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

Sefton review

CSP: Sefton Published: August 2023 Extracted: 14 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 report identifies systemic failures in recognising domestic abuse indicators within a mother-daughter relationship, inadequate inter-agency information sharing, and misapplication of confidentiality policies. Agencies also failed to fully explore the impact of alcohol misuse on family dynamics.

Home Office classifications

36 tags

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

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - depression
  • Victim - self harm
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to health 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 mental health services
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - other educational institution 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 - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

14 recommendations pulled from the report · 3 matched to organisations in the index

Recommendation 1

Addressed to Sefton CSP

Review domestic abuse policies, and work with partners to review their policies, so as to ensure it is clear when confidentiality can be breached and how suspicions of crime should be reported;

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

Recommendation 1.

Addressed to Lifeline Sefton

Recommendation (internal and external) Within six months, approach SWACA to see whether they can provide a training session to the team in Sefton – to team covering the three areas (i) confirm the team’s understanding of appropriate responses to disclosures of domestic violence, (ii) describe the support that they can offer and in the circumstances in which they can provide support, and (iii) support us to reflect on whether our usual responses to disclosures of domestic violence should be any different if the perpetrator is the victim’s child, sibling, etc.

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

Recommendation 1.

Addressed to Southport College

To have one central tracking document per student. Develop and implement a new single tracking document for each student receiving support.

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

Recommendation 2

Addressed to Sefton CSP

Review domestic abuse policies, and work with partners to review their policies so as to ensure that the circumstances in which behaviour amounts to abuse is clear and how it should be reported;

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

Recommendation 2

Addressed to NWAS

Publish learning lessons from this review in the ‘Clear Vision’ Bulletin. Write an article highlighting the importance of risk assessment and information sharing in relation to domestic abuse.

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

Recommendation 2.

Addressed to Lifeline Sefton

Review staff awareness of their role in responding to disclosures of domestic abuse, and confidence in fulfilling these roles – with individual development plans to address any identified needs

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

Recommendation 2.

Addressed to Southport College

Advice should be sought from the LCSB as to the appropriateness of key College staff having a Level 3 Safeguarding qualification.

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

Recommendation 3

Addressed to Sefton CSP

Work with partners to review their domestic abuse policies so as to ensure that direct questions are asked of those who abuse alcohol to establish if they present a risk of being a perpetrator or victim of domestic abuse;

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

Recommendation 3.

Addressed to Southport College

External supervision should be available to staff with safeguarding responsibilities. College to source appropriate external supervisor.

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

Recommendation 4

Addressed to Sefton CSP

In delivering these recommendations reinforce to partner agencies the complexities of family violence within a domestic abuse framework. In doing so they should consider using the death of the victim as a case study. It illustrates well that domestic abuse occurs in many different relationships between family members and not just between those who are, or have been, in an intimate relationship.

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

Recommendation 4.

Addressed to Southport College

Implement a new model of delivering conduct, welfare and support in College. Review roles, responsibilities and delivery models for conduct, welfare and support and make appropriate structural changes.

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

Recommendation 5

Addressed to Commissioned Services within Sefton CSP

That agencies who are commissioned to provide services should be required to inform their Commissioners when they become engaged in a DHR and of any recommendations arising.

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