Somerset review

The Police to review its Procedural Guidance for Deployment and Crime Allocation to support case management approach for vulnerable individuals.

The police to take steps to ensure officers recognise coercive control more readily and take time to pursue further lines of enquiry when indicators of coercive control more readily and take time to pursue further lines of enquiry when indicators of coercive control are evident when dealing with domestic incidents.

All agencies involved in this review, implement agency recommendations and report the outcomes to the Safer Somerset Partnership within six months of publication of this DHR.

Health practitioners, police and adult social care to understand the suicide risk and links to domestic abuse and the impact of grief when a family member has experienced a death by suicide. Professionals within the mentioned organisations to also understand what support is available to families with this experience.

SSP to review its training to professionals and practitioners to include all definitions of domestic abuse relating to interpersonal violence but also adult family violence.

The police identified that each incident was investigated as a discrete and unconnected case. If a case management approach had been implemented, then this should have allowed for improved professional curiosity.

If a person shares with a GP practice that they have been taken advantage of with the suggestion that the sexual activity was not consensual then the GP should refer to SARSAS and SARC.

Mental health services should always explore domestic abuse when relationship difficulties are mentioned and or in cases where there is a coexistence of relationship difficulties and suicide ideation.

MHSC to ensure that case recording on individual case records is accurate. MHSC teams to have monthly audit focussing on accuracy.

To understand the MARAC referral pathway so high-risk DA cases ( whether actual score or professional judgment ) should always go to a MARAC and even where there is more than one perpetrator.

The police have also recognised that further training and support for officers in recognising and investigating coercive behaviour as a learning point for the police and this is already a recommendation to improve practice.

Details of SARSAS including Welcome SARSAS Survivor Pathways (including a list of sexual violence services) should be included in the new CCG Safeguarding Service directory being developed by SCCG for GP Practices.

Psychiatric Inpatients Units should always complete a DASH with clients who have been admitted to a ward when domestic abuse has been reported including reports of historical abuse to ensure robust risk /safety planning.

MHSC to communicate the assessment outcomes to the person involved.

SARSAS and SARC to be invited to a GP learning event.

To liaise with SOMFT Safeguarding Service when domestic abuse has been identifies through the completion of a DASH.

MHSC to ensure relevant documents relating to the person are saved to their records.

If a person has contact with a GP service about their mental wellbeing and /or alcohol substance misuse /or chronic pain and there is no clear medical cause a GP practice should include a routine enquiry about domestic abuse.

Domestic Abuse Awareness raising with the Mental Health Teams to embed routine enquiry in domestic abuse in clients who present suicidal ideation or relationship difficulties.

MHSC professionals to ensure risk assessments are completed in full and guidance is given to staff when this has not been possible.

To carry out a review of the MARAC, its procedures, referrals by agencies and identification of support /safety planning offered to victims of domestic abuse.

All agencies to be reminded via the SSP newsletter the importance of recording ethnicity of victims and perpetrators of domestic abuse on records e.g. Patient records/user records and crime records.

Somerset Safeguarding Adult Board (SSAB) to review “What to do if it’s not Safeguarding” guidance and how it interacts with a MARAC. Also, SSAB to promote to agencies and practitioners in Somerset the model to support a vulnerable individual who may not meet the threshold of an adult safeguarding referral or a MARAC.

The Police, SomFT and CCG to identify /promote to relevant professionals and practitioners training and guidance on adopting a trauma informed approach to supporting a victim of domestic abuse. This to include identification of trauma relating to family background, grief, mental health and substance abuse. This training should also include unconditional bias, knowing how it manifests and what professionals can do to challenge it and how this impact on support to a victim of domestic abuse.

As part of SSP communication strategy to the wider community to communications which include information about adult family violence (AFV), what it is (how to identify it) and to identify what support there is for a victim of AFV.

To act upon the recommendations within the RCA relating to mental health and impatient processes of which all have been actioned and completed.

MHSC to review assessment templates to ensure. • -they are fit for purpose • -Still relevant • -Staff know when to apply them • -Review effectiveness of the tools • -MHSC to ensure that all relevant and appropriate timescales for onwards referrals are made.

MHSC and SOMFT to review their working together arrangements specifically information sharing arrangements. (To note- at the time of the incident , MHSC staff would have had access to SOMFT’s electronic record system and would have recorded on the same system. Each agency would have seen each other’s notes.

SCC to review MHSC attendance at DA training.

SCC to ensure MHSC staff know how to recognise , respond ,report and record concerns about domestic abuse.