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
Uttlesford review
CSP: Uttlesford
Published: August 2023
Year of death: 2015
Extracted: 13 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 concerns regarding agencies' fragmented responses to familial domestic abuse, particularly where co-existing mental health and substance misuse issues were present. It identifies failures in holistic risk assessment, inter-agency communication, continuity of care for offenders, and proactive engagement with victims and non-compliant individuals.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | West Essex Clinical Commissioning Group to ensure that training is made available to General Practices on identifying domestic abuse and risk to ensure that they are equipped to refer appropriately to the MARAC; to have reference to the materials available through the IRIS project42 to support this. To report to the Uttlesford Community Safety Partnership on the actions taken. | West Essex Clinical Commissioning Group |
| 10 | That NHS England share nationally the learning from this Review, as addressed by recommendation 13, and encourage all mental health Trusts to ensure their Discharge Policies adequately address cases where patients transfer into or between prisons. | NHS England |
| 11 | Hertfordshire MAPPA Strategic Management Board to work with the Local Authorities to ensure that housing departments and housing associations are adequately represented at and engaged with MAPPA and that a position of flexibility in relation to housing options for offenders is taken to support the management of risk. | Hertfordshire MAPPA Strategic Management Board |
| 12 | The Essex Southend and Thurrock Domestic Abuse Strategic Board to direct all members to review their onward referral processes in light of the learning in this DHR, and make changes where necessary to ensure that referrals are: recorded where possible; followed up to ensure they have been received; and appropriate action taken if referral has not been received / accepted. For member agencies to feedback to the Strategic Board on this. | The Essex Southend and Thurrock Domestic Abuse Strategic Board |
| 13 | STaRS, EPUT, ADAS and Victim Support to review their approach and response to people who ‘don’t engage’ in the service, in light of the learning identified in this DHR, to ensure barriers to people’s engagement are identified and acted upon, and that motivational work is done that aims to improve engagement. To take appropriate action where necessary and feed back to the Uttlesford CSP. For the learning from these agency reviews to be shared through the Essex Southend and Thurrock Domestic Abuse Strategic Board. | STaRS | EPUT | ADAS | Victim Support |
| 2 | West Essex Clinical Commissioning Group to work with EPUT, STaRS, ADAS and other commissioned drug and alcohol and mental health services to establish a procedure for joint working with General Practices to ensure that individuals receive support in a coordinated way. To report to the Uttlesford Community Safety Partnership on the actions taken. | West Essex Clinical Commissioning Group |
| 3 | Her Majesty’s Prison and Probation Service to take action to ensure all prisons have adequate structures in place to communicate with the NPS prior to an offender being released to ensure that licence conditions reflect sentence plans. | Her Majesty’s Prison and Probation Service |
| 4 | Essex Police, Hertfordshire Constabulary, EPUT and STaRS to review their domestic abuse training and materials to ensure that practitioners understand domestic abuse as a pattern of coercive and controlling behaviours, not as a single incident. For local commissioned domestic abuse specialist services to be involved to support this understanding. To report to the Uttlesford CSP and the Essex Southend and Thurrock Domestic Abuse Strategic Board on the actions taken. | Essex Police | Hertfordshire Constabulary | EPUT | STaRS |
| 5 | Home Office to utilise DHR findings to develop and share nationally an in-depth understanding of the risk factors relating to familial abuse. | Home Office |
| 6 | STaRS and EPUT to review their dual diagnosis approach in light of the learning in this DHR, for example through a dip sample audit of cases, to ensure that policy is reflected in practice; and to ensure that, where a person presents with substance misuse and mental health issues, that both are addressed before a person is discharged. To take appropriate action where necessary and feed back to the Uttlesford CSP. | STaRS | EPUT |
| 7 | The Essex Adult Safeguarding Board to review, and amend where necessary, multi-agency policy and training to address the learning from this Review concerning support offered for families with caring responsibilities, specifically: conversations with those who have caring responsibilities should not be limited to offering carer’s assessments, and must be open, non-judgemental and avoid labelling someone as ‘a carer’, to allow individuals and families to express their needs and wishes, and be directed to appropriate support. | The Essex Adult Safeguarding Board |
| 8 | The Essex Southend and Thurrock Domestic Abuse Strategic Board to share with all members the learning in this DHR in relation to the need for agencies to engage with individuals holistically: and for agencies to integrate this into training to ensure that all of an individual’s issues and needs are identified, and appropriate referrals are made where necessary. | The Essex Southend and Thurrock Domestic Abuse Strategic Board |
| 9 | The mental health NHS Trusts named in this Report to amend their Discharge Policies to ensure that they set out clearly the procedure for when a patient under their care is transferred into prison (or into a different prison), and that these procedures take into account the learning from this Review. | North Essex Partnership University NHS Foundation Trust | Northamptonshire Healthcare NHS Foundation Trust | Sussex Partnership NHS Foundation Trust | Oxleas NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||