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

Sefton review

CSP: Sefton Published: September 2023 Year of death: 2012 Extracted: 33 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
Agencies failed to adopt a coordinated, problem-solving approach to persistent domestic abuse, often dealing with incidents in isolation. Flawed risk assessments, ineffective MARAC processes, and poor information sharing meant the victim's escalating risk and the perpetrator's alcohol misuse were not adequately addressed.

Home Office classifications

48 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • 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 social services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by mental health services
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - technology systems recommendation themes
  • 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

Extracted recommendations

33 recommendations pulled from the report · 21 matched to organisations in the index

Recommendation 1

Addressed to Merseyside Police

Introduce time parameters for creating a full and meaningful entry on PROtect for gold victims, with risk assessment and appropriate referrals. To meet such deadlines, all FCIU would need dedicated risk assessors.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Merseyside Probation Trust

The Trust will prepare advice for staff in the use of restrictive requirements with particular reference to Domestic abuse scenarios. The Trust will also take legal advice to consider the impact that article 8 of the Human Rights Act i.e. the right to have a family life, may have upon any guidance to be issued.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Sefton Safer Community Safety Partnership

That the actions from MARAC Review are reviewed by Sefton Safer Community Safety Partnership to ensure that they take place.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Sefton Safer Communities Partnership

The Council led review of domestic abuse services has been completed and the recommendations implemented.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Merseyside Police

Review procedures force-wide for the storage of completed VPRF 1 forms, which should be retrievable for evidential or audit purposes. It may be feasible to scan the original forms onto a system such as Niche.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Merseyside Probation Trust

The Trust will develop staff to ensure that triggers for escalating risk, including arrests that do not result in prosecution are properly assessed and the risk assessment and risk management plan reviewed and updated. In cases characterised by volatile relationship OMs should ensure an investigative approach is applied by actively seeking information on a regular and frequent basis.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2b

Addressed to VVAT Team

put into place effective systems and processes should be put into place to hold and share information which all organisations are able to access

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Merseyside Police

A supervisor should be informed when a domestic abuse incident is reported and his or her details recorded on the Storm log. The supervisor should ensure that a VPRF 1 is submitted prior to the end of the tour of duty, having quality assured it and having appended his or her name and signature.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Merseyside Probation Trust

The Trust should review its strategy for managing cases in which domestic abuse features either as the index offence or as a known factor in cases where it is not the index offence.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to VVAT | Sefton MARAC

That VVAT and MARAC look at all of the evidence from the victim, perpetrator and agencies and develop more imaginative and collaborative solutions. Initial contact methods with victims and ongoing methods need to be improved and reduce the reliance on phone contact based on the needs of the victim.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Sefton Safer Communities Partnership

Domestic abuse training includes the complex nature of the issues facing victims, particularly the pressures they face when reporting abuse and leaving relationships.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Merseyside Police

Agencies must work together to address underlying causative factors, such as alcohol dependency, and must ensure that vulnerable victims are not left in an isolated situation. Perpetrator programmes should also be available.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Merseyside Probation Trust

The Trust should satisfy itself that all operational staff including managers, have a sound understanding of when and how they should make referrals to the MARAC.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Sefton Safer Communities Partnership

Alcohol services are available for victims and perpetrators of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Merseyside Police

Once gold risk assessment status is reached, a single FCIU investigator should be identified and assigned to the individual or family concerned as a point of contact and, as far as practicable, should deal with all cases. That individual would then be responsible for case-building and should liaise with the CPS at an early stage to discuss the options available, rather than considering each incident in isolation.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Merseyside Probation Trust

Trust should remind its MARAC Representatives that information from the MARAC relevant to the case should be recorded in the non disclosure section of OASys and an email sent to the Offender Manager to alert them.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Sefton Safer Communities Partnership

Its constituent agencies understand how to identify and assess domestic abuse risk factors, alter risk levels when factors change and produce appropriate risk management plans.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Merseyside Police

‘Location of interest’ (LOI) markers must be regularly reviewed, with an updated risk assessment, to ensure they are still appropriate and sitting on the right address. They should contain details such as bail conditions and any harassment notices, which should be acted upon.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Merseyside Probation Trust

The Trust should satisfy itself that OM 1 and 2 are sufficiently responsive to issues of increased risk in cases where there is known domestic abuse; there is evidence that assessments which have been reviewed are accurate and that sentence plans are fully implemented.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Merseyside Police

Incidents of concern such as critical incidents and high risk missing persons should be clearly defined and classified and an officer at inspector level (usually a CIM) or above should be identified as the person in charge of it. That individual’s details should be recorded on Storm and if responsibility is passed to another officer, that person must be fully briefed and must ensure that his or her details are recorded on the Storm log.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Merseyside Probation Trust

Improve the ability of all TMs to provide appropriate advise and guidance in the management of domestic abuse including how domestic abuse registers should be reviewed for best effect.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Merseyside Police

Regular audit and inspection should ensure that policy and procedure is adhered to. Particular attention should be paid to the reporting and recording of domestic abuse incidents, with risk assessment and referrals, and the requirements of both force ‘Domestic Abuse (Policy and Procedure)’ and the ‘Code of Practice for Victims of Crime’ issued by the Home Secretary to inform victims of a suspect’s release and any bail conditions.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Merseyside Probation Trust

The Trust should satisfy itself that all operational staff and managers can articulate how information gained by a SARA assessment can enhance risk assessment and management.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Merseyside Police

Appropriate supervisors, particularly critical incident managers (CIM), should be provided with regular training updates regarding any effective practice and lessons learned from relevant reviews.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Merseyside Probation Trust

The Trust should review its Domestic Abuse Policy and in doing so ensure OM responsibilities are clear re how and when to refer to MARACs and IDVAs . The review should also consider how the policy may be re formatted to make it more accessible.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Merseyside Probation Trust

The Trust should ensure that newly qualified staff are afforded the correct level of caseload protection .

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to Merseyside Probation Trust

The Trust should require LDU leaders to reinforce with their staff the guidance in the Acceptable Absence policy in relation to managing ongoing health issues.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to Merseyside Probation Trust | Merseyside Police

The Trust should work with Merseyside Police to try and identify a mechanism whereby any domestic abuse calls which involve an offender currently managed by the Probation Trust results in an immediate notification of the circumstances to the Offender Manager.

Verified wording from the published review · Original review (PDF) ↗