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
Bedford review
CSP: Bedford
Published: September 2023
Year of death: 2011
Extracted: 57 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 identifies concerns regarding inadequate inter-agency coordination, inconsistent information sharing, and insufficient use of risk assessment tools. It also highlights gaps in professional training on domestic abuse and a need for a stronger focus on children's experiences.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 3.10 | In addition to risk assessment and MARAC training the Partnership should ensure that multi-agency training includes identification of domestic abuse, and strategies and resources for working with those affected. This should including safety planning. | Bedford Borough Domestic Abuse Partnership |
| 3.11 | The training course delivered by the Partnership on working with domestic abuse perpetrators should continue to be provided and be publicised. It should be aimed at those practitioners whose work involves assessing or supporting families where the perpetrator is still in the family or has contact. | Bedford Borough Domestic Abuse Partnership |
| 3.12 | The Partnership should review the current process of inter-agency notification of domestic abuse incidents. It is recommended that this review look at notifications across agencies and not just from the Police to Children’s Social Care. Consideration should be given to a system which targets notifications safely on a need to know basis, for example a notification sent securely to the specific Health Visitor for the family and/or a children’s school Safeguarding Lead. | Bedford Borough Domestic Abuse Partnership |
| 3.14. | The LSCB may wish to encourage a more consistent and coordinated approach to risk assessment across agencies by reviewing the range of guidance used by agencies and seeking to integrate these processes where possible. | Bedford Local Safeguarding Children Board |
| 3.15. | Multi-agency training should be available on the effects of domestic violence on children for all those working directly with or assessing children. | Bedford Local Safeguarding Children Board |
| 3.16. | Consideration should be given to delivering training in working with hostile families and those who use ‘disguised compliance’ or other obstructive and avoidant behaviours. | Bedford Local Safeguarding Children Board |
| 3.17. | Consideration should be given to publicising the guidance and pathway to seeking a paediatric medical opinion in cases of injuries sustained by children. | Bedford Local Safeguarding Children Board |
| 3.19. | Where domestic violence is identified during an assessment or other agency activity this should trigger the completion of the DASH risk assessment. This should be completed with the victim unless it is unsafe to do so to ensure that the most up to date and accurate assessment can be made. Where information is not available from the victim, for example previous criminal history, this may need to be sourced from another agency to complete the full picture of risk. Familiarisation with the DASH risk assessment checklist and its use is relevant for all agencies. | All Agencies |
| 3.20. | Training in the DASH risk assessment and referral process to MARAC should be provided on a regular basis and all professionals and their managers in frontline services who work with families or individuals affected by domestic violence should attend whether statutory or voluntary sector, and organisations such as Housing Associations. This training should include a full explanation of the DASH and the evidence which underpins it so that practitioners understand the full implications and reasoning behind the assessment tool. The outcome should be that all professionals are confident in its use and in the referral criteria and methods of referral to MARAC. | All Agencies |
| 3.21. | Agencies working with families or individuals where domestic violence is present or suspected are recommended to keep a chronology of significant events and up to date records to detect patterns, escalation, new risk indicators such as pregnancy, and rising levels of risk. | All Agencies |
| 3.22. | Multi-agency services working with children and families should ensure that staff undertake domestic abuse training to increase their understanding and identification of domestic abuse, and the strategies and resources available for working with those affected. This should including safety planning. | All Agencies |
| 3.23. | Agencies who work directly with families should ensure that their staff are given training in working with hostile families and those who use ‘disguised compliance’ or other obstructive and avoidant behaviours. | All Agencies |
| 3.24. | Managers and Supervisors should ensure that their staff whose work involves assessing or supporting families where the perpetrator may still be in the family or has contact, receive training on working with perpetrators of domestic abuse. | All Agencies |
| 3.25. | Practitioners should be supported by their Managers and Supervisors to gain confidence in debating with multi-agency colleagues regarding areas of differences of opinion concerning the way safeguarding children or domestic violence cases are handled. The Local Safeguarding Children Board has in place an agreed escalation process to assist this. Professionals should be supported to recognise that child protection is a multi-agency responsibility and a variety of agencies can request a child protection conference. | All Agencies |
| 3.26. | The holding of strategy or professionals meetings to agree and determine the route to be taken with a case on completion of a core assessment should take place in line with procedures. This will facilitate exchange of information, pre planning of meetings which may be confrontational, and increase multi-agency joint responsibility. | All Agencies |
| 3.27. | Agencies should be aware that the removal of an abusive partner through legal means, or separation due to the victim ending the relationship is not a time to end involvement or support. Separation represents a heightened risk to victims and children and safety planning and support should be increased at this time, not reduced or ended. | All Agencies |
| 3.29. | Seeing and speaking to a child alone when appropriate as well as with parents is important when completing an assessment. This is particularly critical where domestic violence or possible harm to a child is suspected. To minimise distress it is important to see children in an environment where they feel safe. For younger children being seen at school may be appropriate especially where there is domestic abuse in the household where they may have learnt or been threaten to keep secrets. | Social work Teams |
| 3.3 | Consideration should be given to including the ACPO CAADA DASH risk assessment into the initial and core assessment processes. Where domestic abuse is alleged or found to be a component of a household or an individual’s life, a question asking about the presence of domestic abuse on the assessment should trigger the completion of the DASH and consideration of a referral to MARAC. | National |
| 3.30. | Core assessments should include an expectation that the family history of all household members is collected. It is critical that transient male figures are identified and included in history taking. Lack of cooperation by family members is grounds to consider escalating the intervention to child protection processes. Where domestic violence or physical abuse is a possible issue keeping safe work should be undertaken with the victim and the children separately. | Social work Teams |
| 3.31. | When gathering information from other agencies Social Workers should ask for a full chronology of events and concerns at least in the last year, and for criminal background seek full disclosure of any known history. Where DASH or other assessments have been completed the Social Worker should ask that the agency share full details of the risk assessment. This should be updated with any additional information known to the Social Worker from records. Risk and resilience tools and the DASH assessment tool would be more routinely used by Social Workers if integrated into the current assessment processes. Consideration should be given to doing this. | Social work Teams |
| 3.32. | Social Work Teams should review the training needs of their staff to identify those needing to access e-learning or more extensive training on domestic violence issues. Those involved in assessments and/or child protection should have a thorough knowledge to ensure that their level of proficiency and understanding is sufficient to enable them to identify domestic abuse, recognise its impact, risk assess, safety plan, and coordinate support safely. | Social work Teams |
| 3.33. | Social Workers should familiarise themselves with the guidance and pathway procedures for seeking medical advice. The advice of the Paediatrician on the Child Protection Medical Rota should be sought for a child protection or welfare medical when assessing the likely cause of injuries sustained by a child. A more enquiring approach should be used when taking histories of injuries to establish that explanations given are consistent and feasible for the presenting injury. A series of injuries should be assessed thoroughly. This may be more effectively achieved with the benefit of expert medical advice. | Social work Teams |
| 3.34. | The removal of, or separation from, an abusive partner is a time to support victims and their children, not to close the case. Separation heightens risk, it does not reduce it. Support needs, and safety and security should be addressed at such times to help survivors through this period of adjustment. Personal safety should be a priority following separation. | Social work Teams |
| 3.35. | The sending of letters to victims, or victims and perpetrators asking them to address their domestic abuse behaviour should be reviewed. This practice has been shown to be ineffective and can cause further abuse of the victim or heighten risk. | Social work Teams |
| 3.37. | Schools should use the Common Assessment Framework (CAF) to support their own assessment of children’s needs. This would make their referrals to other agencies more effective. Assessment is a process which should always capture schools in depth knowledge of a child. Schools should review and share their chronology of concerns and ensure these are detailed on referral or following their referral to other agencies. | Schools |
| 3.38. | Schools should ensure that as a minimum their Safeguarding Lead is knowledgeable about the affects of domestic abuse on children’s educational attainment, their behaviour, and other impacts of living in a family where domestic abuse is present. This should be shared with their colleagues to increase knowledge within schools. | Schools |
| 3.4 | The current time limits on initial and core assessments are too limiting and constraining and have an adverse impact on the quality of the assessment. Consideration should be given to implementing the findings of Professor Munro’s review on the current time limits. | National |
| 3.40. | Casework files (where an official referral has been received) should be kept until the individual pupil has reached the statutory school leaving age. These files should then be archived in line with the Bedford Borough Council policy. Liaison files should be kept for three years. | Education Welfare Service |
| 3.42. | Notifications of domestic abuse incidents to Children’s Social Care should be clearly identified as such, especially where the crime committed may not be readily identified as domestic abuse i.e. criminal damage, anti-social behaviour. A DASH risk assessment should be attached to notifications or referrals. | Police |
| 3.43. | A more thorough method of flagging domestic violence incidents to the Police Public Protection Unit is needed to prevent these incidents falling through the net, and clarification of closure categories needs to be given to frontline Officers to ensure that incidents are recorded correctly as domestic violence. | Police |
| 3.44. | Consideration should be given to formalising a procedure to ensure referrals are made to Children’s Social Care and the Child Protection Unit when children are found during Police operations in circumstances which raise concern for their safety and wellbeing; for example during the execution of drugs warrants. | Police |
| 3.45. | A system of sending repeat victim cases to the Domestic Abuse Unit would be valuable to consider so that the history of incidents can inform an holistic assessment of risk to identify increased frequency and escalation. | Police |
| 3.46. | The ‘sig marker’ system needs to be reviewed periodically to ensure that the address it holds is accurate for all victims to which it applies. Where there are child protection concerns linked to domestic abuse changes of address should be shared with partner agencies, unless there are safety reasons why the address needs to be kept secure or restricted. Sig markers would benefit from having the addition of the risk status of the victim, and if the case has been to MARAC this should be highlighted so that repeat victimisation can be referred to the MARAC coordinator or the lead professional for that case. | Police |
| 3.47. | Consideration should be given to a triage system for reviewing and assessing incidents to identify repeat victims who may appear low or medium risk, but where incidents are escalating in frequency or seriousness so that incidents are not viewed in isolation and are thus at risk of being overlooked. A variety of agencies, not just the Police, will have knowledge of these cases therefore multi agency coordination of this process would be helpful. | Police |
| 3.49. | Probation Officers should ensure that information is shared with Children’s Social Care as soon as possible where children are in the household of an offender on IDAP and they are breached for non attendance or behaviour which increases risk to their partner or former partner, such as increased use of alcohol or drugs which has been a previous risk factor in assaults. | Probation |
| 3.5 | The victim’s family believe more should be done to publicise domestic abuse both aimed at victims and at raising awareness of signs to look out for by family and friends and what they can do to help. They wish to make a recommendation that there should be strong impactful advertisements in a range of media, from billboards to radio adverts which will make people take notice. They should be in a variety of settings including doctor’s surgeries and dentists. | National |
| 3.50. | For those offenders without children, or where the family is unknown to other agencies, consideration should be given as to how a new increase in risk posed by an offender can best be mitigated to reduce the risk to the partner, former partner, or children. | Probation |
| 3.51. | This Review acknowledges that Bedford Probation Trust has taken action concerning the consistency of enforcement action following its own internal enquiry, and has issued a detailed briefing to all staff regarding information sharing and risk management within a safeguarding framework. This Review would reinforce the importance of a consistent and robust approach to enforcement action for breaches by those on IDAP. | Probation |
| 3.53. | The complex and multi-layered structures within Health can pose barriers to effective communication and clarity of responsibility. All professionals need to take personal responsibility for acting on their concerns for a patient’s wellbeing and safety, be that for a victim of domestic abuse or the safeguarding of children. Staff raising concerns should expect to have feedback to confirm the actions taken and who is responsible for those actions. Clear lines of responsibility and accountability are needed for staff. | Health Agencies |
| 3.54. | All medical professionals should take a more enquiring and questioning approach when taking histories of injuries to establish that explanations given are consistent and feasible for the presenting injury. If establishing the aetiology of the injury is outside the scope of the practitioner examining the patient a suitably qualified practitioner’s opinion should be sought. | Health Agencies |
| 3.56. | Where concerns are raised about a domestic abuse/safeguarding issue during the maternity period this should be recorded in the hospital notes of any children in that family who have accessed Bedford Hospital. | Hospital |
| 3.57. | Effective and timely communication between Community/Hospital Midwives and Health Visitors should take place. This is to ensure that information about domestic abuse or safeguarding issues are shared to facilitate safety planning (a discrete activity undertaken with a victim of domestic abuse), and risk reduction during pregnancy or for those in the post natal period. | Hospital |
| 3.58. | Notification of children treated in Accident and Emergency or admitted for treatment should take place between the Safeguarding Liaison post and the patient’s GP. | Hospital |
| 3.6 | The family would wish to see a more robust approach to offenders who breach their Probation Orders or who break the law further, whether linked to domestic abuse related crimes or not so that a suspended prison sentence is served. | National |
| 3.61. | Consideration needs to be given to affecting a more timely access to archived Health Visitor case notes to facilitate the smooth transfer and access to previous case history notes to a new case holder, to inform case management, and decision making regarding children and families. | Health Visitors |
| 3.62. | A more coordinated approach to Health Visitor and GP communication is recommended where safeguarding concerns can be shared and agreed actions and outcomes can be clearly recorded and accounted for. | Health Visitors |
| 3.63. | Although supervision has totally changed since the early days of this case, consideration may need to be given to how Community Health Service 0-19 years team professionals identify cases for safeguarding supervision. Therefore a review of the oversight of caseload management by 0-19 years Team Leaders needs to be undertaken with a view to the development of guidelines to support this process. | Health Visitors |
| 3.64. | Health Visitors may wish to consider a system of taking all their safeguarding children cases to supervision on a regular basis. Health Visitors should also access their Named Nurse for Child Protection when they feel the need to discuss issues of concern between supervision sessions if their Line Manager is not available. | Health Visitors |
| 3.66. | GPs may wish to consider the use of a communication tool such as SBAR (Situation, Background, Assessment, Recommendation)1 to facilitate, recorded, productive discussions in Health and other organisations. This communication tool will ensure that there are no misunderstandings between agencies when agreeing appropriate actions and responsibility for actions are identified from the outset. | General Practitioners |
| 3.67. | GPs should familiarise themselves with the DASH risk identification checklist, and with the referral pathway to MARAC to enable them to make appropriate referrals where a patient is identified as high risk. | General Practitioners |
| 3.68. | If a patient is identified as being at risk of harm (missed appointments, unexplained injuries and maternal concern around minor complaints) the information should be shared with other appropriate agencies and Children’s Social Care as needed. | General Practitioners |
| 3.69. | Where children are seen to be missing a substantial number of appointments for immunisations, clinic appointments, and other medical or developmental assessments, thought should be given to discussing these concerns with the named Health Visitor for the GP surgery and/or Children’s Social Care. | General Practitioners |
| 3.70. | Health Visitors need to be kept up to date on children’s attendance at A & E and hospital admissions to enable them to support children and families effectively. GP’s are recommended to take steps to ensure that this takes place following their notification of such admissions from the hospital. | General Practitioners |
| 3.71. | GP’s are recommended to consider the efficacy of the current GP electronic data entry system and to identify areas where the system could be improved. For example data entries should include clear historical accounts of the patient and detailed documented evidence of patient examinations and contacts. | General Practitioners |
| 3.72. | GPs would find it useful to access the Royal College of General Practitioners e-learning course for guidance and practice advice regarding domestic violence. This is available on the Royal College’s website2 at: http://elearning.rcgp.org.uk/course/view.php?id=88.3 | General Practitioners |
| 3.8 | The Domestic Abuse Partnership is advised to review the extent of the implementation of multi agency domestic abuse protocols and procedures such as the domestic violence guidance and procedures for using DASH and MARAC. Multi agency procedures including domestic violence procedures and guidance should be reviewed to ensure they are brief, focussed and inform practitioners in a straightforward way about what they should do. The status of these protocols and procedures in relation to other single agency assessment processes, needs to be clear. Procedures should be easily accessible so that they are fit for use by busy front line staff. | Bedford Borough Domestic Abuse Partnership |
| 3.9 | The Partnership may find it useful to conduct a multi-agency audit into levels of knowledge and training with regard to the understanding of domestic abuse and its impact, knowledge of risk assessment, and MARAC referral processes. This would assist the planning of a training programme for the Borough. | Bedford Borough Domestic Abuse Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||