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
Tendring review
CSP: Tendring
Published: September 2023
Year of death: 2015
Extracted: 27 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 identifies systemic failures in information sharing, risk assessment, and inter-agency coordination regarding the perpetrator's history of violence, mental health needs, and accommodation. Gaps in planning for release from custody and untimely enforcement of court orders were also key concerns.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The learning from this and previous Reviews confirms that information on arrests of persons already supervised by Probation (CRC or NPS) is not routinely shared by Police because it is difficult for Police to ascertain where a person is being supervised. There is no single or national platform for communication between agencies. The Home Office may therefore wish to consider a review of how information is shared between Police and probation service providers to ensure that all known risks are shared and breaches of existing Orders are quickly acted upon for the protection of the public. | The Home Office |
| 10 | Responsible Officers must adopt an investigative approach to the management of service users, demonstrating professional curiosity which is an essential skill in offender management. | Essex Community Rehabilitation Company |
| 11 | Responsible Officers must adhere to the minimum standards in relation to home visits and reviewing risk assessments following any change in accommodation or circumstances. | Essex Community Rehabilitation Company |
| 12 | Whether an offender is in an intimate relationship or not at the time of assessment, where there is a history of domestic abuse/ violence a SARA must be undertaken to inform risk. | Essex Community Rehabilitation Company |
| 13 | Supervising managers should ensure that appropriate guidance and challenge is given in supervision sessions to ensure sight is not lost of the victims of crime, and that risk assessments contain thorough risk assessments to others which are regularly reviewed. | Essex Community Rehabilitation Company |
| 14 | Where a 'care of' address has been used for correspondence the Responsible Officer needs to ensure that this is recorded on the case management system and the National Probation Service made aware of the address on the breach documentation. | Essex Community Rehabilitation Company |
| 15 | Reports for the court should be informed by information from an offender's current offender manager where relevant, and any other professional involved in their care and/or supervision, in addition to a full criminal history. | National Probation Essex |
| 16 | An offender's cognitive and intellectual abilities should be taken into account to establish that they fully understand the instructions given to them and the actions they need to take prior to release. | National Probation Essex |
| 17 | With the consent of the service user, where they are subject to a court mandated Mental Health Treatment Requirement their GP should be informed and provided with the contact details of the mental health service member of staff responsible for their patient's care. GPs should be given information explaining Mental Health Treatment Requirements. | North Essex Partnership Foundation NHS Trust (Mental Health Services) | NHS England East Region |
| 18 | That Essex Community Rehabilitation Company and Essex Partnership Foundation NHS Trust providers of Mental Health Services, should ensure that a secure process is established whereby an offender's mental health care plan and risk management plan is shared between the staff responsible for the management of the offender with the joint goal of coordinating work to achieve both plan's outcomes. | Essex Community Rehabilitation Company | Essex Partnership Foundation NHS Trust (Mental Health Services) |
| 19 | The Trust should confirm that the new format of their records enables clinicians to gain an overview of a patients full history and care. | North Essex Partnership Foundation NHS Trust (Mental Health Services) |
| 2 | That the specification for the provision of prison healthcare services includes the requirement for the service provider to have in place a clear care pathway for service users who are to be released from prison with a diagnosis of a mental health condition which ensures referral to Community Mental Health Services prior to release to ensure there is no delay in receiving care and treatment following release. The pathway should include: (a) A fast track referral system agreed with Community Mental Health Services for those with a diagnosis of mental illness or a Mental Health Treatment Requirement which has been imposed by the courts. (b) Where a prisoner is released straight from custody by the courts the prison healthcare service on notification of this event should take responsibility for any referral to the Community Mental Health Services as soon as possible and liaise with Probation or other supervisory agency. (c) The referral pathway should be shared with the necessary agencies including Probation and other offender management agencies. | NHS England Midlands & East (East) |
| 20 | That the Trust develop a care pathway for patients who are released from prison with a diagnosis of a mental health condition to ensure there is no delay in receiving care and treatment, and that there is a fast track system for those with a diagnosis or a Mental Health Treatment Requirement which has been imposed by the courts. | North Essex Partnership Foundation NHS Trust (Mental Health Services) |
| 21 | The Trust should review its policy of discharging offenders who go into custody from their service with a view to achieving a seamless service back into the service when custody ends. | North Essex Partnership Foundation NHS Trust (Mental Health Services) |
| 22 | To review ACE staff's access to the Summary Care Record to enable them to be alerted to patients' known vulnerabilities. | Anglia Community Enterprises |
| 23 | A section should be added to the generic referral form to enable early recognition of safeguarding concerns and any reasonable adjustments required. | Anglia Community Enterprises |
| 24 | A three monthly audit of patient records should be developed and undertaken over a period of twelve months to monitor compliance with the use of and effectiveness of the safeguarding adults’ template. Findings of the audit should be used to identify further quality improvement opportunities. | Anglia Community Enterprises |
| 25 | A three monthly audit of patient records should be developed and undertaken over a period of twelve months to monitor compliance with the holistic assessment template. Findings of the audit should be used to identify further quality improvement opportunities. | Anglia Community Enterprises |
| 26 | It is recommended that performance feedback is given to the case officer regarding the timely progression of the investigation (for the incident on 25.06.2013) the accurate recording of enquiries in the investigation log, and performance advice is provided to their supervisor who should have ensured a timely investigation being conducted by their officer. | Essex Police |
| 27 | In light of the age of the documents entitled Court Issued Warrants Strategy (undated) and the accompanying schedule dated 2004, and more importantly, in light of the circumstances and learning from this case, this DHR considers that a review of the Policy in relation to warrants is carried out as a matter of urgency. | Essex Police |
| 3 | NHSE Midlands & East (East) should share the learning from this case with GP practices across Midlands & East (East) to highlight what a Mental Health Treatment Requirement is and why a court imposes it. This should outline that notification from Probation or the Community Rehabilitation Company, or Community Mental Health Services is to ensure that GP practices are aware their patient is receiving mental health services, and that this information must be recorded on the patients’ health records. If they have concerns about their patient's mental health, they should liaise promptly with their patient's mental health worker. This learning should highlight that where a mental health service user has refused to share this information with their GP, the practice would not receive notification and may therefore be unaware of the order. | NHS England Midlands & East (East) |
| 4 | A review should take place into the system of releasing an offender from prison custody from court without accommodation and/or a prescription for existing medication being arranged, especially where the person being released has been in receipt of prison health services and prescribed medication for mental illness or disorder. | Essex Criminal Justice Board |
| 5 | The Adult Safeguarding Board should disseminate the learning from this Review via their newsletter and website for practitioners. | Essex Adult Safeguarding Board |
| 6 | Responsible officers must ensure that they draw on previous risk assessments and historic information to inform current risk assessments. | Essex Community Rehabilitation Company |
| 7 | Police intelligence checks and children’s safeguarding checks must be completed as soon as possible after sentence and the outcome of these enquiries documented on the Delius database and OASys assessment. | Essex Community Rehabilitation Company |
| 8 | Where an issue is linked to Risk of Serious Harm, this needs to be outlined in the Risk Management Plan with specific actions identified. | Essex Community Rehabilitation Company |
| 9 | Responsible Officers must record attendances and failures against Court requirements on Delius to ensure progress is monitored and enforcement action taken as required. | Essex Community Rehabilitation Company |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||