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
Welwyn Hatfield review
CSP: Welwyn Hatfield
Published: August 2023
Year of death: 2017
Extracted: 40 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review identifies systemic failures in recognising the victim as a repeat victim of domestic abuse by multiple perpetrators, leading to her suicide due to coercive control. Agencies demonstrated a lack of professional curiosity, inadequate risk assessment, and insufficient information sharing, resulting in missed opportunities for intervention and specialist support.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | An allocated lead at the Home Office is responsible for establishing a national fund to enable a package of therapeutic and advocacy support to be put in place for child survivors of Domestic Homicide and suicide linked to domestic abuse. The Home Office to report back to Hertfordshire County Council on this recommendation and its implementation. | Home Office |
| 1 | All Agencies involved with this review to report that they are now sharing information on a consistent basis with pathways and checks in place to ensure the right information is being shared. Agencies to confirm they are sharing historic as well as current information about domestic abuse. | Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service |
| 10 | Agencies involved in this review to check their policies, communications, training, and records to ensure they avoid victim blaming which prevents the professional from seeing the whole history of abuse. | Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service | Hertfordshire Domestic Abuse Partnership |
| 11 | Hertfordshire Domestic Abuse Partnership facilitates training which includes learning about: a) Domestic abuse and suicide b) Attempted strangulation as an indicator of the escalation of domestic abuse with risk of homicide and suicide. | Hertfordshire Domestic Abuse Partnership |
| 12 | Hertfordshire Domestic Abuse Partnership to review services across the County with a view to ensuring therapeutic support is available to all survivors of domestic abuse, including children. | Hertfordshire Domestic Abuse Partnership |
| 2 | That the Home Office issue guidance that repeat victims of multiple perpetrators are treated as a special category of domestic abuse victim/survivor with automatic escalation to MARAC; that the DASH risk assessment is amended to reflect this change with guidance and training in place. | Home Office |
| 2 | Hertfordshire Domestic Abuse Partnership to roll out an agreed community awareness and training programme over the next 12 months with the aim of increasing awareness amongst all communities of domestic abuse and the role organisations, family and friends can play in tackling and reporting domestic abuse. | Hertfordshire Domestic Abuse Partnership |
| 3 | National Tier 1 training to include the importance of developing the professional curiosity skills of students, using domestic abuse case studies and national guidance to assist in improving this skill. This recommendation is linked to issues arising following the lack of professional curiosity used which impacted on decision making and professional judgement in this case. | Home Office |
| 3 | Hertfordshire Domestic Abuse Partnership to publish, publicise, and maintain updated lists of organisations who can offer help and support to victims and survivors, ensuring these are available to communities across the County. | Hertfordshire Domestic Abuse Partnership |
| 4 | Police, Health Services and Children’s Social Care increase their awareness of the role of the different third sector and specialist organisations in Hertfordshire, including therapeutic trauma services and ensure they refer their clients/patients/service users appropriately into these services. | Hertfordshire Constabulary | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Hertfordshire Children’s Services |
| 5 | Statutory and voluntary sector agencies involved with this review to confirm that they include a trauma-informed approach to their work with victims/survivors and train and support their staff in this approach. | Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service | Hertfordshire Domestic Abuse Partnership |
| 6 | Hertfordshire Domestic Abuse Partnership to develop a policy which recognises the particular vulnerability of repeat victims of multiple perpetrators and ensures they are treated as a special category with referral into MARAC and specialist outreach support to ensure they can engage with services. | Hertfordshire Domestic Abuse Partnership |
| 7 | Children’s and Adult Care Services to include in their safeguarding training an awareness of the link between domestic abuse, substance use, mental ill health and trauma and the services available for those impacted including counselling and therapeutic support. | Hertfordshire Children’s Services | Hertfordshire Adult Care Services |
| 7 | Children’s Services, CGL and the IDVA teams to work together to develop a joint understanding of alcohol dependency and domestic abuse which is reflected in policy, training, and support pathways. | Hertfordshire Children’s Services | Spectrum CGL | IDVA teams |
| 8 | Hertfordshire Domestic Abuse Partnership ensures all agencies are aware of their changed responsibility under the Domestic Abuse Act 2021 | Hertfordshire Domestic Abuse Partnership |
| 9 | Hertfordshire Domestic Abuse Partnership considers establishing community-based support for domestic abuse perpetrators and that a report, outlining successes elsewhere and the cost of a programme, is presented to the CSP. | Hertfordshire Domestic Abuse Partnership |
| a | Schools are currently notified of domestic abuse incidents. This has not yet been extended to under-fives. This recommendation to be implemented alongside safeguarding reorganisation plans. | Hertfordshire Constabulary |
| a | To share the reflections gained in this IMR with the workforce (by way of a learning bulletin) and in particular the impact of repeat victimisation from multiple partners. | Hertfordshire Children’s Services |
| a | The need for a Trust-wide holistic and robust domestic abuse policy which examines the signs of domestic abuse, barriers to disclosure and gives clear guidance on safe and effective domestic abuse enquiry (including specific guidance on ‘asking the question’ and question framing). | East and North Hertfordshire NHS Trust |
| a | HCT policy review to be finalised and to ensure there is adequate response to domestic abuse victims who have been subject to abuse from different partners | Hertfordshire Community NHS Trust |
| a | The Police provide Probation with domestic abuse history alongside other information for Court. Police and Probation to discuss and implement this recommendation. | Hertfordshire Constabulary | Probation Service |
| b | Recommend that Officers discontinue the use of ‘Domestics’ and ‘Domestic Disputes’ and use the term ‘Domestic Abuse’. | Hertfordshire Constabulary |
| b | To consider additional ways of supporting victims/survivors including young parents who are experiencing substance use and domestic abuse to ensure they can access support. | Hertfordshire Children’s Services |
| b | Areas within the Trust, such as Adult ED, Maternity, Community Paediatrics, Gynaecology, Plastics & Orthopaedics to have an enhanced provision of domestic abuse training which supports the development & understanding of the purpose of routine domestic abuse enquiry within those areas and equips staff with knowledge and experience in the recognition, response, and risk assessment of domestic abuse. This training will also focus on case scenarios regarding how to create an environment to support safe enquiry. | East and North Hertfordshire NHS Trust |
| b | HCT Domestic Abuse training to be updated to ensure that greater awareness is raised regarding coercive control and victim suicide. | Hertfordshire Community NHS Trust |
| b | As a matter of good practice all offenders at Court interview stage are asked about their relationship status, previous relationships, and the quality of those relationships. | Probation Service |
| c | Children are seen by officers in domestic abuse call outs and where appropriate, spoken to individually and separately from the perpetrator. | Hertfordshire Constabulary |
| c | Hertfordshire Children Services contacts the carers of the three children in this case and establishes whether they have access to the therapeutic resources needed to support the three children. If this is not the case that they establish a fund to enable the children to access the support, they need. | Hertfordshire Children’s Services |
| c | Further review of the Specialist Health Visitor assessment tool; to incorporate domestic abuse routine enquiry as a standard for each initial assessment, to gather family functioning/dynamics and identification of men in children’s lives. | East and North Hertfordshire NHS Trust |
| d | Information shared with Children’s Services and within MASH to include any domestic abuse and other violence, including abuse involving previous partners of both the perpetrator and the victim. | Hertfordshire Constabulary |
| d | The review supports the recommendation of community services employed by East & North Hertfordshire NHS Trust to have read access to community records (System one) to enhance communication and information sharing with universal services. | East and North Hertfordshire NHS Trust |
| e | Information is passed to all victims of domestic abuse about domestic abuse support services and victims are encouraged to contact services for support. | Hertfordshire Constabulary |
| e | Information sharing between specialist HV service and community services – a review of current information sharing practices in place should take place. | East and North Hertfordshire NHS Trust |
| f | Special consideration to be given to escalate repeat victims of multiple perpetrators to MARAC. | Hertfordshire Constabulary |
| f | Development of domestic abuse care bundles: domestic abuse care bundles are a bundle of information/documentation which will support a clinician where there is a suspicion of disclosure of domestic abuse. This will include the domestic abuse pathway, clinical photography prompts, body maps & literature for safety planning and onward referrals to IDVA and safeguarding services. | East and North Hertfordshire NHS Trust |
| g | Training to include the danger of attempted strangulation as an indicator of escalation of abuse. | Hertfordshire Constabulary |
| g | Trust-wide annual domestic abuse audit to be commenced, examining efficacy of domestic abuse enquiry, recognition, and responses to domestic abuse. This will be the foundation for future training and service improvements. | East and North Hertfordshire NHS Trust |
| h | The Police provide Probation with domestic abuse history alongside other information for Court. Police and Probation to discuss and implement this recommendation. | Hertfordshire Constabulary | Probation Service |
| h | Development of domestic abuse champions within each department within the trust, who will receive additional local training on domestic abuse, risk assessment and safety planning, to help develop knowledge from the ‘ground up’. The role of the domestic abuse champion will be to support the frontline staff on domestic abuse identification, domestic abuse enquiry and to ensure the victim & their children get the right and appropriate support in a timely manner. | East and North Hertfordshire NHS Trust |
| i | Domestic Abuse awareness raising throughout the organisation (e.g., screensavers, active participation in awareness days and regular internal communications) alongside the above recommendations will provide a further reinforcement. | East and North Hertfordshire NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||