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

Norfolk review

CSP: Norfolk Published: September 2023 Year of death: 2012 Extracted: 15 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 health agencies to identify domestic abuse due to insufficient training, inadequate policies, and the perpetrator's presence during consultations. It also highlights inadequate information sharing between agencies and limitations in firearms licensing procedures concerning domestic abuse.

Extracted recommendations

15 recommendations pulled from the report

#	Recommendation	Addressed to
1	That NHS England build into its contractual and performance management arrangements a requirement that GP practices should implement the Identification and Referral to Improve Safety (IRIS) system in coordination with Independent Domestic Violence Advocacy Services.	NHS England
10	The following are recommended when assessing and monitoring patients suffering from longstanding depression and should be disseminated throughout GP practices and Mental Health providers and commissioners by December 2013: (a) NICE Guidance26 is available to support the management of Depression in Adults and Depression in Adults with Chronic health problems and should be utilised as this provides a clear, structured and tested framework. If there is variance to the guidance a rationale for decision making should be documented within a patient’s clinical records to clarify choices and options made. (b) A clear risk assessment process should be undertaken for patients with depression which gauges the behaviour of a patient and determines how they may react to various methods of treatment. It should identify the level of depression and identify any suicidal ideation; this is clearly stated within NICE Guidance. Treatment options and onward referral should be structured to fit appropriately with the patient’s level of need determined from risks assessed. (c) Where treatment of depression is being managed between primary care and mental health community or secondary care services, information should be complete and accurate, providing a clear chronology of case management activity, treatment and actions taken through the duration of input. The GP is always a central professional in sustaining care for an individual and therefore must be in receipt of all information that will allow them to effectively manage and consider patients future needs.	NHS CB \| Clinical Commissioning Groups \| GP Practices \| Mental Health Trust
11	The Community Safety Partnership should monitor the progress and impact of the protocol between the Safeguarding and Firearms Units introduced in mid 2013 concerning domestic abuse and checking firearms databases to ensure that it is able to be implemented effectively in practice. The Partnership may wish to be made aware on an annual basis of the effect of this policy vis a vis the number of licences or shotgun certificates revoked due to incidents of domestic abuse.	Community Safety Partnership \| Police
12	The Community Safety Partnership should support and monitor the implementation of domestic abuse policies within Health partner agencies and give appropriate ‘expert’ guidance from board partners from the specialist domestic abuse sector to ensure that policies meet the needs and safety requirements of victims and survivors of domestic abuse.	Community Safety Partnership \| DASVB
13	Information sharing protocols should be reviewed to ensure that all agencies have appropriate agreements in place for the timely and accurate sharing of information. This is particularly the case for the sectors within Health and Mental Health who have undergone radical restructuring in recent months. This should be completed by October 2013. Any necessary amendments to protocols should be completed by January 2014.	All Agencies \| CCSP
14	The Police should ensure that all frontline Officers and the relevant support staff complete training in the DASH risk assessment, its use with victims and the evidence base behind the risk factors. Training should include ensuring that firearms are included when asking questions about weapons.	Police \| NCCSP
15	Where a victim is found to be under the influence of alcohol or other substances at the time of investigating an alleged incident of domestic abuse, a call should be made the following day, or as soon as practicable, to follow-up the incident and to provide advice when the victim is unaffected by substances and the perpetrator is not present.	Police \| CSP
2	That NHS England support primary care services to be more aware of their responsibilities to share relevant information which is required to ensure the safety of their patients and members of the public.	NHS England
3	That there is a national review of the Firearms (Amendment) Act 1997 Section 37 (26B) Applications for shot gun certificates, to include the criteria by which an individual is granted a shotgun certificate. Such criteria should include: (a) A definition of a ‘fit and proper person’ appropriate for being granted a certificate or licence and that it is not a person’s right to have a shotgun certificate, but that they have to demonstrate they are a fit and proper person to be granted a certificate. (b) A requirement to have a medical before the granting and renewal of a shotgun certificate paid for by the applicant. No certificate should be granted before a satisfactory medical is received, and the onus is on the applicant to ensure that this is received by the Firearms Licensing Department in the time required. (c) The checking of Police records and risk assessment of members of the household of applicants. (d) The prohibition of the granting or renewal of a certificate where the applicant or associated person/s has involvement or association with violence or domestic abuse. (e) Whilst gun security is already in the regulations this should be given greater prominence in the declaration so that the certificate holder is clear of their responsibilities to ensure that gun cabinet keys are separately secured and not available to anyone else in the household who is not also a certificate holder. Confirmation of the keys secure location should be part of the inspection process. Failure to comply with this regulation should be an offence, and unlawfully accessing the keys by a third party should be an offence.	Government \| ACPO
4	Training for Health professionals including Mental Health, GPs, and other primary care staff should include mandatory training about domestic abuse separate from safeguarding training. This training should be a rolling programme to encompass new staff and be commenced within 6 months of the publication of this Review. It should include: (a) The identification of domestic abuse, risk assessment, how to engage with patients who may be at risk by being able to ask questions safely and sensitively, and knowledge of specialist support agencies to whom they can refer. (b) An awareness of the evidence base, health markers, and links between domestic abuse and depression, and other medical conditions; (c) An awareness of domestic abuse perpetrator profiles to assist in the identification of high risk behaviours and when and to whom to provide information should a patient’s behaviour cause risk to others. Knowledge of support for perpetrators who wish to change their behaviour should be included and referral routes.	Department of Health \| Clinical Commissioning Groups \| NHS England \| DASVB
5	That all Health agencies and GP practices develop domestic abuse policies and protocols within 1 year of the publication of this Review which clearly outline the responsibilities of staff to understand and respond to the needs of domestic abuse victims. The policies and protocols should be mindful of the Home Office definition of domestic abuse which was amended in March 201320 to include individuals of 16 years and over, and the inclusion of coercive control in the description of abuse. Policies and protocols should include: (a) A domestic abuse care pathway as recommended by the Royal College of General Practitioners, IRIS, and CAADA. (b) The identification of a key individual within the agency or practice who will have additional training and be able to act as more specialist support for other staff. (c) Where an individual is regularly accompanied by a partner, relative or carer a protocol should be put in place setting a clear expectation that opportunities will be made available to see individuals alone in a safe and confidential setting. Advice and guidance on how to achieve this should be included. (d) At the time of writing NICE are in the process of developing guidance to support the prevention and reduction of domestic violence which is due to be published in February 2014. It is proposed that Clinical Commissioning Groups take forward NICE recommendations with its membership at that point.	Health agencies \| GP practices \| DASVB \| Clinical Commissioning Groups
6	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 website at: http://elearning.rcgp.org.uk (enter domestic violence in the search for courses window).	Clinical Commissioning Groups \| NHS England \| GP Practices \| Norfolk County Community Safety Partnership
7	That the Director of Public Health and a leading Practitioner for the county Clinical Commissioning Groups provide leadership to drive forward Health’s contribution to an integrated multi-agency domestic abuse strategy for the whole county by June 2014.	Director of Public Health \| Clinical Commissioning Groups \| DASVB
8	Information about domestic abuse, helplines and routes to support locally and nationally should be provided for victims, family members, friends and work colleagues. This information should be widely available in a variety of venues throughout rural and urban communities. The information should include identifying the signs of domestic abuse, what constitutes increased risk to victims, and where to go for help. It should be available in a variety of formats, including a size which can be easily given discretely and safely to victims at the time of an incident, consultation, or disclosure to a friend. The materials should be available and displayed across the county by January 2014.	Police \| Leeway Domestic Abuse Services \| GP Practices \| DA & SV coordinator \| DASVB
9	GP Practices should provide a protocol for staff involved in patient care by December 2013 which clarifies expectations relating to written record keeping and the maintenance of electronic records which should provide a high level of detail and information pertaining to the treatment and assessment of patients; include the rationale for decisions made; outlines what is offered to patients along with reasons for options being declined, but most importantly offers a clear chronological account of care provided.	GP Practices
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗