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

Liverpool review

CSP: Liverpool Published: July 2023 Extracted: 26 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 systemic failures in multi-agency information sharing, risk assessment, and safety planning for a victim with complex needs, particularly concerning the perpetrator's release from prison after breaching a Domestic Violence Protection Order. There were missed opportunities for routine enquiry and proactive intervention by several agencies.

Home Office classifications

30 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • 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

26 recommendations pulled from the report · 17 matched to organisations in the index

Recommendation 1

Addressed to Merseyside Police

Merseyside Police should produce a documented ‘working procedures’, ‘work allocation’ and ‘personal responsibility’ procedure in relation to each role and working practice within the Protecting Vulnerable Persons Unit (PVPU). This should be published and appended to its ‘Domestic Abuse (Policy and Procedure)’ as a clear reference point, to avoid ambiguity. The procedures should be followed in every Protecting Vulnerable Persons Unit every within the force. (This is a recurring theme from a previous DHR).

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

Recommendation 2

Addressed to Merseyside Police

When completing entries on PROtect logs/Niche, sufficient research should be carried out to identify the most up to date and correct information before it is documented. Doing so will prevent any misleading information being shared with other agencies. This should include current telephone and address details.

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

Recommendation 3

Addressed to Merseyside Police

When seeking CPS advice in cases of ‘domestic abuse’, all available material pertinent to the investigation should be submitted. When reference is made to the ‘mental health’ of either victim or perpetrator, then the provenance/origins of the illness, as held on police systems, must be included.

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

Recommendation 4

Addressed to Merseyside Police

When dealing with repeated low key ‘domestic incidents’ that involve alcohol abuse as a contributory factor, specific interventions and referrals to alcohol support groups must be considered, including referral to adult services.

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

Recommendation 5

Addressed to Merseyside Police

When arrests and subsequent charges are made in relation to ‘domestic incidents’ and alcohol abuse is a contributory and continued factor, then officers dealing with the case must ensure the court is informed and consideration is given to applying for an Alcohol Treatment Referral Order as part of a community service order. This must be considered even if the subject has a history of non-compliance with such orders.

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

Recommendation 6

Addressed to Merseyside Police

For the MARAC to produce meaningful actions, the panel must be provided with the most up to date information relating to the victim and the perpetrator and where that information identifies complex needs ensure they are catered for in the actions.

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

Recommendation 7

Addressed to National Probation Service (Merseyside)

To encourage staff to approach domestic abuse with professional curiosity in each case and to ensure it is recorded on the case record. Risk registers should be flagged and reviewed at least every 16-weeks.

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

Recommendation 8

Addressed to National Probation Service (Merseyside)

Offender Managers should undertake regular Protecting Vulnerable Person Unit checks with the police to verify information and confirm protective measures are in place for the victim and ensure it is documented on the case record.

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

Recommendation 9

Addressed to National Probation Service (Merseyside)

Offender Managers should undertake safeguarding checks/referrals at the commencement of supervision and this information should be included in the risk-assessment and risk-management plan. This should be reviewed if a further domestic abuse or other significant incident takes place and consideration for a referral to MARAC should be made if the threshold is met.

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

Recommendation 10

Addressed to National Probation Service (Merseyside)

In the event of a relationship with a new partner or known perpetrator of domestic abuse, consideration should be made, in consultation with the police, of a disclosure under the domestic violence disclosure scheme (Clare’s Law).

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

Recommendation 11

Addressed to National Probation Service (Merseyside)

Offender Managers should discuss what services are available and undertake referrals with victims of domestic abuse and ensure this is documented on the case record.

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

Recommendation 12

Addressed to National Probation Service (Merseyside)

When there is a change of Offender Manager, a three-way handover meeting should take place between the offender and the outgoing and incoming Offender Manager and details of the meeting should be documented on the case record.

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

Recommendation 13

Addressed to PSS (Person Shaped Support) UK

PSS Women’s Turnaround staff should complete training on awareness of domestic abuse, MERIT risk-assessment and the MARAC process.

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

Recommendation 14

Addressed to PSS (Person Shaped Support) UK

All staff employed on the PSS Ruby Project should complete the ‘Safer Lives’ IDVA training

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

Recommendation 15

Addressed to Crown Prosecution Service

To ensure that CPS managers continue to use the quality assurance process (IQA) to maintain a high standard of advice and analysis in casework, particularly that relate to vulnerable people.

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

Recommendation 16

Addressed to Mersey Care NHS Foundation Trust

To ensure that information sharing between the Trust and GPs is improved and that the exchange of information is properly documented.

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

Recommendation 17

Addressed to General Practitioners

Patients attending with other people should have the name and relationship of that person recorded in the records.

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

Recommendation 18

Addressed to General Practitioners

Patients attending under the influence of drugs or alcohol should have their capacity to make decisions assessed and recorded.

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

Recommendation 19

Addressed to General Practitioners

Practitioners who see patients who are misusing alcohol and drugs should look beyond this for signs of abuse and record their presence or absence.

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

Recommendation 20

Addressed to General Practitioners

Practitioners should continue to offer support and signposting to victims of abuse, even if it has previously been declined.

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

Recommendation 21

Addressed to General Practitioners

The apparent lack of awareness, knowledge and understanding among GP’s as to what range of domestic abuse services patients can be referred to should be addressed.

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

Recommendation 23

Addressed to Royal Liverpool and Broadgreen University Hospitals NHS Trust

To ensure that when checking a patient into the accident and emergency department, full identifying details of next-of-kin are always recorded. Where a patient indicates that they do not have a next-of-kin, this should be clearly documented.

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

Recommendation 24

Addressed to Royal Liverpool and Broadgreen University Hospitals NHS Trust

To ensure that where there are cases of assault, the healthcare professional should document the name of the alleged perpetrator.

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

Recommendation 25

Addressed to Citysafe

That Citysafe determine whether the DVDS and DVPNs and DVPOs are being used effectively in its area to support safety planning for victims of domestic abuse, including safety planning in advance of offenders being released from prison for breaching DVPO.

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

Recommendation 26

Addressed to Home Office

That the Home Office establish nationally whether the use of DVDS and DVPN/DVPO are being used effectively to support victims of domestic abuse.

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