Cornwall review

The Review recommends that the Home Office takes action to amend the wording of information leaflets and statutory Guidance relating to Domestic Homicide Reviews to reflect the increasing number of domestic abuse related suicides.

As this review is not unique in finding that the families of the deceased and her partner were confused by the title of this review “Domestic Homicide Review” resulting in missed opportunities for the safety of future partners; it is recommended that consideration should also be given to changing the title to ‘Domestic Abuse related Death Reviews

That the Home Office seeks clarity from the Dept. of Justice and/or Lord Chancellor’s Office if the judgement in the R (Sec of State for Transport v HM Senior Coroner for Norfolk includes DHRs. That is whether Domestic Homicide Reviews are considered to be a statutory Review within the meaning of the judgement which states that to avoid duplication agencies need only to respond to the Inquest and the information will be shared with other statutory reviews. This issue is likely to come up again in Suicide DHRs so Legal clarity would be beneficial.

That Community Safety Partnerships embed within their Domestic Abuse Strategies that practitioners receive training on legislation and practice relating to stalking and coercive control .This training should encompass grooming

For agencies to be aware of all available civil and criminal justice options to tackle perpetrators of domestic abuse.

Commissioned Cornwall Domestic Abuse Services should have clearly defined processes for supporting victims who may want to stay in a relationship and pass referrals to other support services

Community Safety Partner agencies should be reminded of Para 21 of the Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews which states: ’Any professional or agency may refer such a (domestic) homicide to the CSP in writing if it is believed that there are important lessons for inter-agency working to be learned’

After publication of this Domestic Homicide Review’s reports, relevant Safer Cornwall cross agencies strategies and action plans should be reviewed to ascertain how they can build on the recommendations and action plans of individual agencies set out in this DHR.

Safer Cornwall should remind partner agencies that perpetrators of domestic abuse can self refer into Cornwall based Community Behaviour Change Programme. This is to be expanded to have an out of court IOM/MARAC pathway and a programme for families impacted by child on parent abuse.

Mental Health services to develop an integrated emergency referral pathway and ensure that this is reflected consistently across all policy, process and practice.

CFT should continue to commit to a trauma informed approach to patient care, being one of its 4 quality priorities.

CFT should ensure that all midwives receive operational Safeguarding and Domestic Abuse training.

The Cornwall Foundation Trust and Cornwall Council should review and agree a safer information sharing process to enable previous CFT services to access their own historic records where required. That is an Information governance and named nurse to review and agree a safer process for information sharing across the two agencies.

As the success of the MARAC and associated reduction in risk and increased positive outcomes for all impacted parties is entirely dependent on service engagement and prioritisation of the MARAC; Cornwall MARAC management & members have developed an improved MARAC process in Cornwall. To maximise its potential, all services and agencies must continue to resource MARAC representatives and support the delivery of the MARAC, ensuring information is shared in a timely fashion and multi-agency working initiates as soon as referrals to MARAC are made.

As part of the MARAC pilot review to continue MARAC awareness raising process, to move away from DASH scoring as a sole referral criteria to MARAC and focus more on risk of escalation and professional judgement

Public Health will target the need for a better understanding of the links between self-harm and suicide. Self-harm is a way of communicating distress and may be used as a coping strategy. However, for some people it can be a risk factor in suicide. Self-harm in itself is not an indicator of suicidal intent.

That key agencies gain a deeper understanding of the risk factors and their prevalence in deaths by suicide.

Devon & Cornwall Police should issue a Force wide Policy reminder of D34 to all officers and staff to include the definition of a domestic incident, the need to promptly record the relevant crime or enquiry and the necessity for a DASH and any necessary ‘ViSTs’ to be included in all cases.

Devon and Cornwall Police should remind all trained gatekeepers of the importance of evidence led prosecutions. The Gatekeeper training module should be modified to emphasise the importance of evidence led prosecutions where the victim has declined to support a prosecution or has since died.

It is recommended that the officers who dealt with incidents involving Lucy and Lee without fully following relevant Force policies would benefit from advice on the need to follow Force policy for the benefit of future victims of DA.

An ‘Evidence Led Prosecutions’ audit should be conducted to assess knowledge and implementation.

The Devon and Cornwall Police Public Protection Unit’s Serious Case Review Team should consistently be fully staffed to ensure that incidents warranting a statutory review are correctly identified and referred to the specific authorities responsible for initiating statutory reviews.

First Light are encouraging the expansion of multi-agency working and sharing of information. This will promote the development and implementation of multi-agency support plans, assertive outreach approaches to work more effectively with families with multiple support needs.

First Light to commit to updating the Trauma informed practice, training, knowledge and culture within the service – and recognising the signs of CSE, CSA and exploitation and the impact this has on current presentation and behaviour incorporating ACE’s into current assessment processes.

First Light are committed to the improvement of recording and reporting all information onto the current data base to include and evidence professional curiosity within the recording.

For GPs to be informed at the time an urgent referral assessment to CMHT is either declined or passed to another agency. For all patients to be receptive to confidential information sharing of concerns.

The Company will revise its Case Supervision Template and one to one process.

The Company will reaffirm the Domestic Abuse Policy and the Cause For Concern Procedure to all staff within Ocean Housing.

There will be a review of the Domestic Abuse Policy and Housing Management System to identify any triggers / contacts that could identify domestic abuse.

DASH training to be provided as a refresher to all staff.

That the recently introduced Trauma Informed Programme be continued within schools for children and young people.

The significant issues identified in the TFF Education IMR which relate to Lucy’s time at secondary school should be discussed in detail with the current management team at the school (which is under new management) and more generally with other Cornwall secondary school head teachers.

Learning from this review has identified the need for practitioners working with victims of domestic abuse to find ways of engaging parents where there are challenges in exploring domestic abuse where the perpetrator is close by.

Recognising signs of CSE and exploitation: Significant progress has been made within the workforce about signs and understanding of exploitation, this review highlights the progress that has been made and need for continual focus and systemic work in this area of practice