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

Gwynedd review

CSP: Gwynedd Published: September 2023 Year of death: 2019 Extracted: 12 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identified missed opportunities by health services to recognise and respond to domestic abuse, particularly involving older individuals and a female perpetrator. There was a lack of professional curiosity, and age and gender bias may have influenced decision-making, alongside challenges with patient consent and differing family accounts.

Home Office classifications

25 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - cognitive disorder (dementia or alzheimer's disease)
  • Victim - depression
  • Victim - suicidal thoughts
  • Victim - serious or life limiting illness
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - cognitive disorder (dementia or alzheimer's disease)
  • Perpetrator - serious or life limiting illness
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

12 recommendations pulled from the report · 9 matched to organisations in the index

Recommendation 7.1.1

Addressed to Betsi Cadwaladr University Health Board

That BCUHB ensures that the relevant legislative information on Violence Against Women Domestic Abuse Sexual Violence (VAWDASV) and the VAWDASV Service User Procedure, be shared across all GP practices in North Wales.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.1.2

Addressed to Betsi Cadwaladr University Health Board

That BCUHB ensures training in relation to domestic abuse is available to all GP practices in North Wales, and seeks assurance from managed GP practices in relation to training compliance.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.1.3

Addressed to Betsi Cadwaladr University Health Board

That BCUHB reviews MDT documentation to ensure consideration for the wider engagement of services to identify a clear pathway of communication between Mental Health and Learning Disability (MHLD) services and GP practices.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.2.1

Addressed to Betsi Cadwaladr University Health Board

That BCUHB ensures regular quarterly audits of the clinical records in relation to key domestic abuse targets.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.2.2

Addressed to Betsi Cadwaladr University Health Board

That BCUHB update and facilitate Level 3 safeguarding training across MHLD services, in relation to domestic abuse legislation and practice.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.2.3

Addressed to Betsi Cadwaladr University Health Board

That BCUHB ensures that the relevant legislative information on VAWDASV and the VAWDASV Service User Procedure, be shared across all MHLD services with a particular emphasis on domestic abuse and older people.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.2.4

Addressed to Betsi Cadwaladr University Health Board

That BCUHB reviews MDT documentation to ensure consideration for the wider engagement of services to identify a clear pathway of communication between MHLD services and GP practices.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.3.1

Addressed to Hywel Dda University Health Board

That the UHB holds a reflective practice session with staff, exploring professional curiosity where there are concerns raised by individuals about the action taken and expectations.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.4.1

Addressed to Gwynedd and Anglesey Community Safety Partnership

That the CSP holds a series of awareness raising campaigns in the local area. These should focus upon male victims of domestic abuse and older victims of domestic abuse. The campaigns should be targeted where they are most likely to reach these groups.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.4.2

Addressed to Gwynedd and Anglesey Community Safety Partnership

That the CSP reviews its current publicity arrangements in the local area to ensure that the information that is available on an ongoing basis is providing information about the different aspects of domestic abuse (i.e. it is not just physical abuse), and where support is provided.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.4.3

Addressed to Gwynedd and Anglesey Community Safety Partnership

That the CSP ensures that, as part of the publicity they are using locally, there are clear messages for the family and friends of those who are experiencing domestic abuse about how they can support their loved ones.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7.5.1

Addressed to Welsh Government

That the Welsh Government reviews the content of ‘Ask and Act’ training to ensure it sufficiently demonstrates the prevalence and challenges with DA and older people, and older females as perpetrators of abuse.

Verified wording from the published review · Original review (PDF) ↗