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

Bridgend review

CSP: Bridgend Published: November 2023 Year of death: 2012 Extracted: 18 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 concerns regarding mental health services' compliance with care planning guidance, particularly the lack of holistic risk assessments for violence and substance misuse, insufficient family involvement, and inadequate discharge planning for the perpetrator. There were also missed opportunities for multi-agency information sharing.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
1	ABMU Health Board should give assurance to the Community Safety Partnership that all individuals, including their carers where appropriate, who are entitled to and requesting a care and treatment plan under the Mental Health Measure should have one in place and care coordinators will inform the person and / or their carer of the minimum level of contact they can expect.	ABMU Health Board
1	Documentation used during the assessment process should be subject of review. This is to ensure that the assessment process captures the current circumstances of the person subject of the referral and all avenues are explored to their fullest extent. Should the assessment document be completed in its entirety or only mandatory fields completed?	Regional Area Planning Group – substance misuse services , Western Bay Area
1	When a referral with a high priority status is received, where possible telephone contact should be made with the client to discuss their immediate support needs.	WCADA
1	Changes to care and treatment plans on handover or transfer between services should be properly recorded with rationale in patients’ healthcare records.	ABMU HB
2	The Local Mental Health, Learning Disabilities and Criminal Justice Planning Group for the South Wales Area should review the multiagency training needs related to psychiatric assessment of fitness for police interview and diversion from custody of people detained on suspicion of any violent offence who have or appear to have serious mental ill health where the person has a need that may require a joint response from health/social care and the criminal justice system.	Local Mental Health, Learning Disabilities and Criminal Justice Planning Group for the South Wales Area
2	Clear policy and procedure or guidance should be provided to practitioners in respect of how the assessment process (within Bridgend Assessment Centre and other similar service areas) should be progressed and how documentation should be completed.	Regional Area Planning Group – substance misuse services , Western Bay Area
2	Model of care for acute inpatient wards should specify the role of allied health professionals (psychology and OT) particularly in relation to informing risk assessments, and following through findings from assessments into care and treatment plans.	ABMU HB
3	ABMU HB should give assurance to the Community Safety Partnership that, where a history of violence is noted in any person requiring care and treatment planning under part two of the Mental Health Measure, a validated violence risk assessment tool will be completed and a violence risk formulation and management plan included in the care and treatment plan.	ABMU HB
3	The common assessment form utilised during the assessment of the alleged perpetrator should be subject of review. In particular the use of ‘closed questions’ should be questioned. When closed questions are used, then if required further ‘open’ questions need to be asked to identify intentions or any proposed actions of the person being assessed. This will enable any risks to be identified and if need be concerns can then be shared with relevant agencies.	Regional Area Planning Group – substance misuse services , Western Bay Area
3	Formal violence risk assessment tools should be used in all cases where violence / violent ideation are indicated.	ABMU HB
4	Bridgend Community Safety Partnership considers organising a ‘Learning Event’ involving practitioners involved in this case once the Overview report has been presented and accepted by the Community Safety Partnership Board, in order that the recommendations and learning from this review can be disseminated.	Bridgend Community Safety Partnership
4	Section relating to ‘Domestic Abuse’ in assessment process should be completed in all cases. In particular if identified that person subject of assessment is dependent on substance then the question should be asked how this may be impacting upon home or social circumstances/ environment.	Regional Area Planning Group – substance misuse services , Western Bay Area
4	Service users presenting with violence / violent ideation associated with mental illness should have a relapse plan included in their care and treatment plan.	ABMU HB
5	Section relating to Dependency – consideration for this section to be fully completed in relation to both the main substance and also the substance misuse checklist	Regional Area Planning Group – substance misuse services , Western Bay Area
5	A carers assessment should be completed for patients presenting with violence / violent ideation associated with mental illness and living with family.	ABMU HB
6	For patients presenting with violence / violent ideation associated with mental illness, a specific risk assessment and risk management plan concerning family members should be completed.	ABMU HB
7	All qualified staff within the mental health directorate should receive training in dual diagnosis substance misuse and mental illness	ABMU HB
8	Substance misuse and adult mental health services should be integrated to support accessible and acceptable services from the point of view of service users.	ABMU HB
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗