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: Sandwell Published: September 2023 Year of death: 2020 Extracted: 5 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 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.

Extracted recommendations

5 recommendations pulled from the report

#	Recommendation	Addressed to
1	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 Steering Group - Assessing Risks, Needs and Strengths
2	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.	The Probation Service National Team
3	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.	NHS South Tyneside CCG
4	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.	The Community Mental Health Team Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
5	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.	The Safer Sandwell Partnership \| Birmingham Children’s Services \| Sandwell Children’s Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗