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

South Worcestershire review

CSP: South Worcestershire Published: August 2023 Year of death: 2016 Extracted: 9 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
Key concerns include the failure of multiple agencies to share and utilise information about the perpetrator's violent history, leading to missed opportunities for risk assessment and intervention. There was a lack of professional awareness of domestic abuse, particularly for individuals with learning disabilities, and insufficient opportunities for the victim to speak confidentially with support services.

Home Office classifications

28 tags

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

  • Victim - had been a victim of an abuser before
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - suicidal thoughts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police 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 family as a domestic abuse perpetrator
  • 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 - health services recommendations
  • DHR process - housing services recommendations
  • DHR process - employer recommendations
  • DHR process - community safety partnership 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

9 recommendations pulled from the report · 7 matched to organisations in the index

Recommendation 1

Addressed to Worcestershire Safeguarding Adults Board

That Worcestershire Safeguarding Adults Board seeks assurance that clear guidance is provided to staff from all relevant agencies over the need to check previous assessments when conducting a fresh assessment.

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

Recommendation 2

Addressed to Worcestershire Safeguarding Adults Board

That Worcestershire Safeguarding Adults Board seeks assurance that all relevant partner agencies have robust processes for the handover and closure of cases and effective managerial oversight of those processes.

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

Recommendation 3

Addressed to Worcestershire Safeguarding Adults Board | North and South Worcestershire Community Safety Partnerships | Public Health

That Worcestershire Safeguarding Adults Board and North and South Worcestershire Community Safety Partnerships request that Public Health establish and co-ordinate a joint task and finish group to make use of the learning from this review to ensure that the safeguarding adults and domestic abuse agendas are more closely aligned and that professional practice in respect of safeguarding adults and tackling domestic abuse is as integrated as possible. Amongst the issues that the task and finish group could consider are:
 ensuring that staff understand that many circumstances are both safeguarding situations and domestic abuse, and that they have a range of social work and legal options with which to work with people
 ensure that organisational policies, protocols and procedures about safeguarding explain the links with domestic abuse and, similarly, policies, protocols and procedures about domestic abuse refer to safeguarding.
 considering integrated training that covers both safeguarding and domestic abuse rather than treating them as separate issues.

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

Recommendation 4

Addressed to Worcestershire Safeguarding Adults Board | North and South Worcestershire Community Safety Partnerships

That Worcestershire Safeguarding Adults Board and North and South Worcestershire Community Safety Partnerships ensure that the learning from this case is disseminated widely and informs single and multi-agency training and amongst other key issues, highlights the impact of the rule of optimism in this case.

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

Recommendation 5

Addressed to Worcestershire Safeguarding Adults Board | local CCG’s | GP Confederations

That Worcestershire Safeguarding Adults Board requests local CCG’s and GP Confederations incorporate questions on domestic abuse into the learning disability annual review and seeks assurance that GP surgery staff and partner agencies receive the training and support required to enquire about domestic abuse.

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

Recommendation 6

Addressed to WSAB | local CCGs | GP Confederations

That WSAB seeks assurance from local CCGs and GP Confederations and partner agencies that all patients with a learning disability are identified by their GP in order that they can receive the learning disability annual review to which they are entitled.

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

Recommendation 7

Addressed to Worcestershire Safeguarding Adults Board

That Worcestershire Safeguarding Adults Board obtain assurance that assessments of service users with care and support needs are carried out in as holistic a manner as is practicable and that all agencies providing relevant support to the person being assesses are consulted as part of the assessment.

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

Recommendation 8

Addressed to North and South Worcestershire Community Safety Partnerships | Home Office

That North and South Worcestershire Community Safety Partnerships write to the Home Office to ask them to consider how to tailor awareness raising messages about domestic abuse to people with a learning disability. That those Community Safety Partnerships also review their own domestic abuse publications and consider whether “easy read” versions should be made available.

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

Recommendation 9

Addressed to Worcestershire County Council | Lifeways

That Worcestershire County Council challenges Lifeways to produce a single agency action plan which substantially addresses their learning from this review and also considers how to obtain assurance that Lifeways and other providers of care and support have the policies and staff training in place to enable them to address domestic abuse effectively.

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