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
South Worcestershire review
CSP: South WorcestershirePublished: August 2023Year of death: 2018Extracted: 13 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identifies that the victim's mental health and substance misuse issues often obscured the recognition of domestic abuse, leading to missed opportunities for intervention, multi-agency collaboration, and appropriate risk assessment. There was a failure to fully utilise the Domestic Violence Disclosure Scheme and address coercive control.
Home Office classifications
35 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - died by suicide
Victim - mental ill health
Victim - depression
Victim - suicide attempts
Victim - had been a victim of an abuser before
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - self harm
Perpetrator - suicidal thoughts
Perpetrator - suicide attempts
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to mental health services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - supervised by mental health services
Aggravating factors - coercive or controlling behaviour
Aggravating factors - psychological or emotional abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family consulted about terms of reference
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - police recommendations
DHR process - health 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 - record keeping recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
13 recommendations pulled from the report · 4 matched to organisations in the index
Addressed to
South Worcestershire Community Safety Partnership
The constituent partner Agencies of the South Worcestershire Community Safety Partnership should review the advice given to: a) Agencies when responding to domestic abuse concerns where there are known risks of mental illness and substance misuse. b) The public through online communication and links placed on Agency websites and elsewhere.
Addressed to
South Worcestershire Community Safety Partnership
The South Worcestershire Community Safety Partnership should review its use of social media and print media and seek to identify opportunities of raising the level of public awareness about domestic abuse.
Addressed to
South Worcestershire Community Safety Partnership
The impact of the current training regarding the Domestic Violence Disclosure Scheme should be audited to ensure that the learning is embedded in practice.
Addressed to
South Worcestershire Community Safety Partnership
The South Worcestershire Community Safety Partnership should review the information available about the Domestic Violence Disclosure Scheme and ensure that guidance for professionals and leaflets to raise awareness generally are available.
Addressed to
All Agencies | Commissioners of Services
All Agencies and commissioners of services should review existing Re-Engagement Policies with the aim of identifying and reaching out to service users who have found it hard to engage for whatever reason.
Modifications to DASH risk assessments made by Domestic Abuse Risk Officers (DARO’s) should be referred back to the Officers responsible for the original assessment to explain why the change was made and to ensure that this is a safe decision. Frontline officers should be made aware of the mechanisms for escalating concerns to the MARAC if this is warranted in their professional judgement.
Training on the impact of domestic abuse, substance misuse and mental health should be provided for frontline Officers to raise awareness of these complex issues.
Share learning regarding the importance of having a clear re-engagement plan for service users who are NFA (No Fixed Abode) or rough sleeping, as per Service Engagement Policy. Identify any training requirements for staff on this issue.
Ensure that all staff are aware of the importance of sharing and corroborating information provided by service users where there is an indication of domestic abuse.
Surgeries should consider adding an alert to patient records when a trusted agency reports the potential risk of abuse/violence to either staff or other service users.
The GP practice to consider reviewing their protocol in respect of relatives phoning on behalf of patients concerning the potential risk of coercion and control.