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

Peterborough review

CSP: Peterborough Published: September 2023 Year of death: 2019 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 systemic failures in identifying and responding to domestic abuse, particularly for foreign-born victims, due to language barriers, cultural factors, and a lack of integrated multi-agency information sharing. It also noted insufficient focus on the perpetrator's abusive behaviour amidst health concerns and missed child protection opportunities in multi-occupancy households.

Extracted recommendations

16 recommendations pulled from the report

#	Recommendation	Addressed to
1	Significant proactive work is required with the Lithuanian community in Peterborough. With three Domestic Homicides of Lithuanian women in the city in the last eight years it is clear this is a particularly vulnerable group. Data suggests only 4% of the local population originate from Lithuania yet 75% of the Domestic Homicides are Lithuanian females. Some good work is already underway (e.g. use of Health Care Assistants fluent in Eastern European languages) but a complete multi-agency working group should be established to ensure Lithuanian voices are heard and services adapted to meet their needs. Themes running across previous homicides include regular exposure to violence, poor experience of authorities in their home country, lack of trust, lack of clarity in communication and issues linked to significant alcohol abuse.	Community Safety Partnership
10	The Community Safety Partnership explore opportunities for proactive engagement with families who may not have ‘leave to remain’ in the UK. This is a national issue but there are clear indications from this review that such family concerns can prevent victims having confidence to report crimes or to prosecute offenders.	Community Safety Partnership
11	The Community Safety Partnership should review arrangements for accessing interpreters. There are several examples throughout this review of professionals being unclear of events due to language problems. The use of family members is not always appropriate as they may display misguided loyalties to loved ones.	Community Safety Partnership
12	Cambridgeshire Constabulary should ensure its internal systems of management and supervision have checks to ensure all multi-agency referrals (in this case a ‘form 102 adult at risk’ form) are submitted to partner agencies when required.	Cambridgeshire Constabulary
13	North West Anglia NHS Foundation Trust reviews their procedures for ‘high intensity users’ of its services. These procedures to consider holistic (i.e. medical and environmental) approaches.	North West Anglia NHS Foundation Trust
14	The Community Rehabilitation Company reviews its protocol for contact with partners and family members when staff are managing cases that may be linked to domestic abuse.	Community Rehabilitation Company
15	The Community Safety Partnership should review policies and procedures in place for inter-agency referrals of medium and standard risk cases of domestic abuse.	Community Safety Partnership
16	Cambridgeshire Constabulary should reflect on the learning identified linked to a lack of follow-up action when the perpetrator had been admitted to hospital. Although offences had been committed, there was a lack of coordination to ensure robust subsequent investigations. The police should ensure systems are in place that prompt such follow-up enquiries even if there has been a delay from the reporting of the initial incident to the suspect being declared medically fit.	Cambridgeshire Constabulary
2	Many agencies taking part in this review have comprehensive safeguarding policies in place. However, several do not have a stand-alone domestic abuse policy. Given the prevalence of domestic abuse in society and the impact on services, the drafting of specific policies linked to domestic abuse would provide a focus and clarity in relation to identification and initial actions required when dealing with a victim or perpetrator of domestic abuse.	All agencies involved in the review
3	The Community Safety Partnership should seek assurance that all agencies involved in the safeguarding of vulnerable people have training in place for initial identification of domestic abuse and conducting subsequent risk assessments to protect the victim. Such training should be regarded as mandatory with staff required to attend regular refresher training.	Community Safety Partnership
4	GP Practices should review their procedures for exchange of information following a disclosure of domestic abuse. The disclosure could be from a victim or perpetrator. This links with recommendation 6 on ‘Information Sharing Protocols’ so that professionals have confidence in balancing patient confidentiality with risk of serious harm. Such procedures may also include increasing knowledge on referral pathways to local domestic abuse support.	GP Practices
5	Each individual agency should explore the feasibility of creating a ‘flagging’ marker for domestic abuse cases on their internal systems. Such considerations should balance any potential improved service to victims against an organisation becoming overwhelmed with information.	Each individual agency
6	The Community Safety Partnership review its Domestic Abuse Information Sharing Protocol (ISP) to ensure multi-agency professionals are confident in the effective and early use of information exchange. Any revised procedures to be circulated as widely as possible.	Community Safety Partnership
7	Cambridgeshire Constabulary review its processes for the application of DVPNs / DVPOs. All staff to be aware of the value of these tools and create a culture of proactive consideration of such interventions in all domestic abuse incidents. Such considerations should be the default position.	Cambridgeshire Constabulary
8	The Community Safety Partnership consider the adoption of a MATAC system for multi-agency proactive management of repeat and serial perpetrators of domestic abuse.	Community Safety Partnership
9	All agencies should review their protocols for dealing with vulnerability in multi-occupancy households. Such households are not uncommon within the Eastern European community that have chosen to settle and make their home in the UK. Such protocols must put a child at the centre of the considerations of all professionals dealing with that extended family or household; irrespective of whether or not the child’s biological parents are directly involved in the incident.	All agencies
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗