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
Wiltshire review
CSP: Wiltshire
Published: September 2023
Year of death: 2014
Extracted: 16 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 concerns regarding inadequate information sharing between primary and secondary mental health services, and within secondary care, about the perpetrator's history of severe depression and stated risk to the victim. There were also issues with delays in assessment, staff training for older adults, and service capacity.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 8.2.1 | Primary and secondary health services in Wiltshire to work together to produce a referral template that is quick and easy to electronically complete at the GP surgery, whilst transferring all relevant clinical and social information to the secondary care service | Primary and secondary health services in Wiltshire |
| 8.2.2 | For all involved organisations to review internal cultures to embed the spirit of organisational participation in future Domestic Homicide Reviews, improving information sharing to reassure families that organisations are supporting the Review process with transparency, integrity and fairness. | All involved organisations |
| 8.4.1 i) | Ensure that there is a system in place for: Routinely screening information that is sent to the team by referrers | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.1 ii) | Ensuring that a record is made to indicate that this screening process has taken place, and to alert clinicians to new information, for example by recording its existence in the progress notes. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.2 i) | Ensure that a paper copy of information sent to either team by referrers is filed in the ‘blue folder’ and that this folder is handed over to any team which subsequently takes over the care of the service user | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.2 ii) | Ensure that a person’s veteran status is highlighted in the Ex-British Armed Forces Indicator, under additional personal information, on RIO. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.2 iii) | Ensure that Team Members are familiar with the Veteran’s Service website, so that they can suggest service users access it when appropriate | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.3 i) | Ensure that ageless services/teams are provided with appropriate training in the needs of both adults of working age and older adults with functional illnesses | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.3 ii) | Review the staffing of the PCLS service to ensure that there are adequate numbers of substantive clinical and administrative staff | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.3 iii) | Liaise with primary care services to review the process for sharing information at the point of referral to ensure that: Key information is highlighted and unnecessary information is not provided (as this may breach the patient’s confidentiality and may make significant information harder to identify) | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.4 i) | Review the process for obtaining paper records in the light of the feedback that this process has ‘slowed down’ since the advent of RIO and that teams are, therefore, less inclined to seek these out. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.4.4 iv) | Review whether the ‘Working with Military Veterans’ training should be made available again. | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 8.5.1 | GPs should be reminded re the risk of prescribing amitriptyline when there is a risk of overdose. | Salisbury Plain Health Partnership |
| 8.5.2 | Patients who have previously overdosed should be searched for on the clinical system and a screen note added to their notes to act as a reminder prompt for the GPs when consulting with these patients. | Salisbury Plain Health Partnership |
| 8.5.3 | Administration team should follow all standard operating procedures, a reminder to this effect and review of the “Fax out” standard operating procedure. | Salisbury Plain Health Partnership |
| 8.5.4 | consideration should be given to improving communication from the Intensive Team/ AWP back to the GP regarding their involvement with patients. | Salisbury Plain Health Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||