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
Nuneaton and Bedworth review
CSP: Nuneaton and Bedworth
Published: August 2023
Year of death: 2012
Extracted: 37 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 identified weaknesses in multi-agency information sharing, MARAC processes, and risk assessment practices, leading to missed opportunities to identify escalating domestic abuse risks and provide effective support to the victim, who was reluctant to engage with services.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Safer Warwickshire Partnership Board to develop Domestic Violence and Abuse Procedures that include: a. Clear, written policies for all agencies in the county explaining when and how to refer to specialist domestic violence support services e.g. Refuge (for accommodation services) and Stonham Home Group (the organisation now running IDVA and outreach services in the county) to ensure vulnerable victims do not fall between services. b. A process to ensure that feedback is requested and given on the outcome of referrals, especially if no contact can be made or support is declined, so that alternative options can be explored. c. A reminder to officers/agencies investigating or reporting domestic abuse incidents of the importance of recording the full names and home addresses of any children witnessing domestic abuse – this is especially important when they are visiting a parent and are not residing at their usual home address | Safer Warwickshire Partnership Board |
| 10 | The MARAC steering group develops a robust process for identification of MARAC repeat cases from other agencies along with subsequent MARAC referral, as part of the MARAC Improvement Plan. | MARAC Steering Group |
| 11 | The MARAC steering group ensures that all recommendations of the CAADA Quality Assurance assessment have been implemented. | MARAC Steering Group |
| 12 | Warwickshire Police review the investigative decision-making process relating to ‘high risk’ domestic abuse incidents, to ensure that the appropriate level of skill and type of resources and supervision is allocated to each specific Domestic Abuse investigation. | Warwickshire Police |
| 13 | Warwickshire Police ensure that the findings of the review of the police Referrals & Assessment Unit (RAU), which identified the need for better levels of supervision and processes to facilitate more efficient management of caseloads of staff, has been fully implemented, including: a. Development of a policy that identifies acceptable levels of inputting backlogs dependant on risk level, and that includes a mechanism for reporting when the levels are exceeded. b. Embedding the new process that has already been introduced to actively manage and triage any backlog to identify any case that relates to either a pre-existing or subsequent ‘high risk’ incident is working effectively c. That the business case to introduce a new structure within the RAU with dedicated supervisory roles has been fully implemented. (This was accepted as part of the new joint policing arrangements between Warwickshire Police and West Mercia Police with new posts to be in place by December 2013.) | Warwickshire Police |
| 14 | Warwickshire Police share the learning points from the IMR and the DHR as a whole with all police officers and staff using DASH to ensure that the risk assessments are applied with consideration of all available information. | Warwickshire Police |
| 15 | Warwickshire police ensure that they take positive action to: a. Arrest perpetrators of all alleged crimes relating to domestic violence when the opportunity arises b. Collect all available evidence including at initial call-out to increase chance of prosecution (always assume the victim will not support the prosecution.) | Warwickshire Police |
| 16 | Warwickshire Police to review the DASH “aide memoire” card to include breach of bail conditions as a high risk indicator | Warwickshire Police |
| 17 | The local Criminal Justice Board to improve the process for completing inter- agency checks by: a. Considering prioritising resource allocation to the information exchange process b. Liaising with the HMCTS/sentencers to tolerate adjournments for this to take place where it is recommended by the Probation Court Duty Officer | Local Criminal Justice Board |
| 18 | The Probation Trust ensures that the actions, set out below, that were agreed in relation to the Serious Further Offence (SFO) investigation have been fully implemented in line with agreed timescales: a. Previous convictions must be used to inform every Pre-Sentence Report risk screening or their absence should be noted and corrected as soon as possible: i. All court duty staff to be reminded of this core practice expectation ii. Take appropriate internal action in relation to the conduct of officers not following procedures iii. Area Office Administrators to review court administrative practice to ensure pre cons are collected and passed to Unpaid Work immediately post sentence iv. Unpaid Work operational managers to be reminded that previous convictions must be checked before risk screenings are signed. Also that in signing risk screenings they are confirming they are satisfied themselves that the information is accurate b. Address the potential for inconsistency and inappropriate judgements in relation to enforcement when offender reporting illness or death of significant others: the Unpaid Work manager to circulate guidance to all operational managers on decision making in relation to this issue. c. Ensure that these requirements are incorporated into new contracts/SLAs with the new Community Rehabilitation Company. | Probation Trust |
| 19 | That information provided by friends and family is shared with the Offender Manager who is preparing post-sentence assessments as this will be of significant help in developing the perpetrator’s profile. | Probation Trust |
| 2 | Safer Warwickshire Partnership Board to direct the MARAC Steering Group to take the following actions to improve the DASH risk assessment process and : a. Develop and implement multi-agency training on the use of DASH to assess risks and ensure that risk assessments are i. in line with CAADA guidelines ii. use professional judgement in cases where the victim is unable or reluctant to fully disclose information that might highlight the risks more iii. take into account the history and full circumstances of the case iv. repeated when circumstances change – i.e. following a withdrawal of statement, a breach of police bail conditions and when a decision is made not to charge b. Explore the options for developing risk assessments of the risks posed by perpetrators, and linked to this, the identification of serial abusers. | Safer Warwickshire Partnership Board |
| 20 | George Eliot Hospital develops and implements a Domestic Abuse Policy and seeks multi-agency validation via members of the Review Panel to ensure that the policy is fit for purpose and reflects best practice. | George Eliot Hospital |
| 21 | George Eliot Hospital targets front line staff in A&E with specific domestic abuse training to enable them to identify people at risk and initiate appropriate supportive and preventative actions. | George Eliot Hospital |
| 22 | George Eliot Hospital put in place appropriate training for senior managers and ensures that there is effective leadership to support cultural change within the organisation to improve practice in domestic abuse cases. | George Eliot Hospital |
| 23 | George Eliot Hospital puts in place procedures to ensure that correspondence from A&E to GPs is legible and forwarded without delay following presentation of a patient with serious issues such as self-harm, a suicide attempt or abuse. | George Eliot Hospital |
| 24 | George Eliot Hospital to either explore the possibility of an IDVA being based on site, or to put in place a procedure by which A & E staff can contact the on call IDVA. | George Eliot Hospital |
| 25 | All agencies disseminate the learning from this DHR and review the recommendations to identify any changes that need to be made to their internal practice or procedures | Warwickshire Police | Probation Trust | Coventry & Warwickshire Partnership Trust | George Eliot Hospital | West Midlands Ambulance Service | South Warwickshire Nhs Foundation Trust | Harmoni | Warwickshire County Council | Nuneaton & Bedworth Council | Children’s Services |
| 26 | All agencies ensure that all ‘client facing’ staff, particularly those undertaking assessment, complete training regarding Domestic Violence and Abuse (DVA) awareness that is in line with the NICE Guidance (Feb 2014), proportionate and relevant to their role. This needs to include: a. Understanding of indicators of domestic abuse from the perspective of perpetrators and / or victims, and the impact upon victims, particularly children b. Responding to disclosures of domestic abuse including knowledge around specific assessment tools such as DASH, support services available and professional responsibilities. c. Explicitly highlighting domestic abuse issues in the current safeguarding sessions delivered within induction to all staff, and including awareness of how to access specialist advice and support that is available both within and external to the agency | Warwickshire Police | Probation Trust | Coventry & Warwickshire Partnership Trust | George Eliot Hospital | West Midlands Ambulance Service | South Warwickshire Nhs Foundation Trust | Harmoni | Warwickshire County Council | Nuneaton & Bedworth Council | Children’s Services |
| 27 | All agencies review administrative procedures and support within front line services to ensure that correspondence to other agencies is completed within an appropriate timescale. | Warwickshire Police | Probation Trust | Coventry & Warwickshire Partnership Trust | George Eliot Hospital | West Midlands Ambulance Service | South Warwickshire Nhs Foundation Trust | Harmoni | Warwickshire County Council | Nuneaton & Bedworth Council | Children’s Services |
| 28 | All agencies include a link to the Warwickshire Against Domestic Abuse website on their safeguarding website. | Warwickshire Police | Probation Trust | Coventry & Warwickshire Partnership Trust | George Eliot Hospital | West Midlands Ambulance Service | South Warwickshire Nhs Foundation Trust | Harmoni | Warwickshire County Council | Nuneaton & Bedworth Council | Children’s Services |
| 29 | The CCG and Local Area Team, as the commissioner of primary care services, ensure through their contractual arrangements that all GP practices are aware of, and complying with, guidance published by the Royal College of General Practitioners (RCGP), Identification and Referral to Improve Safety (IRIS) and CAADA on responding to domestic violence | Warwickshire North Clinical Commissioning Group | Local Area Team |
| 3 | Safer Warwickshire Partnership Board delivers a public awareness campaign (e.g. production of information leaflets / posters which can be distributed throughout agencies) that addresses the myths about stereotypical victims of abuse. | Safer Warwickshire Partnership Board |
| 30 | The CCG considers commissioning the IRIS project, which is a general practice- based domestic violence and abuse training support and referral programme, based on collaboration between primary care and third sector organisations specialising in domestic violence abuse. The CCG should note that the Department of Health is also funding some roll-out of IRIS through its Innovation, Excellence and Strategic Development (IESD) Fund. | Warwickshire North Clinical Commissioning Group |
| 31 | The CCG and Local Area Team, as the commissioner of primary care services, disseminates the learning from this DHR to all GP practices within the County and request that GP practices implement the following improvements to their administrative procedures: a. When information in relation to correspondence is added to the electronic records a note of the date the information is received must be made in the record. b. To introduce a flagging system for Domestic Abuse history to be recorded on the electronic record system c. GP practices to consult their Software producer for the GP practice IT system to identify if an update to the electronic records system can be made to enable the system to make automatic links of registered patients by address d. Safeguarding and Domestic Abuse training to be completed by all staff at the primary care practice, including awareness of MARAC process. e. To introduce a system to ensure that unreadable & unclear correspondence received is requested in a legible format from the agency sending correspondence and to escalate concerns if a pattern or theme is spotted with an agency. | Warwickshire North Clinical Commissioning Group | Local Area Team |
| 32 | The CCG and Local Area Team, as the commissioners of health services, put in place measures to improve the sharing of information between health agencies around domestic abuse and violence, including: a. Disseminating the new Code of Practice on Information Sharing within the NHS, when this is issued by the Department of Health b. Focussing specifically on the context of deliberate self-harm and other mental health assessments within A & E. c. Working with NHS providers to improve communication between services to highlight potential at risk individuals and families so these cases can possibly be picked up using early warning signs, including links to any “frequent flyer” programmes. This applies in particular to communication across mental health, A & E, GP and substance misuse services. d. Reducing delays in sending correspondence to GPs especially related to a serious incident such as attempted suicide e. Improved clarity for the respective agencies of follow up arrangements following an attempted suicide with less reliance on the patient to make contact for follow-up f. To ensure that reduced staffing services over Christmas and New Year or other holiday periods do not negatively impact upon communication to other health and social care agencies | Warwickshire North Clinical Commissioning Group | Local Area Team |
| 33 | That the CCG ensures that all NHS providers have a Domestic Abuse Policy in place as a contractual requirement. | Warwickshire North Clinical Commissioning Group |
| 34 | The CCG/Local Area Team circulates information about the MARAC process to all GP practices along with the new CAADA Guidance for GPs. | Warwickshire North Clinical Commissioning Group | Local Area Team |
| 35 | The CCG, through the Health Panel, takes action to improve awareness of domestic abuse at a senior management level to ensure better leadership and cultural change across organisations. This could be linked to implementing the NICE guidance which is due to be published in February 2014 and should include embedding domestic abuse in the “Making Every Contact Count” approach to addressing health inequalities. | Warwickshire North Clinical Commissioning Group |
| 36 | Children’s Services ensure and reinforce that Children’s Teams follow the existing guidance in respect of referrals where children may be at risk of significant harm and the protocol for Domestic Abuse referrals in a timely manner. | Children’s Services |
| 37 | Children’s Services to develop guidance/ process for frontline staff to support them in risk assessing victims when domestic abuse is disclosed by clients/ children. This should also extend to when historic abuse is disclosed by a partner who still has contact with the perpetrator due to child access arrangements. | Children’s Services |
| 4 | Safer Warwickshire Partnership Board develops an Information Sharing Protocol, with accompanying guidance, for all partner agencies regarding sharing information within DHRs. This should include guidance on collecting information in a timely way so that any information that cannot be shared with the Panel pre-trial has been secured internally, thus avoiding the difficulty caused by staff moving on or forgetting detail. | Safer Warwickshire Partnership Board |
| 5 | The Chair of the Safer Warwickshire Partnership Board raises with the Home Office and with CAADA the following national concerns: a. The lack of sanctions available to police regarding breaches of police bail. b. The need for CAADA to revise the guidance on the definition of repeat incidents, to include incidents where bail conditions have been breached | Safer Warwickshire Partnership Board |
| 6 | The Chair of the Safer Warwickshire Partnership Board raises with the CPS the following national concern: that the CPS explores whether there are opportunities to speed up the process for progressing charges to reduce the risks of withdrawal or retraction | Safer Warwickshire Partnership Board |
| 7 | Warwickshire County Council, as the commissioner of domestic abuse services, completes a review of the IDVA service to ensure that resources are maximised and deployed effectively to adequately support high risk victims across the County. This should include exploring alternative, flexible models of multi- agency support. The findings of the review should be reported to the Safer Warwickshire Partnership Board and identify the strategy for managing workload within the context of diminishing resources. | Warwickshire County Council |
| 8 | The MARAC steering group develops and ensures implementation of an induction programme for new MARAC agencies and representatives to support them in understanding their roles and the requirements of MARAC agencies. | MARAC Steering Group |
| 9 | The MARAC steering group implements the following improvements to MARAC processes and procedures, ensuring that these are all compliant with CAADA guidance and checklists: a. Completes and circulates the revision of the MARAC Operating Protocol b. Completes and circulates the MARAC Information Sharing Protocol c. Improves and re-formats the MARAC minutes template to ensure that it includes: i. Whether the victim is aware of the referral ii. The contribution of each agency iii. Detail of the discussion of the case iv. The rationale of why actions were not pursued v. The risks identified, how these risks will be addressed, by whom and by when vi. Identification of the support agency for the victim to feedback the outcome of the MARAC to the victim vii. That clear SMART action points are included in MARAC minutes following all MARAC meetings to prevent ambiguity.(refuge) d. Clearly defines the role of the IDVA in relation to the MARAC, including the requirement to contact the victim prior to the meeting and to ensure that there is clarity about ongoing contact e. Makes a formal decision regarding the flagging of files, and inform all agencies of the outcome and the procedure for doing so f. Reminds all agencies of their responsibilities relating to attendance, including sending deputies and/or written notes in the absence of the usual representative g. In view of the high number of cases referred to the North MARAC, to split the monthly meeting into 2 (if less than 20 cases referred, the second meeting can be cancelled). h. Completes a feasibility study as to whether a multi-agency web-based database for MARAC cases (e.g. Paloma’s MODUS database) would be beneficial. | MARAC Steering Group |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||