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

Tendring review

CSP: Tendring Published: August 2023 Year of death: 2012 Extracted: 12 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 highlights systemic failures in inter-agency information sharing, particularly between Police, Probation, and Mental Health services, which hindered comprehensive risk assessments. It also identifies inadequate domestic abuse policies, procedures, and training across various agencies, leading to missed opportunities to identify and support victims and manage perpetrator risk.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
1	Information sharing protocols between agencies should be reviewed to ensure that they are effective in empowering practitioners to share information across disciplines and agencies for the purpose of gathering an offender’s full criminal and mental health history to inform comprehensive risk assessments. Practitioners should take an investigative approach and offenders self reports should be corroborated by reference to additional sources.	Tendring County Community Safety Partnership
10	The Mental Health Trust should review the Care Programme Approach to ensure that it is effectively coordinating the needs of its service users and the agencies supporting them by: (a) That robust auditing of CPA is implemented where Consultants act as the care coordinator. (b) Ensure that relevant agencies such as Probation and others are invited to CPA case meetings when they are held concerning their service users.	North Essex Partnership NHS Foundation Trust
11	That the Community Safety Partnership writes to the Chief Executive of MIND to request that they review their safeguarding policy to strengthen their policies and training around domestic violence, and is signposted to the appropriate lead in the Safeguarding Essex Board.	Tendring County Community Safety Partnership
2	Safeguarding policies should be reviewed to ensure that domestic abuse has an explicit pathway which includes the DASH risk assessment checklist, MARAC referral process, and options for support and actions, so that practitioners have ease of access to clear guidance about the steps to take and processes. This could be as an addendum to existing policies, but preferably a standalone document or handbook.	Tendring County Community Safety Partnership
3	Domestic abuse training content should be reviewed to ensure that it includes a module on the indicators and identification of perpetrators including criminogenic typologies for high risk perpetrators, additional risk factors such as mental ill health, personality disorders, substance misuse, and risk assessment.	Tendring County Community Safety Partnership
4	A process should be put in place between the Police and Probation that results in offenders supervised by Probation being flagged on Police systems for the duration of their supervision, and that a notification of any incidents involving a Police intervention with a supervised offender is emailed to Probation to enable their Offender Managers to be alerted. The notification should take place whether an offender is involved in an incident which results in a non-crime, a caution, or a crime. The process should aim to be put in place by April 2014.	Essex Constabulary \| Essex Probation
4.2	That NHS England supports the introduction of IRIS within GP practices by building into its contractual and performance management arrangements a requirement that practices should implement the Identification and Referral to Improve Safety (IRIS) system in coordination with Independent Domestic Abuse Advocacy Services.	NHS England
5	Essex Probation will remind staff to use professional judgement in making home visits, which are not confined to cases assessed as high risk, particularly where an offender has caring responsibilities either for children or a vulnerable adult.	Essex Probation
6	All GP practices should develop a robust domestic abuse policy and protocols within X months of the publication of this Review which clearly outline the responsibilities of staff to understand and respond to the needs of domestic abuse victims. The policies and protocols should be mindful of the Home Office definition of domestic abuse which was amended in March 2013 to include individuals of 16 years and over, and the inclusion of coercive control in the description of abuse. Policies and protocols should include: (a) A domestic abuse care pathway as recommended by the Royal College of General Practitioners, IRIS, and CAADA: this can be found at http://www.rcgp.org.uk/clinical-and-research/clinical-resources/domestic-violence.aspx (b) The identification of a key individual within the practice who will have additional training and be able to act as more specialist support for other staff. (c) Where an individual is regularly accompanied by a partner, relative or carer a policy should be put in place setting a clear expectation that opportunities will be made available to see individuals alone in a safe and confidential setting. Advice and guidance on how to achieve this should be included. (d) GPs would find it useful to access the Royal College of General Practitioners e-learning course for guidance and practice advice regarding domestic violence. This is available on the Royal College’s website at: http://elearning.rcgp.org.uk (enter domestic violence in the search for courses window).	North East Essex Clinical Commissioning Group
7	GPs should review their safeguarding adults and children strategies to ensure a standardised approach. The strategies should reflect the requirements of the Essex Safeguarding Adults Board and be in line with the Southend, Essex & Thurrock Safeguarding Guidelines. A lead practitioner for safeguarding should be identified who will have a governance and co-ordinating role, overseeing and recording training requirements and attendance, and ensuring that staff managing safeguarding issues receive formal supervision. The level of training provided will be determined by the responsibilities of the post holder as per the Southend, Essex and Thurrock Guidelines.	North East Essex Clinical Commissioning Group
8	At the time of writing NICE are in the process of developing guidance to support the prevention and reduction of domestic violence which is due to be published in February 2014. It is recommended that Clinical Commissioning Groups, Hospital and Mental Health Trusts take forward NICE recommendations with its membership at that point.	Clinical Commissioning Groups \| Hospital and Mental Health Trusts
9	The Mental Health Trust should ensure that appropriate procedures are in place to implement NICE guidelines so that practitioners are clear that where the consent of the person diagnosed is obtained, their family or carer should be consulted, have a carer’s assessment if appropriate, and be provided with information about local support groups. This should be done at the time of diagnosis or as soon as practicable following diagnosis.	North Essex Partnership NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗