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
Leicester review
CSP: Leicester
Published: September 2023
Year of death: 2013
Extracted: 41 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
Agencies failed to share information effectively, leading to incomplete risk assessments and missed opportunities to intervene in domestic violence and manage the perpetrator's risks. There were also deficiencies in supervision and adherence to established procedures.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| ASC_R1 | Raise awareness of the role domestic violence services can play in safeguarding vulnerable adults. | Leicestershire County Council Adult Social Care |
| LDAOP_R1 | Before a specialist domestic abuse services closes a referral that they have not been able to make contact with they take it to a JAG or appropriate multiagency meeting | Local Domestic Abuse Outreach Provider |
| LDAOP_R2 | DASH risk assessment training to include details of local services. | Local Domestic Abuse Outreach Provider |
| LP_R1 | It is recommended that Leicestershire Police reissues guidance reminding officers of the need to add a separate Crime Intelligence System incident for all breaches of bail conditions. | Leicestershire Police |
| LP_R2 | It is recommended that Leicestershire Police reissues guidance reminding officers that when granting bail for Crown Prosecution Service referral or after charge for domestic abuse, conditions are attached or, where applicable, reasons why conditional bail has not been given are recorded. | Leicestershire Police |
| LP_R3 | It is recommended that Leicestershire Police puts in place a system, with the assistance of the courts, whereby the reasoning behind discontinuances of domestic abuse cases at court are recorded. | Leicestershire Police |
| LP_R4 | It is recommended that Leicestershire Police engages at a strategic level with the CPS and HM Courts and Tribunals Service to develop and implement a clearer, stronger and more victim-focused policy on how and when ‘victimless’ prosecutions (cases where the victim is unwilling to support a prosecution)should be progressed; this should also include standardising the terminology used. | Leicestershire Police | Crown Prosecution Service | HM Courts and Tribunals Service |
| LP_R5 | It is recommended that Leicestershire Police makes changes to the DASH risk assessment on Crime Intelligence System ensuring the collar number of the officer completing the form is added and restricting officers from adding their supervisor’s collar number; this will ensure that all incidents involving domestic abuse are subject of supervisory review. | Leicestershire Police |
| LP_R6 | It is recommended that as part of its current review of the Comprehensive Referral Desk and Domestic Abuse Investigation Unit, Leicestershire Police considers the line management of the Assistant Referral Officers working within the Domestic Abuse Referral Team and ensures a more cohesive approach is taken to dealing with outreach referrals and looking at repeat victims. | Leicestershire Police |
| LP_R7 | It is recommended that, following the IMR for FN and the implementation of a system that identifies and reviews repeat victims of domestic abuse, Leicestershire Police reviews the current process, evaluating the sustainability of this work being completed by LPUs and whether it is having a positive impact on reducing further victimisation. | Leicestershire Police |
| LPT_R1 | Francis Dixon Lodge LPT to develop an operational policy which clearly describe all aspects of service delivery and care planning e.g. risk assessment, implementing the CPA process, the service approach to risk assessment, the triage process, admission and discharge planning & effective communication and interagency working. | Leicestershire Partnership NHS Trust |
| LPT_R2 | Risk assessment refresher training to be delivered to staff within Francis Dixon Lodge to increase capability and confidence of practitioners. The LPT CPA lead will deliver this training on risk management planning following assessment for FDL (TSPPD) team. | Leicestershire Partnership NHS Trust |
| LPT_R3 | Risk assessment forms to be shared systematically and in a timely way across all involved teams within AMH division, with team members in Francis Dixon Lodge and to agree how this information is shared with GPs | Leicestershire Partnership NHS Trust |
| LPT_R4 | Consideration to be given to the reciprocal information sharing agreement with GP’s as part of the development of the ‘RiO’ Electronic Patient Record system | Leicestershire Partnership NHS Trust |
| LPT_R5 | Individualised care plans to be implemented for Francis Dixon Lodge clients | Leicestershire Partnership NHS Trust |
| LPT_R6 | To continue to deliver Domestic Violence training across the Trust within the Adult Service Safeguarding programmes. | Leicestershire Partnership NHS Trust |
| LPT_R7 | To provide staff training and improve staff awareness of MAPPA procedures and processes across the Trust | Leicestershire Partnership NHS Trust |
| LPT_R8 | Joint working arrangements across In-Patient and CMHT’s to be reviewed to ensure that on balance they are providing the best configuration in relation to information sharing, effective and seamless transition and continuity for patients. | Leicestershire Partnership NHS Trust |
| LRPT_R1 | Accurate completion of Spousal Abuse Risk Assessment (SARA) and Specific; Measured; Achievable Realistic Time-bound Supervision plans – sample check Offender Managers’ SARA and supervision plans | Leicestershire and Rutland Probation Trust |
| LRPT_R2 | Liaising with statutory agencies. Ensure that anyone subject to a Drug Rehabilitation Requirement or Alcohol Treatment Requirement, that their GP is routinely notified | Leicestershire and Rutland Probation Trust |
| LRPT_R3 | Liaising with other statutory agencies. To go through all Offender Manager’s domestic violence cases to ensure offender manager has gathered and shared information with other relevant agencies. | Leicestershire and Rutland Probation Trust |
| LRPT_R4 | Risk management plans incorporate direct reference to victims. Ensure that domestic violence risk management plans are making reference to victims. | Leicestershire and Rutland Probation Trust |
| LRPT_R5 | Use of weapons are addressed in risk management plans. LRPT to review resources re working with perpetrators who use a weapon. | Leicestershire and Rutland Probation Trust |
| LRPT_R6 | Levels of Offender management contact and home visiting. Recommend changes to LRPT Domestic Violence policy so that Offender managers are clear about the levels of contact expected in Domestic violence cases. | Leicestershire and Rutland Probation Trust |
| LRPT_R7 | Quality of Domestic violence work with medium risk of harm cases and oversight by line managers. The majority of Serious Further Offences come from medium risk cases, and are most often domestic violence in nature. In line management supervision, there is inevitably a focus upon high risk cases. LRPT will be doing sample audits across all Offender Manager teams once a month, looking at medium risk domestic violence and safeguarding cases using the RADAR tool. | Leicestershire and Rutland Probation Trust |
| MP1_R1 | Case to be discussed at Practice clinical meeting once outcome of review known and final recommendations made. | Medical Practice 1 |
| MP1_R2 | Practice education around domestic violence, its signs and assessing risk | Medical Practice 1 |
| MP1_R3 | At the point of registration with a GP; patients to be asked for consent to allow relevant and proportionate information about them to be shared and received with other services to reduce the risk of harm and safeguard themselves or others | Medical Practice 1 |
| S_R1 | Swanswell will continue to attend to each meeting MARAC on an on-going basis | Swanswell |
| S_R2 | Swanswell will introduce information around domestic abuse into our pregnancy pack from Oct 2013 | Swanswell |
| S_R3 | All team members have been mandated to complete AVA's new e-learning programme, Complicated Matters: addressing domestic and sexual violence, substance use and mental ill-health. They will have completed this by end of Sept 2013 | Swanswell |
| S_R4 | Swanswell will include training around Domestic Abuse within its mandatory training program starting in January 2014 | Swanswell |
| S_R5 | DASH training to be arranged for all staff. Currently being arranged but it is hoped that this will take place in Nov/Dec 2013 | Swanswell |
| S_R6 | A Domestic Abuse pack will be developed. This will include advice and information for workers and for potential victims. It will also include contact details and referral pathways for all relevant services. This is due for completion end of Oct 2013 | Swanswell |
| S_R7 | Representatives from domestic abuse services will be invited to attend team meetings of all Swanswell teams from Oct 2013 | Swanswell |
| S_R8 | Although the supervisor role has a significant clinical element we are re-shaping the supervisor role to enhance its clinical overview of domestic abuse cases. This will take from Jan 2013 | Swanswell |
| S_R9 | Supervisor’s will audit all cases where there is mental health involvement to ensure joint working procedures are being adhered to | Swanswell |
| UHL_R1 | That MARAC referrals completed by UHL ED will be received by MARAC co-ordinator -Amend the Emergency Department domestic violence procedure to include a prompt for staff to ensure that a fax receipt, which confirms successful transmission, is obtained and filed in the notes (when a MARAC referral is completed). This is already completed | University Hospitals of Leicester NHS Trust |
| UHL_R2 | Explore the possibility of MARAC referrals being completed electronically by senior ED staff | University Hospitals of Leicester NHS Trust |
| UHL_R3 | Emergency Department medical staff will advise GPs, through the GP letter, when a patient has attended ED following episodes of domestic violence. | University Hospitals of Leicester NHS Trust |
| UHL_R4 | Develop a standardised protocol (for adult areas) when responding to adults who disclose domestic violence – this will be developed in consultation with other agencies. | University Hospitals of Leicester NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||