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 Worcestershire Published: August 2023 Year of death: 2018 Extracted: 13 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
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

Recommendation 14.6a

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.

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

Recommendation 14.6b

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.

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

Recommendation 14.7

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.

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

Recommendation 14.8

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.

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

Recommendation 14.9

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.

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

Recommendation 14.10

Addressed to Police

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.

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

Recommendation 14.11

Addressed to Police

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.

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

Recommendation 14.13

Addressed to Cranstoun Worcestershire

Share learning regarding the importance of recording a service user's partner’s name in sessions for future identification and support purposes.

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

Recommendation 14.14

Addressed to Cranstoun Worcestershire

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.

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

Recommendation 14.15

Addressed to Cranstoun Worcestershire

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.

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

Recommendation 14.16

Addressed to Clinical Commissioning Group

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.

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

Recommendation 14.17

Addressed to Clinical Commissioning Group

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.

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

Recommendation 14.18

Addressed to Clinical Commissioning Group

All staff who have face-to-face contact with patients and service users should undertake learning activities connected to domestic abuse training.

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