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

St Helens review

CSP: St Helens Published: August 2023 Year of death: 2019 Extracted: 10 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 identifies systemic failures in inter-agency communication, a lack of professional curiosity regarding domestic abuse risks, and missed opportunities to conduct risk assessments and provide timely support to the victim. Key issues include inadequate response to disclosures of coercive control and alcohol abuse, and insufficient training for frontline staff.

Extracted recommendations

10 recommendations pulled from the report

#	Recommendation	Addressed to
10	Staff to complete an Internal Referral to NWBH Safeguarding Team with a communication form highlighting concerns.	North West Boroughs Healthcare
11	Staff to update the Individual Risk Assessment document upon receipt of any information considered to be a risk.	North West Boroughs Healthcare
25.2	In the area of mental health care and safeguarding, professional curiosity at the initial screening and throughout patient contact to be developed through further domestic abuse training and supervision.	North West Boroughs Healthcare
25.3	Recognition of the need to complete domestic abuse risk assessments within G.P. practices.	St Helens Clinical Commissioning Group
25.4	Staff from 3rd Sector agencies engaged in front line service provision to people with mental health conditions are provided with multi-agency training on the signs and symptoms of domestic abuse and the pathways into the reporting of and support for these victims and the completion of risk assessments. This should be an ongoing program to capture new entrants into the services.	St Helens Council Adult Safeguarding \| IDVA Service
25.5	The Mental Health Service will continue working with staff from within mental health care providers, mental health services, and Adult Safeguarding to provide ongoing safeguarding supervision thereby ensuring that the need for domestic abuse risk assessment is recognised and provided.	North West Boroughs Healthcare
25.6	The current practice of telephone triage for patients with complex needs to cease and those identified patients be offered face to face appointments.	North West Boroughs Healthcare
25.7	Development of a system of referral to Adult Safeguarding which is open, transparent and auditable between mental health care providers, mental health services and the Adult Safeguarding team	St Helens Council Adult Safeguarding
8	There will be a clear consistent process based on NWBH Policy & Procedure that can be appropriately bench marked and which will; provide clear direction to staff around the regrading of CPA and the involvement of service users and other agencies involved in care and support of patients. CPA Policy & Procedure is currently being reviewed.	North West Boroughs Healthcare
9	Care records will clearly document sharing of information alongside evidence of staff escalating concerns and acting on concerns where it is appropriate to do so. Invitation to be offered to Making Space Team to attend Recovery Team meeting and for Recovery team management to attend Making Space Team meeting to establish better communication links and foster a more appreciative understanding of any barriers to closer working.	North West Boroughs Healthcare
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗