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
Gloucester review
CSP: Gloucester
Published: September 2023
Year of death: 2018
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 systemic challenges in providing consistent mental health support, particularly for individuals requiring regular medication, and highlights gaps in information sharing across healthcare and criminal justice systems. It also notes a need for improved understanding of domestic abuse dynamics, including male victimisation and the impact of trauma, to better engage and support vulnerable individuals with complex needs.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The National Criminal Justice Board use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support for their mental health and ensuring they are housed appropriately. | National Criminal Justice Board |
| 1 | Gloucestershire Criminal Justice Board to use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support for their mental health and ensuring they are housed appropriately. | Gloucestershire Criminal Justice Board |
| 1 | Ensure effective handover of serious crime investigations between OICs and Supervisors with a clear investigation strategy which is endorsed on the crime report. | Gloucestershire Constabulary |
| 1 | All social workers to have updated training on patterns of domestic violence with focus on child protection, parenting capacity and how to support parents who are victims and/or perpetrators of domestic violence following this DHR’s publication, and refreshed on a regular basis. | Gloucestershire Children’s Social Care |
| 1 | Probation services to continue working with domestic abuse perpetrators to get immediate starts on the Building Better Relationships Programme, or to identity where this intervention may not be suitable for an individual, so that the court can be informed of this and an alternative sentence imposed. | BGSW CRC |
| 1 | Gloucestershire Clinical Commissioning Group to advise primary care regarding their response to vulnerable patients and where there are safeguarding concerns. The advice should include: • Practices to regularly discuss vulnerable patients amongst the team to ensure awareness of cases • Patient notes to be kept up to date regarding vulnerability and safeguarding discussions, and management plans. • The challenges to continuity of care – such as temporary registrations, prison time, or missed appointments for vital medications – to be document, discussed and escalated where unresolved by previous management plans. | Gloucestershire Clinical Commissioning Group |
| 1 | Cognitive Behaviour Coaching training to be delivered to support staff in the South West. | The Riverside Group |
| 1 | Upon breakdown of the Homeless Hostel placement due to non-engagement, GCH should make a referral to a homeless rough sleeping outreach service, if available, to flag the vulnerable person to attempt further follow-up engagement. | Gloucester City Housing |
| 1 | Where there is a known history of domestic abuse within a relationship, GHC Trust staff will take every opportunity to explore this with the victim when it is safe to do so and demonstrate consistent professional curiosity. This will be reinforced with the review of the policy and training, group supervision and all GHC Trust staff forum. | Gloucester Health and Care NHS Foundation Trust |
| 10 | All Panel agencies to regularly provide details of their domestic abuse training to Safer Gloucestershire so they have oversight of the levels of training in the workforce. All Panel agencies to ensure that their domestic abuse training includes recognising and responding to male victims of domestic abuse. | All Panel agencies | Safer Gloucestershire |
| 11 | Gloucestershire MARAC agencies to review their policies and practices regarding risks to staff from clients and to consider how they share such information with other agencies. MARAC Steering Group to consider how the MARAC system can assist in the distribution of such risk information to partner agencies. | Gloucestershire MARAC agencies | MARAC Steering Group |
| 12 | Gloucestershire MARAC to ensure decisions around whether to hold a formal or virtual MARAC are made on the basis outlined in the Gloucestershire MARAC Protocol and that virtual MARACs achieve the same outcomes regarding the sharing of information and bespoke multi-agency action plans for victims of abuse. Annual dip sampling and auditing to be undertaken to monitor this. | Gloucestershire MARAC |
| 13 | Gloucestershire MARAC review its current capacity against the expected volume of cases for the population it covers and look to increase capacity, particularly around decision-making. An additional MARAC decision-maker would increase capacity and resilience in the model. | Gloucestershire MARAC |
| 14 | DASV Strategic Coordinator to organise a multi-agency task group to review the risk factors in this case and how temporary situational factors affected risk assessment. Task group to dip sample standard and medium risk DASH RICs from partner agencies to be sure that the DASH RICs identify all the risks in cases and do not reduce risk based on temporary factors or short-term interventions. The learning form this exercise to be disseminated to MARAC partners. | DASV Strategic Coordinator |
| 15 | If there is another DHR in Gloucestershire, Safer Gloucestershire to provide a workshop for agencies on writing clear and analytical IMRs for domestic homicide reviews. | Safer Gloucestershire |
| 16 | DASV Commissioning Partnership and GDASS to review the IDVA provision and explore specialist IDVAs for repeat victims of domestic abuse and those with complex needs. | DASV Commissioning Partnership | Gloucestershire Domestic Abuse Support Service |
| 2 | NHS England to ensure that, at regional and national level, patients with severe mental health issues (such as schizophrenia) requiring regular antipsychotic medication have clear and specific care plans that identify their regular medication needs. This information must be contemporaneous and should be visible across all healthcare systems, including prison, and accessible as patients are transferred and move across care locations. NHS England to update Safer Gloucestershire every six months until complete. As part of this, NHS England to consider the value and viability of a lead professional for this patient group who could follow up as a patient moves between institutions (e.g. mental health in-patient care) and the community. | NHS England |
| 2 | Safer Gloucestershire to create a multi-agency working group to develop a care pathway for those with multiple disadvantage or complex needs, and to advise partner agencies on training their staff to respond to such clients, including trauma-informed practice. | Safer Gloucestershire |
| 2 | Ensure relevant domestic abuse and/or child protection records are copied onto Storm incident to assist attending Officers’ decision-making process when dealing with a domestic abuse incident. | Gloucestershire Constabulary |
| 2 | All social workers to have an improved understanding in their team meetings about impact of multiple removals of children on parents, especially mothers. | Gloucestershire Children’s Social Care |
| 2 | Probation services to develop a pathway with P3 to effectively challenge each other’s risk assessments when looking at a service user’s suitability for accommodation. This may prevent delays in the system for vulnerable service users. The first step in this process will be to engage with the Gloucestershire Reducing Reoffending Board who are focussing on the Homelessness Reduction Act and accommodation for offenders as one of their objectives. | BGSW CRC |
| 2 | Gloucestershire CCG to encourage primary care that when registering a patient, to enquire about household members and social history. | Gloucestershire Clinical Commissioning Group |
| 2 | Ensure the Riverside Domestic Abuse policy and procedure includes any good practice and lessons learnt from the DHR. | The Riverside Group |
| 2 | GCH to put a ‘flag’ on the housing management systems to identify vulnerabilities/cautions concerning tenants to indicate that follow-up with an ASB officer is necessary to monitor safety. | Gloucester City Housing |
| 2 | To review the GHC Trust Domestic Abuse Policy as the current focus is for staff to know what to do in the event of a disclosure. More guidance is required within this policy about the indicators of potential domestic abuse to enable more effective signposting to specialist services. | Gloucester Health and Care NHS Foundation Trust |
| 3 | NHS England to ensure that community GPs promptly provide comprehensive details of a patient’s health records when asked by a prison healthcare team for this information. This should include details of the prisoner’s history of both physical and mental health problems. | NHS England |
| 3 | Safer Gloucestershire to share the action plan created from this DHR and report to Scott’s family every six months on the progress being made. | Safer Gloucestershire |
| 3 | Ensure the VIST Risk Assessment is updated with information known by Officers when a victim does not wish to engage with the question set. | Gloucestershire Constabulary |
| 3 | All social workers, their managers and leaders to have workshop, team discussions on ACEs, wellbeing of parents and what resources are available for work with parents. A programme of activity to be started immediately and continue for the next calendar year in support of parents who have multiple ACEs. | Gloucestershire Children’s Social Care |
| 3 | Probation services to ensure that Offender Managers are aware of the importance of exploring loss issues with service users when they do not have access to their children. This will need to be part of the Sentence planning process and clearly recorded. | BGSW CRC |
| 3 | Gloucestershire CCG to encourage primary care that patient records should be flagged with social care history, substance misuse as well as the children of the index patient. | Gloucestershire Clinical Commissioning Group |
| 3 | Where a tenant has made statements that suggest vulnerabilities from visitors, GCH to undertake further post-letting informal contacts on a regular basis to help identify if there are further issues. | Gloucester City Housing |
| 3 | GHC Trust domestic abuse training to encompass all the indicators of domestic abuse which may be evident prior to a disclosure. | Gloucester Health and Care NHS Foundation Trust |
| 4 | NHS England to develop capability for prison healthcare to access Summary Care Records for prisoners so that prisoners’ healthcare needs are addressed immediately. | NHS England |
| 4 | Safer Gloucestershire to create a housing lead to oversee housing providers’ updating of their policies and practices to (a) Allow more time to make decisions about letting accommodation when seeking additional information and/or assurances from other professionals on matters of safety. Properties should not be let until safety concerns are addressed. (b) Enable an offer of a tenancy to be withdrawn where necessary reassurances concerning the safety of a proposed tenant and/or member of their household are not obtained. | Safer Gloucestershire |
| 4 | Ensure information regarding potential breaches of bail/licence conditions are added to an individual’s nominal record on Unifi. | Gloucestershire Constabulary |
| 4 | Social workers working with challenging and non-engaging parents and who consider themselves at personal risk, should complete a risk assessment. They should be immediately and effectively supported by their Team Managers. The management of risk should be overseen by their respective Heads of Service. | Gloucestershire Children’s Social Care |
| 4 | Probation services to ensure that all Offender Managers are pro-active in their approach to partnership work, both together and share information, particularly where there are safety concerns. | BGSW CRC |
| 4 | All client-facing staff to have mandatory domestic violence training that is refreshed regularly and that includes information about the dynamics of domestic abuse. | Gloucester Health and Care NHS Foundation Trust |
| 5 | GCSC to work with GDASS to develop guidance for child protection conference chairs to ensure that the dynamics of domestic abuse inform the deliberations. | Gloucestershire Children’s Social Care | Gloucestershire Domestic Abuse Support Service |
| 5 | Ensure notifications of birth received from Social Care / EDT are forwarded to the Central Referral Unit for an individual’s Domestic Abuse / Child Protection records to be updated accordingly, particularly those subject to a Child Protection Plan. | Gloucestershire Constabulary |
| 5 | GCSC and housing providers to regularly liaise in situations where there are child safeguarding concerns for unborn children to ensure that the impact on a tenancy or housing provision is understood, assessed and an appropriate contingency is in place. | Gloucestershire Children’s Social Care |
| 5 | Probation services to continue to roll-out DASH RIC and SARA training and to ensure, through case audits and discussion in supervision, that this is being applied. Probation services to monitor the identification of both male and female victims through these processes. | BGSW CRC |
| 6 | Gloucestershire’s Joint Commissioning Partnership consider the evaluation of the commissioned pilot for supporting vulnerable women and use that to inform specific support for women who have had multiple children taken into care. | Gloucestershire’s Joint Commissioning Partnership |
| 6 | Ensure full review of intelligence systems to be completed upon receipt of intelligence linked to domestic abuse to identify opportunities to prosecute/safeguard and task appropriately. | Gloucestershire Constabulary |
| 6 | In situations where parents or carers are disengaging and are at risk of being denied services which would impact on their capacity to provide care to their children, social workers should highlight concerns with the relevant agency to inform a multiagency response including the use of multi-agency escalation policy as appropriate. Children’s Social Care to follow its responsibility to children if there is non-engagement. This will be highlighted through multi-agency arrangements and the GSCE (Gloucestershire Safeguarding Children’s Executive). | Gloucestershire Children’s Social Care |
| 6 | Probation services to identify a Women’s SPOC in Gloucestershire LDU in line with BGSW CRC’s policy in relation to working with female offenders. | BGSW CRC |
| 7 | Gloucestershire County Council supported housing commissioners to work with Gloucestershire local authority strategic housing officers to run a workshop for relevant front line, operational housing staff and housing providers (to include supported housing providers, temporary homeless accommodation providers and registered providers) using this case to improve practice. The workshop should include: • The role of housing in responding to domestic abuse, including MARACs • How to safely provide housing to victims of domestic abuse • How domestic abuse risk informs responses to victims and perpetrators, including timely processes when a victim goes missing • Key partner agencies in the coordinated community response to domestic abuse • Consideration of DAHA accreditation for housing providers. | Gloucestershire County Council |
| 7 | Where intelligence is received relating to a live suspect on a crime, FIB to update the crime report to advise the Officer in Charge to review intelligence for information. | Gloucestershire Constabulary |
| 7 | Probation services to ensure that Offender Managers are aware of the importance of exploring disclosures of mental health issues and that they are proactive in making contact with mental health services to provide further information and support, if required. | BGSW CRC |
| 8 | GCCH and Gloucestershire local authority strategic housing officers to work with Registered Housing Providers (RPs) to create a common protocol when housing households that include those who may be perpetrators, and victims of domestic abuse. The protocol should prioritise victims’ safety and demonstrate an understanding of the dynamics of domestic abuse. | Gloucester City Council Housing | Gloucestershire County Council |
| 8 | Ensure officers are aware of Crown Prosecution Service advice that proof of service of a Non-Molestation Order is only required where the suspect raises knowledge of the Order as an issue in interview. | Gloucestershire Constabulary |
| 8 | Probation services to work with housing providers to agree service level standards on response times following enquiries about offers of housing accommodation where there are concerns involving a particular individual or individuals. A process for escalating concerns to also be agreed. | BGSW CRC |
| 9 | GDASS and Nelson Trust to work more closely together, such as GDASS providing a drop-in service at the Nelson Trust Women’s Centre. GDASS to advise NT staff when they are supporting women who are the victims of domestic abuse. | Gloucestershire Domestic Abuse Support Service | Nelson Trust |
| 9 | Ensure that supervising police officers review the quality of VISTs and request improvements/re-completion prior to sign off. Police to also consider how the Daily DA meeting can be utilised to provide feedback on VIST quality as a second review to ensure consistent quality of VIST completion across the force. | Gloucestershire Constabulary |
| for GHT maternity st | An anonymised audit of maternity records to be undertaken and results reported to Safer Gloucestershire. Audit methodology must demonstrate that questions have been asked about domestic abuse on two or more occasions antenatally, that risk factors for domestic abuse have been assessed (and addressed if identified) and that the expectant mother has been asked about domestic abuse without anyone else present. This audit to be undertaken for the next two years or until an electronic patient record is in place across maternity which provides assurance with respect to compliance with screening procedures. | Gloucester Hospitals NHS Foundation Trust |
| Recommendation | Review the Helpdesk practices put in place following this review (regular refreshers from the safeguarding team and regular reviews of referrals not passed to the team) and ensure they are effective. | Adult Social Care |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||