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: 2014
Extracted: 30 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 highlights systemic failures in multi-agency communication, cultural awareness, and routine domestic abuse inquiries for migrant families. It identifies missed opportunities for early intervention due to the victim's isolation and inadequate information sharing between services.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 4.1.1.1 | Sheffield CCG to share the learning from this review, specifically around the link between child neglect and domestic abuse, with lead GPs for safeguarding (adults and children), and for the lead GPs in turn to increase domestic abuse awareness within their practices. | Sheffield CCG |
| 4.1.1.2 | Sheffield CCG to re-issue the recently developed template safeguarding policy developed for primary care, with practice lead GPs for safeguarding (adults and children), for them in turn to consider adopting within their practices. | Sheffield CCG |
| 4.1.1.3 | Sheffield CCG to recommend to practices that GP and health visitor records should be shared where clinical systems allow but concerns should be communicated directly. | Sheffield CCG |
| 4.1.1.4 | Sheffield CCG to encourage practices to display domestic abuse posters in GP practices to promote community awareness of the issue and encourage disclosures. | Sheffield CCG |
| 4.1.2.1 | When using interpreters to ask women for sensitive personal information such as in “routine enquiry” the gender of the interpreter must be considered. A male interpreter could have an impact on the response. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 4.1.3.1 | Raise awareness amongst HVs of the need to discuss challenging cases with safeguarding children supervisors, so that HVs are supported to manage appropriately situations where an assessment of domestic abuse is difficult. For example where a mother is accompanied by her husband or family. This would enable alternative ways of enquiring and assessing domestic abuse to be considered. Health Visitors should include routine enquiry regarding domestic abuse in their assessments of families in line with SSCB procedures. SCNHSFT guidance states, “Where making such an enquiry has not been appropriate or possible, the reason should be clearly documented in the health records, along with a plan stating what actions will be taken and how future enquiries regarding domestic abuse will be made”. | Sheffield Children’s NHS Foundation Trust |
| 4.1.3.2 | Raise awareness amongst school nurses and health visitors of the need to liaise and share information appropriately where there are safeguarding concerns relating to children in the household - school aged and pre-school children. School Nurses and Health Visitors should liaise to share relevant information including meetings held; the outcomes and plan. The liaison and plan of action should be documented on the SystmOne health record. Consideration should be given to the need for a family CAF to be undertaken as appropriate. | Sheffield Children’s NHS Foundation Trust |
| 4.1.4.1 | Undertake a case study based on the events in the Adult G case and present the findings to the Operational Sub Group of the Local Safeguarding Children’s Board. The findings will demonstrate that the missed opportunities to engage with this family would not occur following the recent developments described in the IMR. Develop an action plan to address any gaps. | MAST |
| 4.1.4.2 | Incorporate the findings from this Review into training and supervision for workers in order to help them to identify domestic abuse. | MAST |
| 4.1.5.1 | The archived paper case notes could not be retrieved to inform the author. There is a new ICT system being developed to eliminate this issue which needs to be implemented. | Sheffield City Council Housing Solutions |
| 4.1.5.2 | Quality checking of decisions by officers is now completed by a more senior officer. It is recommended that this is good practice and should continue as part of Procedures. | Sheffield City Council Housing Solutions |
| 4.1.5.3 | The use of Supported Family Accommodation for families with a history of a former failed tenancy is recommended as good practice and to be continued to be used. | Sheffield City Council Housing Solutions |
| 4.1.5.4 | Housing Solutions Officers to receive training to increase knowledge and awareness of: - Homeless Legislation and Security of Tenure - Interviewing different cultural groups including using direct questioning - This is to be assessed within Individual Performance Reviews and one-to-one supervision. | Sheffield City Council Housing Solutions |
| 4.1.5.5 | Procedures will be updated to include the expectation that missed contact between agencies is followed up to ensure that relevant information is shared. | Sheffield City Council Housing Services |
| 4.1.6.1 | Implementing a more individual client focused electronic record keeping system which reflects the individual diverse client’s needs instead of a generic housing related system. | Metropolitan |
| 4.1.6.2 | Review Support Planning and Risk Assessment training to take account of the lessons learned and potential improvements in practice that have been identified in this Report, particularly in terms of follow up where withdrawal from support occurs. Review to be completed by December 2014. | Metropolitan |
| 4.1.6.3 | In working with other services working with refugees and diverse cultures, Metropolitan will encourage community groups and activities to display domestic abuse advice prominently. | Metropolitan |
| 4.1.6.4 | All languages & dialects spoken in the area will be reflected in any literature and pictograms used to demonstrate social and cultural laws, particularly with regard to safeguarding and abuse. | Metropolitan |
| 4.1.7.1 | It is recommended that Atlas Court (police call centre) reviews its procedures for 999 and 101 calls involving non-English speakers, and: a. Where a call is made by a child, an adult should be spoken to in all cases to confirm that police attendance is not required b. Where appropriate “Language Line” will be utilised to assist in communication c. Where welfare cannot be established satisfactorily during the call, a police officer should be deployed to conduct a welfare check | South Yorkshire Police |
| 4.2.1 | MAST to complete a case study evidencing that following the restructure and redesign, the opportunities to engage with this family would not recur. Present to the Local Safeguarding Board Operational Sub-Group, by April 2015. | MAST |
| 4.2.10 | The Domestic Abuse Strategic Board to task an audit of voluntary, community and faith groups to assess awareness of, and compliance with, the domestic abuse pathway, and develop an action plan to address any gaps, by October 2015. | Domestic Abuse Strategic Board |
| 4.2.11 | The myth of acceptable abuse is to be robustly challenged in all services, immediately and ongoing: - IMR authors in debriefing within services will promulgate the message from this Review that domestic abuse is unacceptable and illegal regardless of the faith or culture of service users; and - In training and supervision, staff will be encouraged to be curious about faith and culture, and their access to resources will be facilitated in order that they can research the background and needs of migrant families, and ensure families are aware of the services and support available for domestic abuse. | All agencies represented in the DHR process |
| 4.2.2 | The Domestic Abuse Strategic Board to monitor the impact of the FCAF on the assessment of domestic abuse in families, by receiving a monitoring report from the CYPF member of the Board, in September 2015 and March 2016. | Domestic Abuse Strategic Board |
| 4.2.3 | The Domestic Abuse Strategic Board to require all agencies to review systems in place to evidence that: a) routine domestic abuse inquiries are made of women in migrant families, and b) supervision and support to complete the task is in place, and used, where practitioners find it difficult to do so. and to put an action plan in place to address any gaps, by July 2015. | Domestic Abuse Strategic Board |
| 4.2.4 | All agencies represented in the DHR process to monitor the gender of interpreters in domestic abuse inquiries (face to face and by telephone) with migrant families, during 2015/16. The Domestic Abuse Strategic Board to receive these data 6 monthly in October 2015 and April 2016 and to develop an action plan to address any gaps. | All agencies represented in the DHR process | Domestic Abuse Strategic Board |
| 4.2.5 | The Domestic Abuse Strategic Board to organise a workshop with the women-only Focus Group (from this DHR) in order to develop a guideline for services working with migrant families to be able to ask appropriate questions about domestic abuse. The guideline to include: a) A model script for staff, and guidance as to when this might be appropriate, i.e. when it is necessary to be flexible and culturally aware; b) Guidance on preparing and using interpreters in domestic abuse inquiries, including ensuring the gender of the interpreter is the same gender as the service user. | Domestic Abuse Strategic Board |
| 4.2.6 | Sheffield City Council to review the information on its website regarding City of Sanctuary and migrant communities and ensure that up to date demographic information is provided about asylum seeker and refugees currently seeking sanctuary in the City. This should be a resource for staff and the public providing up to date information about new migrant groups, by September 2015 and ongoing. | Sheffield City Council |
| 4.2.7 | Sheffield City Council to work with City of Sanctuary to develop a plan for improving the welcome to Sheffield for migrant families. In addition to meeting the SCC’s own aims of reducing exclusion, this project should demonstrate meeting the key aim from this DHR, of reducing the isolation of women in migrant communities in order that they may feel safer. This will include provision of information about domestic abuse, information and support for women to access English classes. To consult and involve community, voluntary and faith groups in this process. Report on this plan to the Domestic Abuse Strategic Board by September 2015. | Sheffield City Council |
| 4.2.8 | The Domestic Abuse Strategic Board to task a meeting with faith leaders to discuss the issues raised in this case and invite participation in the recommendations and the action plan. Of interest in this regard is the current work by the Metropolitan Police Service in developing a women-only initiative with local mosques to address domestic abuse in South Asian communities. | Domestic Abuse Strategic Board |
| 4.2.9 | The Domestic Abuse Strategic Board to receive a report from those tasked with actions from the DHR for Adult D which are relevant to Adult G, to ensure these have been progressed, namely to report how migrant women can be referred for support for domestic abuse. It is recognised this wouldn’t have helped in this case. However, for future assurance, how will vulnerable people from migrant communities be supported in relation to domestic abuse? | Domestic Abuse Strategic Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||