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
Newcastle upon Tyne review
CSP: Newcastle upon Tyne
Published: September 2023
Year of death: 2012
Extracted: 58 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 identified under-resourced IDVA services, fragmented information sharing across agencies and with external parties, and MARAC capacity issues. Missed opportunities in the criminal justice process and a lack of clear post-MARAC coordination hindered effective support for the victim to safely disengage from the abusive relationship.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Raising Public Awareness • Increase public awareness of the important role of friends, family and work colleagues of victims of domestic violence and abuse; and • Raise awareness with local employers of domestic violence and abuse through publicity and local input into business groups. To include the need for larger employers to have a domestic abuse policy. | Safe Newcastle |
| 1 | Northumbria Police to review and amend their Investigation of Domestic Abuse Procedure in light of this case, specifically with regard to: • Recontacting informants in cases of possible on-going or previous domestic violence to establish if they have any further relevant information; • The use of bail with conditions to enable victims of domestic violence to be supported by a service such as an IDVA prior to a final decision about supporting a prosecution is made; • Risk assessing both parties when there is a lack of clarity as to who is the victim of abuse; and • Reiteration of the charging decisions appeal process. | Northumbria Police |
| 1 | Develop a pathway “aide memoire” poster for staff across the Trust to build awareness of domestic violence across the organisation. Increased knowledge of referral and support available. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 1 | Ensure a working knowledge and awareness across the Primary Care Mental Health service of issues associated with domestic violence. To increase awareness of issues linked to domestic violence, knowledge of MARAC and multi-agency procedures including introducing CAADA DASH checklist. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 1 | Safeguarding alert to all GP practices highlighting importance of using standard codes for domestic abuse and MARAC. | NHS North of Tyne |
| 1 | YHN to review the number of staff that have contact with customers who receive MARAC / domestic abuse training. To provide broader range of YHN staff equipped with skills to recognise domestic abuse cases and to respond to, or advise the customer accordingly. | Your Homes Newcastle |
| 1 | Newcastle Women’s Aid and IDVA Service to clarify roles in order to ensure clearer routes to safety and greater understanding of what support options are available to victims | Newcastle Women’s Aid | IDVA Service |
| 1 | Victim Support to ensure that an offer of face to face contact and any reason for refusal/reluctance is recorded on the case management system. This will ensure that information held is accurate and that a consistently pro-active approach has been adopted. | Victim Support |
| 1 | Pre-Sentence Report (PSR) writers should be instructed to contact MARAC for full information on cases which had not previously been known to the Trust but are now the subject of a PSR. Full information will enable the report writer to assess risk more accurately, thereby ensuring that the proposal in the report is best suited to risk management of the offender. | Probation Trust |
| 1 | Amend NECA comprehensive assessment documentation to include more specific details of domestic violence and MARAC status for clients. NECA assessment documentation to collect and record on the data base MARAC and domestic violence information. | North East Council On Addictions (NECA) |
| 1 | Domestic violence training package to be delivered to all front line staff by March 2013. | Northumbria Police |
| 10 | Increased reporting to safeguarding teams and referrals to MARAC procedures. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 10 | Role of the IDVA is not clear from YHN’s internal procedures on domestic abuse. Staff should be clear about the role of the IDVAs and when to refer to MARAC and refer to the IDVA. | Your Homes Newcastle |
| 2 | MARAC Process/Capacity To review the current MARAC process, in light of this case, examining specifically: • The current number of ‘high risk’ and repeat MARAC referrals, against current and future capacity to be able to review case each effectively; • To enhance clarity around risk identification with action plans clearly linked to the reduction of risk; • Explore the use of the CAADA minute template; and • Explore how victims’ employers can be better engaged in the MARAC process. | Safe Newcastle |
| 2 | When victims of domestic violence and abuse referred into MARAC are identified as parents with children living in another local authority area, that area should be contacted to establish if the children are known to the local children service. If they are, that area to be informed about the MARAC. | Children’s Services |
| 2 | Improve initial triage/information gathering in Emergency Department in order to enhance information gathering regarding domestic violence. Recording to occur in a timely manner so all staff are aware of the circumstances, for example in cases of assault or overdose. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 2 | To implement changes planned in relation to student induction, supervision and mentoring, to provide more robust information about safeguarding and domestic violence for students prior to commencing clinical work. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 2 | Practice to consider standards for record keeping and conduct an audit. | NHS North of Tyne |
| 2 | YHN to review the housing application form to ensure it is clear when an applicant is applying for re-housing due to domestic abuse, and to also highlight a preferred method of contact, so YHN staff can identify rehousing requests for domestic abuse more easily. Customers can highlight their preferred method of contact more easily to help protect their welfare. | Your Homes Newcastle |
| 2 | Newcastle Women’s Aid to seek guidance from Newcastle MARAC regarding which risk assessment tool to use. | Newcastle Women’s Aid |
| 2 | Pilot new way of recording safety plans to make them faster and easier to view, resulting in greater clarity. | Victim Support |
| 2 | Improve contact and communication with GPs and partner agencies through email contact when telephone contact fails, to ensure that information shared in a timely way. | North East Council On Addictions (NECA) |
| 2 | Use the appeal procedure regarding charging decisions with the CPS where the Police think the charge authorised by the CPS does not reflect the severity of the circumstances. | Northumbria Police |
| 3 | Risk Assessments • Identify how risk assessment processes can continue to be developed and improved ensuring that when new risk assessment procedures are being considered that they are introduced across all agencies within a short time scale; and • To ensure that there is clarity/reinforcement amongst all agencies about the post MARAC risk assessment processes, ensuring that all agencies know they have a responsibility post MARAC to share any further information about the victim. | Safe Newcastle |
| 3 | For a patient subject to MARAC, referring services must be informed , when engagement concludes or there is disengagement; • Cancelling of appointments by partners in known domestic abuse cases, subject to MARAC, must be followed up immediately and information shared with other agencies; and • Background information and history of domestic violence, should be shared in a referral for commissioned services for victims of domestic abuse and particularly those in MARAC. | Health Agencies |
| 3 | Explore the potential to review all incidents of recorded assault by Independent Domestic Violence Advisor - IDVA. To Improved identification of domestic violence. Especially those who are repeat and high risk victims. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 3 | Take a more pro-active role as practitioners in relation to domestic violence and safeguarding using established mechanisms in the organisation. In order to increase activity from primary care mental health services in relation to recognition and response to the victim. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 3 | Safeguarding alert to all GP practices highlighting importance of recording all patient contacts, failed contacts and third party contacts. | NHS North of Tyne |
| 3 | YHN staff are reminded of YHN’s Information Policy, the importance of accurate record keeping and date stamping customer information on receipt, that clearly indicates when and where it was received, and by whom. | Your Homes Newcastle |
| 3 | Newcastle Women’s Aid to review the case management system they use. To ensure and clarify accurate and essential information is collected, recorded and shared. | Newcastle Women’s Aid |
| 3 | Clarify roles and responsibilities of support agencies working with victims of domestic abuse and develop clearer referral pathways to reduce risk of duplication and make best use of depleting resources. | Victim Support |
| 3 | To implement the DASH risk assessment model. | Northumbria Police |
| 4 | IDVA Capacity • On the back of this review and the Council’s review into local IDVA provision, to undertake a multi-agency discussion to identify how increased funding can be secured to increase IDVA capacity in line with national recommendations. | Safe Newcastle |
| 4 | Ascertain formal feedback from the Police on effectiveness of information sharing, to improve information sharing with the Police. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 4 | Consider implementation of specialist supervision and training update sessions for practitioners in order to support for staff, especially in relation to information sharing and appropriate referrals. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 4 | Training in domestic violence to be offered to all GPs by enhancing the domestic abuse component of single agency safeguarding children training and by offering standalone training. RCGP online module “Violence against Women and Children” to be promoted as an alternative. The training should include: ▪ Awareness of the CAADA-DASH risk assessment tool; and ▪ MARAC process and GP role within it. | NHS North of Tyne |
| 4 | YHN to review the current ‘sign up check list’ to clearly indicate where the advice and support service has been offered. In order to improve record keeping and consistency of support services being offered to new tenants. | Your Homes Newcastle |
| 4 | Newcastle Women’s Aid to inform the referring agency (if there is one) in the event of a victim subject to MARAC stops engaging with their service. This would provide an opportunity for continuous monitoring of a victim at high risk. | Newcastle Women’s Aid |
| 4 | Ensure that all high risk and repeat MARAC victims are discussed at MARAC, regardless of volume by April 2013. | Northumbria Police |
| 5 | Central Referral • To review, in light of this case, possible options for centrally recording referrals and lead agency responsibility for the coordination of subsequent intelligence in respect of domestic violence and abuse. | Safe Newcastle |
| 5 | Improve coding of assaults by clinical staff to reference domestic violence by clinical staff in Emergency Department, to ensure appropriate support and referral to other agencies for victims. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 5 | Proactive enquiry by staff regarding injuries sustained and identification of domestic violence victims. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 5 | Safeguarding alert to all GP practices highlighting CAADA/RCGP guidance on responding to domestic abuse. | NHS North of Tyne |
| 5 | YHN to review the timescales for awarding priority housing bands to ensure that, where there is a priority need and/or it is an urgent case, this process is completed within a reasonable timescale, including any back office checks. This is in order to ensure that priority housing awards are made within a reasonable timescale. | Your Homes Newcastle |
| 6 | Accommodation Funding • To identify sources of funding that can be made available to support immediate accommodation requirements such as refuge placements or other option. | Safe Newcastle |
| 6 | Raise profile of IDVA service in Emergency Department. To enable cooperation and increase IDVA expertise being utilised more readily in the department and elsewhere in the Trust. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 6 | To improve the identification of situations where domestic violence has caused significant injury. Offer support to victims and undertake referrals to support services and other procedures, e.g. MARAC. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 6 | Safeguarding alert to all GP practices to highlight the need for clear process for timely completion of MARAC requests and to deal with MARAC reports including the highlighting of records. | NHS North of Tyne |
| 6 | Through YHN’s Welfare Reform Project to review the new tenancy sign up procedure in order to improve the identification of vulnerable tenants at the start of their tenancy. | Your Homes Newcastle |
| 7 | Improve local induction in Emergency Department in relation to domestic violence victims, to increase identification of victims and referrals for support. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 7 | Consider availability of IDVA service in trauma clinic sessions. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 7 | Safeguarding alert to all GP practices to highlight the importance of contacting Children’s Social Care about children at risk of domestic violence even if they are not within the household or even the same city. This may involve contacting Children’s Social Care in another area or making contact through local Children’s Services. | NHS North of Tyne |
| 7 | The tenancy notice period could be reduced if the property is still in the same condition as it was when let, given the domestic abuse circumstances. | Your Homes Newcastle |
| 8 | Improve utilisation of information from North East Ambulance service to Emergency Department team. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 8 | Improved information sharing with the Police using existing Trust policy by senior medical staff in cases of serious injury. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 8 | Housing priority awards for domestic abuse do not always involve a referral to MARAC. This should occur to ensure all appropriate cases are considered by MARAC. | Your Homes Newcastle |
| 9 | Review domestic violence training needs in Emergency Department in relation to, recognising and responding to domestic violence and referral to IDVA. | The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
| 9 | The research feedback about MARAC cases should be provided to housing office based staff for all cases including private residents, not just where the person is a tenant. This is to capture any intelligence from the local neighbourhood teams are based on cross tenure estates. | Your Homes Newcastle |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||