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: 11 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 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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 10 | Escalation through internal safeguarding pathways. | North West Boroughs Healthcare |
| 11 | Completion of risk documentation | 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 Community Safety Partnership | St Helens IDVA Service | St Helens Council Adult Safeguarding Team |
| 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 Adult Safeguarding Board |
| 7 | 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 |
| 8 | 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) | North West Boroughs Healthcare |
| 9 | The sharing and acting on information between the two practitioners in Making Space and Recovery team. | North West Boroughs Healthcare |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||