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
Dorset review
CSP: Dorset
Published: August 2023
Year of death: 2019
Extracted: 25 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
Agencies overlooked the victim's risk of familial domestic abuse, influenced by age and gender stereotypes. Gaps in inter-agency information sharing, MARAC processes, and risk assessments for the perpetrator contributed to missed opportunities to safeguard both victims.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | That Safer Somerset Partnership and Dorset Community Safety Partnership widely disseminate the learning from this review locally but also consider preparing a briefing derived from the learning from this case and circulating it nationally. | Safer Somerset Partnership | Dorset Community Safety Partnership |
| 10 | That Safer Somerset Partnership seeks assurance that in discharging their responsibility to engage with service users holistically in order to anticipate and prevent the escalation of future needs, Adult Social Care also enquires about domestic abuse including familial domestic abuse. | Safer Somerset Partnership |
| 11 | That Safer Somerset and Dorset Community Safety Partnership write to the Home Office to alert them to the issue so that they can liaise with the Ministry of Justice and consider what action is necessary. | Safer Somerset Partnership | Dorset Community Safety Partnership |
| 2 | That Safer Somerset and Dorset Community Safety Partnerships make use of the learning from this review to raise public awareness of familial domestic violence and abuse. | Safer Somerset Partnership | Dorset Community Safety Partnership |
| 3 | That Safer Somerset Partnership seeks assurance that the MARAC process is effectively supported and co-ordinated. | Safer Somerset Partnership |
| 4 | That Safer Somerset Partnership seeks assurance that all partner agencies which could have a role to play in safety planning for the victims of domestic violence and abuse are involved in that safety planning. | Safer Somerset Partnership |
| 5 | That Safer Somerset Partnership and Dorset Community Safety Partnership jointly write to the Home Office to recommend a review of guidance in respect of MARAC to MARAC referrals to include consideration of such referrals when a perpetrator moves between areas. | Safer Somerset Partnership | Dorset Community Safety Partnership |
| 6 | That Safer Somerset Partnership seek assurance that where Avon and Somerset Constabulary have intelligence or evidence that a perpetrator of high risk domestic abuse keeps weapons (of any sort), that this information is shared with the IDVA and other services, in order to facilitate effective safety planning. | Safer Somerset Partnership |
| 7 | That Dorset Community Safety Partnership reviews the Data Sharing Agreement with the Ministry of Justice - which would enable Magistrates Courts to contribute to future DHRs - when the agreement is complete and shares it with the Home Office . | Dorset Community Safety Partnership |
| 8 | That Safer Somerset Partnership obtains assurance from Avon and Somerset Constabulary that the review of relevant information on their pocketbook system has fully addressed the learning rising from this review in respect of dealing with breaches of Court imposed bail conditions. | Safer Somerset Partnership |
| 9 | That Safer Somerset and Dorset Community Safety Partnerships review the role of GP practices in addressing domestic violence and abuse, in particular the information which is shared with them and the extent to which the information they hold is shared with the MARAC process. | Safer Somerset Partnership | Dorset Community Safety Partnership |
| A1 | Audit VA records where there is a recorded positive outcome to provide assurance that the Police National Computer is accurate. | Avon and Somerset Constabulary |
| A10 | Staff to form a decision based on presenting information, not previous decisions made. They need to take into consideration the accumulation of concerns to reassess levels of risk. | Somerset Council Adult Social Care |
| A11 | Safeguarding Adults Service to ensure they have oversight of enquiries even if they do not identify any other active role in protection planning. | Somerset Council Adult Social Care |
| A12 | Safeguarding service to ensure they respond to referrers at the point of triage. | Somerset Council Adult Social Care |
| A13 | Locality Teams to undertake assessment of need when there is sufficient information to suggest an adult has needs for care and support. Not to request or rely on other agencies making initial assessments. | Somerset Council Adult Social Care |
| A14 | A visit to be undertaken to Dorothy by Safeguarding Adults Service for welfare visit. | Somerset Council Adult Social Care |
| A2 | Review and update the Domestic Violence Disclosure Scheme in line with the amendments from the Domestic Abuse Bill. This review should include how the use of the Domestic Violence Disclosure Scheme is promoted across the organisation, including when to instigate applications on a ‘Right to Know’ basis, as well as the `Right to Ask’ process. | Avon and Somerset Constabulary |
| A3 | Data Quality - Force Review Officer to issue a communication through ‘Lessons Learned’ bulletin reinforcing the importance of data quality. | Dorset Police |
| A4 | Understanding of Adult at Risk and Domestic Abuse reporting - Dorset Police will use this incident as a case study for the second round of vulnerability training which is scheduled for June 2020. | Dorset Police |
| A5 | MARAC Minutes made available to NPS court report writers | National Probation Service |
| A6 | NPS to review system for obtaining call out information from police forces outside Avon and Somerset Area | National Probation Service |
| A7 | Disclosure of suicidal thinking during a (pharmacy) medication telephone review should be shared with another clinician (GP) and decisions and actions documented. | NHS Somerset Clinical Commissioning Group |
| A8 | The GP as Primary Health Care Provider should be included in information sharing for high risk domestic abuse incidents which relate to their patients, both victims and perpetrators (e.g. police domestic abuse notifications and MARACs) | NHS Somerset Clinical Commissioning Group |
| A9 | Safeguarding Service and Somerset Direct to ensure they are not declining Safeguarding referrals based on consent and advising people to re-refer as per adults wishes. | Somerset Council Adult Social Care |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||