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

Gwynedd review

CSP: Gwynedd Published: November 2023 Year of death: 2012 Extracted: 14 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 identified concerns regarding multi-agency communication, information sharing, and risk assessment practices, particularly concerning the perpetrator's mental health and its impact on the victim and family. There were also issues with compliance with the Care Programme Approach and statutory carer assessment requirements.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
10	BCUHB should review their governance arrangements for the return and storage of post natal midwifery records.	Betsi Cadwaladr University Health Board
11	BCUHB consider ways of increasing engagement with fathers/significant males and ensure that this is documented accordingly in records.	Betsi Cadwaladr University Health Board
12	BCUHB and the Local Authority should complete the review of the Community Mental Health Team and implement the Serious Case Review Report action plan. This should include:  Consideration of the roles and responsibilities of team members for the supervision of cases held as care co-ordinators and for managerial / professional supervision. This will need to take into account professional body supervision guidelines, relevant CPG supervision guidelines and the role of the health care professional as an autonomous practitioner.  Establishing one point of entry for all referrals into the team including those addressed direct to the consultant.  Review the Protocol for allocation of (and assignment of Care Co-ordinator to) clients to ensure that it is led by the clinical need of the client whilst taking into account geography, capacity and work load.  Establishing processes to ensure that all members of the team are aware of each client’s required needs and the implications of this for the development of Care and Treatment Plans.  Ensuring that all assessments and care plans of clients with a family must reflect on the impact of their mental health on the family and any children even if there is no perceived risk to the family.  Ensuring that the team have processes in place to ensure all clients on the caseload of the team are reviewed at a weekly meeting on a regular basis.  Ensuring that all risk management plans should be discussed with colleagues to ensure access to clinicians’ collective skills and experience, awareness of potential hazards and clients’ early warning signs and to prevent team members working in isolation.  Reviewing and developing a robust single discharge procedure and,  Ensuring that all team members should keep accurate and full notes to include assessments and reasons behind key decisions made, and that documents are not post-dated.	Betsi Cadwaladr University Health Board \| Cyngor Gwynedd
1a	That BCUHB ensure that all appropriate staff (including General Practitioners, Consultant Psychiatrists, Health Visitors, Midwives and others) attend the multi-agency re-launch events for this protocol;	Betsi Cadwaladr University Health Board
1b	That the Protocol is circulated to all mental health teams (appropriate staff) with confirmation of receipt and distribution.	Betsi Cadwaladr University Health Board
1c	That the Gwynedd & Ynys Môn Safeguarding Board ensures that all appropriate staff (including Education) attends the multi-agency re-launch events for this protocol.	Gwynedd & Ynys Môn Safeguarding Board
2	In relation to the management of CID’s 16, the ongoing work of the multi-agency safeguarding hub CID 16’s needs to be completed.	Gwynedd Community Safety Partnership \| North Wales Police \| Betsi Cadwaladr University Health Board \| Cyngor Gwynedd
3	All POVA referrals should be made on the designated POVA referral form and screened by the Local Authority POVA coordinator with actions/decisions recorded.	Cyngor Gwynedd
4	BCUHB and Cyngor Gwynedd should review the arrangements for undertaking Carer Assessments and their compliance with statutory requirements and guidance Service level agreement and role of HAFAL should be reviewed It is also recommended that HAFAL undertake an audit of any parallel arrangements across Wales.	Betsi Cadwaladr University Health Board \| Cyngor Gwynedd \| HAFAL
5	The Mental health service provider (The Local Health Board and Local Authorities) should develop and implement a standardised approach to risk assessment. In providing a robust and quantifiable framework for the assessment of risk, such an approach should seek to minimise the potential for:  harm to self (including deliberate self harm)  suicide  harm to others (including violence)  self neglect  adverse risks associated with abuse of alcohol or substances  social vulnerability.	Betsi Cadwaladr University Health Board \| Cyngor Gwynedd
6	In accordance with the Enhanced Care Programme, BCUHB should ensure that care plans and risk assessments are reviewed regularly.	Betsi Cadwaladr University Health Board
7	The Local Authority should ensure that community and faith groups are provided with guidance in relation to the protection of vulnerable adults.	Cyngor Gwynedd
8	BCUHB should add Mental Health Problems to the midwife to HV Liaison Form	Betsi Cadwaladr University Health Board
9	BCUHB should audit a sample of health visiting and midwifery records in accordance with their record keeping policy.	Betsi Cadwaladr University Health Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗