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
Stoke-on-Trent review
CSP: Stoke-on-TrentPublished: August 2023Year of death: 2019Extracted: 9 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified concerns regarding inadequate multi-agency information sharing, inconsistent risk assessment and management for victims and children, and premature case closures. Issues included insufficient police investigation of allegations and retractions, and gaps in health professionals' awareness and response to domestic abuse.
Home Office classifications
34 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Victim - case heard at marac before homicide
Children - under 18 shared parental responsibility (between victims)
Children - under 18 shared parental responsibility (between perpetrators)
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Children - present at homicide (including adult children)
Children - subject to child protection or domestic abuse prior to homicide
Children - removed into care
Child - primary address same as victim
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
Perpetrator - died by suicide
Perpetrator - immigration involvement
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - sexual abuse
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - police recommendations
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - community safety partnership recommendations
DHR process - training recommendation themes
DHR process - multi agency working recommendation themes
DHR process - other recommendation themes
Extracted recommendations
9 recommendations pulled from the report · 5 matched to organisations in the index
Addressed to
Staffordshire Police | West Midlands CPS | Stoke-on-Trent Community Safety Partnership
Staffordshire Police and West Midlands CPS should provide evidence to the Stoke-on-Trent Community Safety Partnership that the possibility of progressing an evidence-led investigation / prosecution in domestic abuse cases, as recommended in national guidance, is always considered, and that this includes effective partnership working with other agencies to establish if they have information and / or potential evidence to assist the investigation.
Addressed to
Stoke-on-Trent Community Safety Partnership
The Stoke-on-Trent Community Safety Partnership should seek assurance that there is effective information sharing and partnership working to assist full exploration by Staffordshire Police of the possible factors which may be leading to an alleged victim of domestic abuse seeking to withdraw their allegations, and / or to investigate reports of abuse where counter allegations are made.
Addressed to
Staffordshire Police | Stoke-on-Trent City Council Children’s Services
Staffordshire Police and Stoke-on-Trent City Council Children’s Services should ensure that there is liaison and joint evaluation of any potential safeguarding risks to children when the police are considering whether to impose police bail or release an alleged perpetrator under further investigation;
Addressed to
Stoke-on-Trent Safeguarding Children Partnership
The Stoke-on-Trent Safeguarding Children Partnership should assure itself that: - there is multi-agency guidance available to all professionals that covers work with families who are hard to engage, or resist professionals’ intervention, and that this is being applied effectively; - professionals are clear about the criteria and arrangements for convening a multi-agency meeting in order to assess risk, and formulate a revised plan of intervention to safeguard children, where there is continuing non engagement and / or access to a child is denied.
Addressed to
Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board
The Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should assure itself that there is evidence that professionals are aware of the processes that have been put in place for escalating concerns, and / or challenging decisions made by partner agencies where it is considered that these may be placing victims of domestic abuse, and / or their children, at further risk.
Addressed to
Stoke-on-Trent Community Safety Partnership
The Stoke-on-Trent Community Safety Partnership should seek assurance that there is evidence that: (i) within the multi-agency processes to assess risk in domestic abuse cases, consideration is always given to a disclosure being made to the new partner of an alleged perpetrator through the “right to know” provisions within the Domestic Abuse Disclosure Scheme; (ii) the protocols agreed by Staffordshire Police and Stoke-on-Trent City Council Children’s Services for the latter to make these disclosures are being applied.
Addressed to
University Hospital North Midlands (UHNM)
University Hospital North Midlands (UHNM) should, when disclosures of domestic abuse have been made, always attempt to complete body maps, with the patient’s consent, to note relevant or significant injuries.
Addressed to
University Hospital North Midlands (UHNM)
University Hospital North Midlands (UHNM) should ensure that hospital discharge letters sent to GPs include a full account of any disclosures made by patients regarding domestic abuse and any actions taken to explore these.
Stoke-on-Trent CCG should provide evidence to the Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board of the impact of Domestic Abuse Awareness Training provided to GPs and other professionals.