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: 2016
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 report identifies systemic failures in inter-agency information sharing, risk assessment, and professional curiosity across police, health, social care, and education. Key concerns include treating domestic abuse incidents in isolation, inadequate record-keeping, and missed opportunities to identify and respond to the victim's vulnerability and mental health issues.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Sheffield First Safer and Sustainable Communities Partnership (SFSSCP) should request that the community safety partnership that covers the Colchester hospital areas seeks assurance from them that they are implementing their action plan and disseminating learning from this review. This CSP should also ensure the same applies for Essex police. | Sheffield First Safer and Sustainable Communities Partnership (SFSSCP) |
| 1 | All staff to be made aware of the recommendations within the IMR and the DHR when published. | Colchester Hospital University NHS Foundation Trust |
| 1 | Where children are recorded on the DASH form, officers should be reminded of the need to obtain their full details including a current address wherever possible. This may require further enquiries and research by the officer submitting the DASH form. | Nottinghamshire Police |
| 1 | When a student states that other agencies are dealing with issues such as those raised in this case either in the Notification of Exceptional Circumstances procedure or via any other contact with the University that our Student Support Services teams do check wherever possible on the information provided that this indeed has been referred to the appropriate agencies to investigate. | Nottingham Trent University |
| 1 | Domestic abuse training to be explicit that clinical enquiry must be carried out when a patient discloses domestic abuse | Nottingham University Hospitals NHS Trust |
| 1 | There is a clear need to re-enforce record keeping and assessments following contacts with clients evidenced within this review. | Nottinghamshire Healthcare NHS Foundation Trust |
| 1 | City Care Urgent Care Centre will continue to implement clinical enquiry around domestic abuse and will continue to be vigilant to signs of domestic abuse during all contacts with service users. | Nottingham CityCare Partnership |
| 1 | The GP practice to develop a protocol for the processing and recording of DART referrals in conjunction with the CCG within a view to this being shared across all City GP practices. | GP practices | Nottingham City Clinical Commissioning Group (NCCCG) |
| 1 | Standard letter for general DART use outlining correct contact number and resources if deemed safe and appropriate. This can be amended according to need, risk and safety aspects. | Nottingham City Council Adult Social Care |
| 2 | The Sheffield First Safer and Sustainable Communities Partnership (SFSSCP) should request that the relevant community safety partnerships within Nottinghamshire seek assurance from the agencies below that they are implementing their action plan and disseminating learning from this review and specifically request: | Sheffield First Safer and Sustainable Communities Partnership (SFSSCP) |
| 2 | Specific training is undertaken on recognising and safeguarding patients who may be victims or perpetrators of domestic abuse in identified high risk areas on admission to CHUFT. This must include A&E, EAU and Maternity. | Colchester Hospital University NHS Foundation Trust |
| 2 | DASU staff are reminded of the requirement to consider safeguarding referrals for children recorded on the DASH form irrespective of the policing area in which they currently reside. | Nottinghamshire Police |
| 2 | Domestic abuse training to be explicit that even if there is already an agency involved that a DASH risk assessment should be completed and relevant referrals made | Nottingham University Hospitals NHS Trust |
| 2 | The GP Practice to change its policy on redacting third part information from DART referrals in line with National IG good practice Guidelines. | GP practices |
| 2 | Explanation should be provided as to why contact is not made via telephone and if the safety of speaking via the telephone is questionable, then evidence of this must be documented. | Nottingham City Council Adult Social Care |
| 2i | Nottingham University Hospitals NHS Trust that they are delivering clear domestic abuse training to its staff so that a clinical enquiry is carried out when a patient discloses domestic abuse. This training must make it clear that even if there is already an agency involved then a DASH RIC should still be completed and the relevant referrals made. | Nottingham University Hospitals NHS Trust |
| 2ii | Nottingham City Council Adult Social Care should ensure that the standard letter for general DART use outlines the correct contact number and the available resources that are deemed safe and appropriate. This can always be amended according to need, risk and safety aspects. There is in place a clear protocol for record keeping which would cover when phone calls will be deemed unsafe. The records need to document why unsafe and clear rationale for this. An audit of records should assure the CSP that the recording policy is being adhered to. | Nottingham City Council Adult Social Care |
| 2iii | NCCCG should work with GP practices to develop a protocol that can be used by them when processing and recording DART referrals. | NHS Nottingham City Clinical Commissioning Group (NCCCG) |
| 2iv | Nottinghamshire Police ensures that where children are recorded on the DASH RIC, Officers should be reminded of the need to obtain their full details including a current address wherever possible. This may require further enquiries and research by the Officer submitting the DASH RIC. This includes the requirement to consider safeguarding referrals for children recorded on the DASH RIC irrespective of the policing area in which they currently reside. Nottinghamshire Police Officers should be reminded that if a victim has moved out of Nottinghamshire the person with that information must ensure that the new Policing Area and Command Unit are informed. The new address should be provided and the Policing Area appraised of the abuse and risk category of the victim. | Nottinghamshire Police |
| 2v | Nottingham Trent University is making sure that their staff use professional curiosity when a student informs them that they are subject to DA and checks other agencies are actually dealing with the abuse. Particularly if a student subsequently drops out of their course / is unable to be contacted. | Nottingham Trent University |
| 3 | In order to help to disseminate learning the SFSSCP should write to the Home Office to ask them for guidance on what good practice is currently happening across the UK in relation to intervention programmes that are delivered to perpetrators. In this case it is felt that a programme could have been a preventative factor however guidance is needed on commissioning such a programme and how to achieve the maximum effect. The SFSSCP should share findings with the other CSP’s involved in this DHR. | Sheffield First Safer and Sustainable Communities Partnership (SFSSCP) |
| 3 | Urgent review of the documentation in ED and EAU should be undertaken to ensure routine domestic abuse enquiry on admission. This routine enquiry should mirror the process already established within Maternity services at CHUFT where domestic abuse information is routinely and explicitly obtained from the patient. | Colchester Hospital University NHS Foundation Trust |
| 3 | Officers should be reminded that if a victim has moved out of Nottinghamshire the officer with that information must ensure that the new force and command unit are informed. The new address should be provided and the new force appraised of circumstances of the abuse and risk category of the victim. | Nottinghamshire Police |
| 3 | Additional training to be delivered to GUM staff to include nursing assistants. | Nottingham University Hospitals NHS Trust |
| 3 | The Nottingham City CCG to issue guidance on the recording of third party information on clinical records to all GP practices in the city. | Nottingham City Clinical Commissioning Group (NCCCG) |
| 4 | Staff must ensure that GP details are routinely checked and documented on admission to CHUFT. | Colchester Hospital University NHS Foundation Trust |
| 4 | GP practice to develop a clear protocol in relation to the contacting of students following the disclosure of deliberate overdose/self-harm | GP practices |
| 5 | CHUFT liaises with Essex Police and MARAC to develop a robust procedure for information sharing. Any information should then be shared within the organisation as appropriate including central alerts on the patient information system (Portal) regarding the risk to an individual. | Colchester Hospital University NHS Foundation Trust | Essex Police | MARAC |
| 5 | Nottingham City CCG to issue information to GP Practices to remind them of the links between mental health, domestic violence and suicide. | Nottingham City Clinical Commissioning Group (NCCCG) |
| 6 | Victims or perpetrators who disclose domestic abuse should be offered the opportunity to speak to a member of staff from EDAAP currently based within CHUFT. | Colchester Hospital University NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||