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

Nottingham review

CSP: Nottingham Published: August 2023 Year of death: 2020 Extracted: 35 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
Concerns include the victim's vulnerability, transient lifestyle, and non-engagement with support. The perpetrator's history of domestic abuse and lack of convictions were noted. Agencies showed inflexible engagement, poor information sharing, and a lack of coordinated multi-agency response.

Home Office classifications

34 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - psychosis
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to housing 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 - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services 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

35 recommendations pulled from the report · 23 matched to organisations in the index

Recommendation 1

Addressed to The Probation Service

The Probation Service to provide evidence to Nottingham Crime and Drugs Partnership that the learning within this review has been embedded into practice.

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

Recommendation 1

Addressed to DLNR CRC

Following new information relating to risk, service users should be instructed in for an additional appointment to discuss new concerns in a timely manner. There should be an appropriate response to this new information by the supervising officer e.g. reassessment of risk.

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

Recommendation 1

Addressed to EMAS

To continue to raise awareness to all EMAS staff via education, alerts, articles and audit the need to make safeguarding personal and the importance of discussing referrals with patients as well as consent.

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

Recommendation 1

Addressed to NHS Nottingham and Nottinghamshire CCG

The CCG need to explore the barriers to completing DASH-RIC in primary care services.

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

Recommendation 1

Addressed to Housing Aid

Consider safe contacts and how to reach the victim where domestic is identified within referral. Be aware when speaking to ‘friends’ of the individual and record name and relationship to the individual within casefile.

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

Recommendation 1

Addressed to Nottinghamshire Police

Nottinghamshire Police promote and raise awareness amongst staff of the use of Bad Character evidence in domestic abuse investigations. A “living” document, for repeat perpetrators, could be created and flagged within NICHE for repeat perpetrators to reduce duplication of effort in repeat cases.

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

Recommendation 1

Addressed to Framework Housing Association

All staff will be fully trained with a refresher course on Domestic Abuse.

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

Recommendation 2

Addressed to Nottingham Crime and Drugs Partnership | agencies involved in the criminal justice system | Witness Care Unit

That Nottingham Crime and Drugs Partnership seeks assurances from those agencies involved in the criminal justice system, and in particular the Witness Care Unit, that the learning from this case has been disseminated and embedded into practice. Also, that all options of engagement and contact with witnesses, including the identification of a main point of contact, are considered as part of the witness management process.

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

Recommendation 2

Addressed to DLNR CRC

All domestic abuse perpetrators to have the following condition added to their licence. “To notify your supervising officer of developing intimate relationships”.

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

Recommendation 2

Addressed to GP Services | NHS Nottingham and Nottinghamshire CCG

GP Services to apply a did not attend process for high risk/vulnerable patients with support of the CCG linking with primary care.

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

Recommendation 2

Addressed to Housing Aid

Where contact cannot be established directly with the individual the Officer will make contact with the referring agency for support in making contact.

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

Recommendation 2

Addressed to Nottinghamshire Police

Nottinghamshire Police promote and raise awareness amongst staff, involved in the investigation of domestic abuse cases, the need to include the DV history of the victim and perpetrator in prosecution/ decision files.

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

Recommendation 2

Addressed to Framework Housing Association

To consider a web based programme for the recording of information to mitigate any further risk of technology issues (access through the Citrix platform).

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

Recommendation 3

Addressed to all agencies involved in this review

That all agencies involved in this review provide evidence to Nottingham Crime and Drugs Partnership that agency referrals, where there is evidence of complex needs and vulnerabilities, are populated with all relevant information including vulnerabilities and risk factors.

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

Recommendation 3

Addressed to DLNR CRC

Probation staff to be reminded to follow the existing policy for full risk assessment and sentence plans (OASYS Layer 3) to be completed on all domestic abuse perpetrators and for risk to be reviewed when there is new significant information.

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

Recommendation 3

Addressed to NHS Nottingham and Nottinghamshire CCG

Use of alerts on system1 to guide professionals to make every contact count.

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

Recommendation 3

Addressed to Housing Aid

In person appointments / drop in offered where victims of abuse are identified and where they do not have their own means of contacting the service.

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

Recommendation 3

Addressed to Nottinghamshire Police

Nottinghamshire Police ensure there is a process in place to manage actions, which may be protracted, raised at MARAC meetings.

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

Recommendation 4

Addressed to Home Office | Government

That the Home Office and Government consider the learning from this case in relation to third-party disclosure of information when reviewing current legislation and guidance in relation to domestic abuse.

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

Recommendation 4

Addressed to DLNR CRC

Probation staff to be reminded to use all available sources of information, e.g. previous records when making risk assessment and sentence plan recommendations.

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

Recommendation 4

Addressed to Housing Aid

Where the service is unable to reach the individual consideration will be given to whether it is appropriate to refer to the Police for support.

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

Recommendation 5

Addressed to Nottingham Crime and Drugs Partnership

That Nottingham Crime and Drugs Partnership ensures that the learning from this review is used to inform the ongoing work around the remit of the Integrated Care Partnership.

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

Recommendation 5

Addressed to DLNR CRC

Probation staff to be reminded to follow the existing policy for police/safeguarding checks to be carried out on all domestic abuse perpetrators at the start of supervision and at points when new information relating to risk emerges.

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

Recommendation 6

Addressed to all agencies involved in this review

That all agencies involved in this review provide evidence to Nottingham Crime and Drugs Partnership that their agency is aware of the Integrated Care Pathway and referral pathway.

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

Recommendation 6

Addressed to DLNR CRC

Probation staff to be reminded to follow the existing policy for home visits to be carried out on all domestic abuse perpetrators upon release and at points when new information relating to risk emerges.

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

Recommendation 7

Addressed to Nottingham Crime and Drugs Partnership

That Nottingham Crime and Drugs Partnership’s Domestic Abuse Strategy details how it will respond to raising awareness on domestic abuse for all areas of the community, in particular, those with complex needs and additional vulnerabilities.

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

Recommendation 7

Addressed to DLNR CRC

Probation staff to be reminded of the existing policy that new information received pertaining to risk is discussed with all appropriate agencies including the agency that provided the information.

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

Recommendation 8

Addressed to Juno Women’s Aid

That Juno Women’s Aid provide evidence and assurances to Nottingham Crime and Drugs Partnership that the operational changes and learning from this review have been embedded into practice. This recommendation should be completed within six months.

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

Recommendation 8

Addressed to DLNR CRC

Probation staff to be reminded to consider issuing formal warning letters to service users in cases where action e.g. recall for breach of licence conditions, is considered but not taken.

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

Recommendation 9

Addressed to all agencies involved in this review

That all agencies involved in this review provide evidence to Nottingham Crime and Drugs Partnership on how their agency has embedded the learning from this review, in terms of engagement and services, including accommodation to victims of domestic abuse.

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

Recommendation 9

Addressed to DLNR CRC

Probation staff to be reminded to refer to Pathway Interventions e.g. Safe Choices/Spectrum for domestic abuse perpetrators, when accredited programmes are not applicable.

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

Recommendation 10

Addressed to DLNR CRC

Probation staff to be reminded to record details of one-to-one work carried out as per existing policy.

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

Recommendation 11

Addressed to DLNR CRC

Probation staff to ensure that the principles of professional curiosity are applied to the risk assessment and risk management of service user.

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

Recommendation 12

Addressed to DLNR CRC

Ongoing quality audits are completed by line managers to ensure that the expectations and requirements of key policy documents are implemented

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