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
Sheffield review
CSP: Sheffield
Published: September 2023
Year of death: 2012
Extracted: 41 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 missed opportunities by health services to assess the perpetrator's substance misuse and mental health crisis, and to inquire about the victim's safety. There was also a lack of routine inquiry into domestic abuse and carer's needs, particularly when the abuser was a non-intimate family member.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | SHSC should review its domestic abuse policy in line with recommendations provided with the ACPO DASH assessment tool | Sheffield Health and Social Care Trust |
| 1 | NHS Sheffield should provide for GP practices information to increase awareness that Domestic Abuse services include support for non-intimate household members such as parents or siblings. | NHS Sheffield |
| 1 | JSP 913: Tri-Service Policy on Domestic Abuse and Sexual Violence provides comprehensive direction for members of the armed forces on this subject. There is a need to ensure awareness of this policy within the unit in order to ensure it is followed. Unit Adjutants to place information about the policy on Unit Part One Orders in order to achieve this. | The Territorial Army |
| 1 | To update the current safeguarding vulnerable adults training needs analysis to reflect the need for specific staff groups to acquire domestic abuse awareness. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 1 | Clinical supervision for registered nurses is not a mandatory undertaking. However it is widely recognised as a beneficial activity that encourages reflection and supports best practice, and is recommended by the Nursing and Midwifery Council (NMC, 2008). The organisation needs to reinforce and remind staff of the availability and benefits of accessing regular clinical supervision. This message will be supported and emphasised at the regular 1 to 1 meetings that all staff have with their line managers from 31 October 2012. To measure this, line managers are asked notify the Education Training & Development Administrator when a member of their team has had clinical supervision, this will then be logged on the training database. | NHS Direct |
| 1 | NHS Sheffield and future commissioners of NHS services should clarify their expectations of their commissioned providers about identification and response to domestic abuse. | NHS Sheffield | future commissioners of NHS services |
| 10 | Providers should ensure a formal letter is written to the client’s GP to notify them of any health/specialist referral or interventions so that there is a complete record of interventions held by the GP. Communication must be clear and indicate the diagnosis, prognosis and package of care. | NHS providers |
| 2 | The awareness of domestic abuse and the prompt use of the ACPO DASH assessment tool should be embedded into practice in all SHSC services | Sheffield Health and Social Care Trust |
| 2 | NHS Sheffield should provide for GP practices information to increase awareness of appropriate alcohol services. | NHS Sheffield |
| 2 | Post Operational Stress Management (POSM) is a key part of our business as a unit following our recent deployment of soldiers on Operations HERRICK 15 and 16 to Afghanistan. Documenting this process is absolutely crucial, and is currently undertaken with due diligence by the welfare team within (redacted – sensitive information). However, it is always worth re-enforcing it’ value across the unit. Unit Welfare Staff are to continue to ensure POSM is carried out within guidelines for all (redacted – sensitive information) personnel. | The Territorial Army |
| 2 | To develop a variety of methods to ensure domestic abuse awareness is widely disseminated across appropriate staff groups in accordance with the safeguarding vulnerable adults training needs analysis. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 2 | Social Workers need to give consideration to the role of wider family members within their assessments if they are frequent visitors to households even if they are not living at the address. This should be reinforced by managers who are authorising the assessments and should form part of the discussion within case supervision. In order to promote good practice early in a Social Workers career this issue will be raised within NQSW network meetings where different subjects are discussed. This message can be disseminated to Assistant Service Managers within the areas for discussion with the Team Managers, for whom they are responsible, to ensure implementation. | Sheffield City Council: Children, Young People and Family Services |
| 2 | Reinforce to staff the importance of following best practice guidance for managing 3rd party calls. This message will be supported and emphasised at their regular 1 to 1 meetings with their line managers. Practice Development Coaches will also reinforce this message when working with colleagues where a work performance issue is identified. This can also be measured in the three random call reviews performed for each member of staff on a monthly basis. Learning from this Independent Management Review will be cascaded to all staff once it is signed off and the scenario used as a training vignette. | NHS Direct |
| 2 | NHS Sheffield and future commissioners of NHS services should clarify their expectations of their commissioned providers about clinical tools/algorithms which should be used (e.g. ACPO DASH is the recommended risk assessment tool for domestic abuse; AUDIT based tools are the recommended clinical tools for identification of alcohol misuse.) | NHS Sheffield | future commissioners of NHS services |
| 3 | SHSC continue to monitor the use of carers assessments via the Key Performance Indicators ((KPI’s) | Sheffield Health and Social Care Trust |
| 3 | NHS Sheffield will suggest to GP’s that they extend their routine enquiry around depression, that they undertake following a significant diagnosis, to include enquiring about domestic stress and/or abuse. | NHS Sheffield |
| 3 | Medical checks require access to cross-departmental data between Government Organisations. Specifically, without an ability for army medical staff to access all required fields of data from an individuals civilian medical history, fully comprehensive medical checks cannot take place prior to an individual joining the TA. Under the new RG8, background checks from a civilian GP are mandatory – ROSO’s are to ensure this guidance is being followed. | The Territorial Army |
| 3 | NHS Direct produces a quarterly internal newsletter ‘Mental Health Direct’. An article on domestic violence and DASH principles will be included in our winter edition. | NHS Direct |
| 3 | NHS Sheffield and future commissioners of NHS services should clarify their expectations of their commissioned providers about identification, assessment and recognition of carers. | NHS Sheffield | future commissioners of NHS services |
| 4 | SHSC policy for Dual Diagnosis and referral to alcohol services should be internally reviewed and amended to promote prompt interventions and prompt referral | Sheffield Health and Social Care Trust |
| 4 | GP practices should have a Domestic Abuse policy that details staff member’s responsibilities including how to recognize possible domestic abuse when stress at home is disclosed and how to refer to domestic abuse services. | General Practice |
| 4 | NHS Sheffield and future commissioners of NHS services, should ensure any signposting directs contacts regarding a mental health crisis to appropriate emergency / urgent care services. | NHS Sheffield | future commissioners of NHS services |
| 4.1.1 | That the Domestic Abuse Strategic Board should ensure that discussions with appropriate commissioners and professional bodies continue with a view to agreeing and supporting the implementation of a simple screening system for General Practitioners to help them assess any risk and required response quickly. These discussions should build on the progress made since the last DHR on Adult A, including training delivered to GPs, and should include discussions about how best the completion of ACPO/DASH can be supported when high risk issues are indicated. The progress of these discussions should be reviewed at the Domestic Abuse Strategic Board meeting in February and a more detailed development plan agreed then. | Domestic Abuse Strategic Board |
| 4.1.10 | The Domestic Abuse Strategic Board should support the principle of a whole household approach to assessments. The issues arising from this DHR should be shared with the group developing the family CAF and the Building Successful Families project team to inform their work on developing the whole household approach in the city. The outcome of this should be reported back to the Domestic Abuse Strategic Board by April 2013. | Domestic Abuse Strategic Board |
| 4.1.11 | That the Domestic Abuse Strategic Board promotes as good practice that agencies across the city have in place up to date policies and procedures, and awareness and training for staff in relation to domestic abuse, and that agencies are ready to engage with and participate in Domestic Homicide Reviews. This should include the agencies connected to this Domestic Homicide Review: Mind, Turning Point and Cavendish Care. The Strategic Board should develop a plan for taking this work forward by May 2013. | Domestic Abuse Strategic Board |
| 4.1.2 | In addition the Panel and the Chair recommends that the Domestic Abuse Strategic Board contact the Department of Health, the General Medical Council and the Royal College for General Practice to express concern in relation to the National Contract for GPs not including any statutory responsibility in relation to the safeguarding of victims of domestic abuse, vulnerable adults and children. This issue is likely to be an issue in subsequent DHR’s and Serious Case Reviews on children and young people. | Domestic Abuse Strategic Board |
| 4.1.3 | That the Domestic Abuse Strategic Board note the review of protocols in relation to dual diagnosis of substance misuse and mental health currently being undertaken by the Strategic Health Authority as part of a national review. This is due to be complete in January and the February meeting of the Group should ensure that the revised protocol adequately addresses related issues of domestic abuse. | Domestic Abuse Strategic Board |
| 4.1.4 | That the Domestic Abuse Strategic Board should ensure that the pathway development work identified in the recent Domestic Abuse Strategic Review is progressed. The pathway development work should be complete by April 2013 and the work to endorse and critically assess the whole pathway by relevant organisations and partnerships should be complete by September 2013. | Domestic Abuse Strategic Board |
| 4.1.5 | That the Domestic Abuse Strategic Board should implement the joint commissioning arrangements proposed in the Domestic Abuse Strategic Review. The Board should also identify the appropriate use of procurement, partnership and contracting processes linked to performance requirements to ensure that issues around domestic abuse in general are taken forward and that recommendations from DHRs will be progressed. This work should be completed by the end of September 2013 for the start of the next commissioning cycle. A variety of arrangements may be acceptable and agreed depending on the services being contracted and commissioned and the range of approaches used. | Domestic Abuse Strategic Board |
| 4.1.6 | That the Domestic Abuse Strategic Board assesses changes in commissioning and governance in relation to the maintenance of the effective delivery of domestic abuse support services. The group should consider its relationship with the new Health commissioning structures and strategic boards as part of its strategic and business planning for the next financial year. Particular consideration should be given to relationships with the Health and Well Being Board, with the Clinical Commissioning Group and with the Local Medical Committee. | Domestic Abuse Strategic Board |
| 4.1.7 | That the Domestic Abuse Strategic Board satisfies itself that the transfer of services from NHS Direct continues to progress smoothly in relation to the issues identified in this DHR. Good joint work in this area is under way. Progress should be reviewed by the Board in February and again following implementation in April. | Domestic Abuse Strategic Board |
| 4.1.8 | That the likely support needs of families and DHR subjects are assessed by future DHR panels when creating terms of reference for future DHRs. These support needs should be actively considered through the process of completing any future DHRs with any relevant learning in relation to supporting families shared appropriately. Engagement of families in the DHR process should be sensitive and responsive to situations family members find themselves in as the timescale of the review unfolds. This requirement should be included in updated guidance when it is issued. | Domestic Abuse Strategic Board |
| 4.1.9 | That the Domestic Abuse Strategic Board asks relevant agencies in the city to consider the research highlighted in this review in relation to their policies and procedures and report back any changes made as a result by September 2013. | Domestic Abuse Strategic Board |
| 5 | When substance misuse is disclosed during a GP consultation, including alcohol excess, this should be documented and READ coded within the GP records. | General Practice |
| 5 | NHS Sheffield and future commissioners of NHS services, should ensure that in their directory of services for the implementation of 111, it identifies the disposition for a mental health crisis to an appropriate emergency / urgent care service. | NHS Sheffield | future commissioners of NHS services |
| 6 | Any psychotic episode that is known to be drug related should be documented and READ coded within the GP records. | General Practice |
| 6 | Providers should keep a current domestic abuse policy. | NHS providers |
| 7 | When excessive alcohol intake is identified or suspected an assessment of alcohol dependence using a recommended tool e.g. AUDIT-C (8), should be undertaken and an appropriate referral made to specialist alcohol services dependent on the results. This should be documented and READ coded within the GP records. This action should be undertaken by GP’s regardless of any actions presumed to be taken by any other service involved with the patient. | General Practice |
| 7 | Providers should make clear and accessible to staff the clinical pathways and recommended clinical tools/algorithms for domestic abuse, alcohol misuse and mental health. | NHS providers |
| 8 | Providers should ensure all staff are aware of the need to recognise carers and offer carers assessments where appropriate. | NHS providers |
| 9 | Providers should make the Dual Diagnosis protocols clear and accessible to staff. Individuals confirmed as reaching the threshold for “dual diagnosis” must have their care co-ordinated by the Mental Health Trust. | NHS providers |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||