Recommendation 13.1
Within 6 months, in light of this review conduct a review of policies and procedures relating to domestic abuse and ensure the lessons are implemented.
Verified wording from the published review · Original review (PDF) ↗
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
Cheshire West and Chester review
CSP: Cheshire West and Chester
Published: February 2024
Year of death: 2020
Extracted: 17 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
Original review (PDF) ↗
Source: Home Office DHR Library
Summary AI-generated
The review identified a lack of holistic understanding and interagency information sharing regarding the victim's alcohol and mental health issues in the context of domestic abuse. Agencies often failed to recognise the full extent of coercive control and its impact on the victim's behaviours.
Home Office classifications
36 tags
Source-supplied classifications used by the Home Office to catalogue this review.
- Victim - died by suicide
- Victim - alcohol misuse
- Victim - substance misuse
- Victim - mental ill health
- Victim - anxiety
- Victim - depression
- Victim - suicidal thoughts
- Victim - had been a victim of an abuser before
- Victim - referred to marac at any time
- Victim - case heard at marac before homicide
- Perpetrator - alcohol misuse
- Perpetrator - substance misuse
- Perpetrator - mental ill health
- Perpetrator - neurodiverse condition diagnosis
- Perpetrator - depression
- Perpetrator - suicidal thoughts
- Perpetrator - known to agencies as a domestic abuse perpetrator
- Perpetrator - known to police as a domestic abuse perpetrator
- Perpetrator - known to health services as a domestic abuse perpetrator
- Perpetrator - known to mental health services as a domestic abuse perpetrator
- Aggravating factors - separation
- Aggravating factors - coercive or controlling behaviour
- Aggravating factors - psychological or emotional abuse
- Aggravating factors - physical abuse
- DHR process - family contributed to dhr
- DHR process - family consulted about terms of reference
- DHR process - family received draft report
- DHR process - police recommendations
- DHR process - health services recommendations
- DHR process - technology systems recommendation themes
- DHR process - identification of risk recommendation themes
- DHR process - training recommendation themes
- DHR process - policy recommendation themes
- DHR process - multi agency working recommendation themes
- DHR process - record keeping recommendation themes
- DHR process - awareness raising recommendation themes
Extracted recommendations
Recommendation 13.2a
Within 6 months, review all internal domestic abuse training and education programmes to incorporate the learning from this DHR, specifically highlighting the impact of alcohol and mental health within domestic abuse relationships.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.2b
Within 1 month, agencies to work in partnership with each other and be aware of the need to take a holistic approach to domestic abuse.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.2c
Within 1 month, services share information and communicate effectively within the guidelines available.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.4a
Within 6 months, develop a bespoke domestic abuse training package to be delivered to the Improving Access to Psychological Therapies (IAPT) service by Cheshire West Domestic Abuse Intervention and Prevention Service.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.4b
Currently, domestic violence and abuse training form part of the level three safeguarding training. Within 3 months consider whether a stand-alone domestic abuse training programme is required for all clinical staff across the trust.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.4c
With immediate effect, the CWP staff will take appropriate action when a disclosure is made.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.4d
Within 6 months, ensure a process whereby MARAC alerts are added to PCMIS systems if service users are heard at MARAC.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.6a
Within 3 months, ensure practitioners in GP practices are trained to approach domestic abuse with professional curiosity.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.6b
Within 3 months, where high-risk domestic abuse is identified, General Practitioners are aware of the need to complete a referral, regardless of other agencies involved. They must inform the client when a MARAC referral is made. For lower risk, referrals with consent can be made to support services.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.6c
Within 3 months, General Practitioners are to be made aware of the need for information sharing with other services e.g., Alcohol and Mental Health Services.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.8
With immediate effect, ensure that staff are aware that where possible contact is made with victims directly and not through a 3rd party.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.10a
Within 6 months, training needs analysis for domestic abuse is to be completed.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.10b
Within 6 months, learning from this review is shared with Countess of Chester Hospital Staff.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.12a
Within 6 months Police to ensure a robust response to non-intimate domestic abuse that reduces risk.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.12b
Within 6 months, review and consider any referral pathways for perpetrators, cascading the information to front-line officers.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 13.12c
With immediate effect, it is critical that MARAC information is available on police systems to inform safeguarding.
Verified wording from the published review · Original review (PDF) ↗