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
Sandwell review
CSP: SandwellPublished: September 2023Year of death: 2020Extracted: 5 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report identifies systemic failures in early intervention, information sharing, and risk assessment by agencies, particularly regarding the profound impact of Adverse Childhood Experiences (ACEs) on the victim and perpetrators, and difficulties in engaging hard-to-reach service users.
Home Office classifications
44 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - substance misuse
Victim - mental ill health
Victim - post traumatic stress disorder (ptsd)
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - housing issues
Perpetrator - mental ill health
Perpetrator - neurodiverse condition diagnosis
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - psychosis
Perpetrator - self harm
Perpetrator - suicidal thoughts
Perpetrator - suicide attempts
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to mental health services as a domestic abuse perpetrator
Perpetrator - known to probation services as a domestic abuse perpetrator
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - physical stalking
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - probation services recommendations
DHR process - community safety partnership recommendations
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - policy recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - awareness raising recommendation themes
Addressed to
The Probation Service National Team Steering Group - Assessing Risks, Needs and Strengths
The Probation Service National Team Steering Group - Assessing Risks, Needs and Strengths review OASys to ensure it reflects the learning and impact of the presence of ACEs on service users on Probation and in Prison. As this case demonstrates that the assessment of factors linked to offending in OASys, which are: • accommodation • education, training & employability • financial management & income • relationships • lifestyle & associates • drug misuse • alcohol misuse • emotional well-being • thinking & behaviour • attitudes • health & other considerations and the Risk of Serious Harm section failed to capture the experience and impact of ACEs on the perpetrators.
The Probation Service National Team sponsor ACEs training with learning outcomes that focus on i) the impact of ACEs on physical and emotional development, ii) identifying and evidencing the presence and impact of ACEs, iii) incorporating this information into NPS assessment documents - OASys, Parole Reports, PSRs etc. This to be targeted at all staff who supervise service users and their line managers.
That the NHS South Tyneside CCG issue best practice advise in line with Royal College of General Practitioners guidance to GP surgeries concerning the recording of information when a domestic abuse disclosure has been made. Where possible include recoding the details of the abuser, victim, partner and (ex-partners) and dependents living at that address. i) That information is communicated to the Police DA/Safeguarding Unit as soon as possible. ii) That guidance be issued in cases in which a disclosure is made by the perpetrator who is registered at the practice involving the victim who may or may not be. iii) That all GP surgeries and waiting rooms have prominently displayed accessible information outlining this policy and practice.
Addressed to
The Community Mental Health Team Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
To review the waiting list policy regarding the triage process and confirm that any known risk of serious harm to others is considered alongside the presenting mental health risks, and the impact of mental health / illness on any risk of serious harm informs the prioritisation of care and treatment.
Addressed to
The Safer Sandwell Partnership | Birmingham Children’s Services | Sandwell Children’s Trust
The Panel would recommend that this case be summarised and used as a case study resource for learning events involving child development and the impact of ACEs, the impact of trauma and how to manage cases like this using an alternative trauma-based approach which can be shared regionally with partner agencies.