policy with clear reference to domestic violence which practices can adopt | Wilts CCG |
| R48 | Share learning at GP forum /GP learning events | Wilts CCG |
| R49 | Consider implementation of IRIS programme | Wilts CCG |
| R5 | 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 |
| R50 | Discuss development of icon specific to domestic violence/abuse to alert practice staff to presence of real/suspected domestic violence | Wits CCG |
| R51 | 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 |
| R52 | 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 |
| R53 | 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 |
| R54 | Children’s Social Care should refer vulnerable young people moving into adulthood to adult safeguarding/social care as routine practice | Children’s Social Care |
| R55 | Action is taken in relation to the individual social workers practice. | Children’s Social Care |
| R56 | 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 |
| R57 | 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 |
| R58 | Training of front line officers on the new coercive and controlling behaviour law | Wiltshire Police |
| R59 | DAIT/MASH to identify potential victims of child sexual exploitation in domestic abuse cases and make a referral to the CSE team. | Wiltshire Police |
| R6 | EWO’s are to be encouraged to undertake home visits in instances of poor or non engagement of family or young person | EWS |
| R60 | Develop a system in order that front line officers can easily identify serial victims and perpetrators when they attend domestic abuse incidents. | Wiltshire Police |
| R61 | Training programme for all relevant clinical staff | RUH |
| R62 | Continue funding for IDVA project at the RUH | CCG |
| R63 | Risk assessment process | RUH |
| R64 | To review internal process for sharing safeguarding information with external agencies other than Social Care. | Ambulance Service |
| R65 | Improve attendance from Drug and Alcohol Services and Mental Health Services | MARAC |
| R66 | Support for MARAC to be placed on a statutory footing | MARAC |
| R67 | 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 Service |
| R68 | 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 Service |
| R69 | Recommendation for an independent review to be undertaken for the DACC. | DACC |
| R7 | EWO’s to build into their practice on a routine basis completion and involvement in CAF process and TAC reviews. | Early Help |
| R70 | 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. | BGSW CRC |
| R71 | 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. | BGSW CRC and NPS |
| R72 | Appropriate enforcement action to be undertaken and use of behaviour contracts to be considered by all Offender Manager’s within BGSW CRC. | BGSW CRC |
| R73 | BGSW CRC to consistently provide intervention and support for female service users. | BGSW CRC |
| R74 | 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. | BGSW CRC |
| R75 | 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. | BGSW CRC and NPS |
| R76 | 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. | BGSW CRC |
| R77 | 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 |
| R8 | Ensure that EWO’s are aware that all avenues of information gathering are considered and evidenced | EWS |
| R9 | Ensure that EWO’s are adequately informed of safeguarding practice and referral routes | Early Help |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||