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

Uttlesford review

CSP: Uttlesford Published: August 2023 Year of death: 2020 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 significant failures in the timely assessment and management of the perpetrator's mental health, a lack of understanding and assessment of the complex caring relationship with the victim, including carer stress and potential coercive control, and poor multi-agency coordination and communication.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
1	The Essex Safeguarding Adults Board (ESAB) should seek assurance from all partners that there is an understanding of the requirement of carer assessments under the Care Act and from Adult Social Care, and that these are effectively undertaken.	Essex Safeguarding Adults Board
10	Contributing agencies to this review should provide the SETDAB and ESAB with assurance that the single agency actions identified in the Individual Management Reports are completed and reported on.	Contributing agencies to this review
11	Essex Adult Social Care should provide assurance to Essex Safeguarding Adults Board that where a care and support package is required immediately but there are moving and handling concerns and a specialist assessment is indicated, consideration is given as to how to provide support in the meantime rather than waiting for the outcome of that additional assessment.	Essex Adult Social Care
12	Uttlesford Community Safety Partnership to ensure that local domestic abuse services and SET DAB resources are promoted to local agencies and communities.	Uttlesford Community Safety Partnership
2	EPUT and Essex Adult Social Care to: - (a) Develop closer working relationships, in particular undertaking coordinated assessments working towards joint care planning and provide a progress update to ESAB. (b) EPUT and Adult Social Care should provide evidence that activity is coordinated withing the terms of the Section 75 agreement (NHS 2006)	EPUT \| Essex Adult Social Care
3	EPUT should provide evidence and demonstrate to ESAB that: - (a)The recommendations within their internal investigation report are being implemented and the progress of that implementation. (b)That the transformation of the assessment service and delivery pathways have delivered the anticipated service improvement. (c)That where referrals are made from the community that the response is timely and feedback on the course of action is offered (d) That where there is evidence of medication misuse by a client a timely medication review is undertaken. (e) That EPUT reviews their Access Policy to take into account the fact that persons not attending appointments are vulnerable due to mental health issues and may require additional support. (f) That all of the above are managed in order to ensure learning is embedded within practice.	EPUT
4	The Essex Safeguarding Board should highlight to partner agencies the importance of making appropriate safeguarding referrals with reference to the LGA/ADASS guidance `Understanding what constitutes a safeguarding concern and how to support effective outcomes and the ‘Safeguarding Concerns Framework’.	Essex Safeguarding Board
5	The Essex Safeguarding Board should use this review to build on the Making Safeguarding Personal Project to include seeking innovative means of facilitating the ability of adult’s voices to be effectively heard.	Essex Safeguarding Board
6	All agencies involved in this review should consider how it can continue to promote a positive culture of professional curiosity which supports effective multi-agency working and how this can be assured and monitored through reflective supervision and performance management	All agencies involved in this review
7	All agencies in this review should ensure that professionals who are responsible for services are aware that coercion and controlling behaviours can form part of complex relationships and of the ways that this may manifest.	All agencies in this review
8	EPUT and their commissioners should review their current policies and procedures in relation to Domestic Abuse and coercive control and provide evidence that this is embedded in their training and practice.	EPUT \| EPUT's commissioners
9	The Essex Safeguarding Adults Board continues to promote the Hoarding Guidance and be assured it is understood and that agencies consider and use the available tools to assess and seek support for hoarding behaviour.	Essex Safeguarding Adults Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗