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 HelensPublished: August 2023Year of death: 2019Extracted: 11 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review highlights systemic failures in inter-agency communication and risk assessment, particularly regarding domestic abuse and mental health. Key concerns include missed opportunities to act on disclosures of coercive control, inadequate safeguarding responses, and a lack of professional curiosity about escalating risks.
Home Office classifications
29 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - was a carer
Victim - alcohol misuse
Victim - mental ill health
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - mental ill health
Perpetrator - psychosis
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 others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - sexual abuse
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family received draft report
DHR process - health services recommendations
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - other recommendation themes
Extracted recommendations
11 recommendations pulled from the report · 9 matched to organisations in the index
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.
Lack of Clarity around the formal CPA process as opposed to the New Ways of Working ‘Care Coordinator Assessment and Review Process’ (Nurse lead MDT Reviews)
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.
Addressed to
St Helens Community Safety Partnership | St Helens IDVA Service | St Helens Council Adult Safeguarding Team
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.
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.
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