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
West Cumbria review
CSP: West Cumbria
Published: February 2024
Year of death: 2020
Extracted: 28 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 missed opportunities by agencies to identify domestic abuse indicators in health settings, engage individuals in substance misuse treatment, and effectively manage a high-risk perpetrator. It highlighted the victim's vulnerability due to long-term abuse, mental ill-health, and problematic alcohol use.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Safer Cumbria Domestic Abuse Partnership Board to promote gender and trauma-informed practice in response to victims of domestic abuse experiencing multiple needs including adverse childhood experiences and mental health, alcohol and substance misuse. Safer Cumbria Domestic Abuse Partnership Board to seek assurance from all affiliated agencies that gender and trauma-informed practice is embedded in their practice response to domestic abuse. | Safer Cumbria Domestic Abuse Partnership Board |
| 10 | Probation Service and Recovery Steps Cumbria to provide assurance to the Community Safety Partnership on the effectiveness of the criminal justice pathway between alcohol treatment and probation services and is able to address the issues over self-referral and information sharing | Probation Service | Recovery Steps Cumbria |
| 11 | West Cumbria Community Safety Partnership to secure the consistent participation of social housing providers in their area through multi-agency pathways in domestic abuse across areas of high risk and earlier intervention. | West Cumbria Community Safety Partnership |
| 2 | West Cumbria Community Safety Partnership should seek assurance and evidence that primary care, Emergency Department, mental health and substance misuse services in their area have implemented policies, pathways and staff training that have resulted in effective, selective, routine enquiry in domestic abuse, particularly where mental health and substance misuse are also involved. | West Cumbria Community Safety Partnership |
| 3 | Cumbria Community Safety Partnership should seek evidence and assurance that agencies are consistently enabling high risk victim engagement with the Independent Domestic Violence Advisors in addition to their own services. | Cumbria Community Safety Partnership |
| 4 | In MARAC cases where the offender is held on remand, the police should alert the prison service to prevent, or if not possible, to proactively monitor telephone contact between the perpetrator and the victim. | police | prison service |
| 5 | West Cumbria Community Safety Partnership should seek assurance from criminal justice agencies that they are able to accurately record and access records on an abuser’s previous violent history and apply this to current risk assessments and responses | West Cumbria Community Safety Partnership |
| 6 | In the development of the national domestic perpetrator strategy, the Home Office considers commissioning research into whether a high-risk domestic abuser will be a high-threat domestic abuser to future partners and by virtue of their serial offending, are worthy of enhanced intervention, management and opportunities for change. | Home Office |
| 7 | The Ministry of Justice to consider how those offenders who are subject to immediate release after serving a period on remand, are flagged for risk management, considered and their management resourced. | Ministry of Justice |
| 8 | West Cumbria Community Safety Partnership to ensure that the evidence provided by criminal justice agencies in response to this review collectively demonstrates a robust multi-agency response to domestic abuse perpetrators and demonstrates effective harm reduction outcomes, particularly in regard: • compliance with DASH • positive action • risk assessment • supervision • bail and responding to intelligence reports • responding to victim minimisation and engagement • ‘Out of area’ incidents • Prison release | West Cumbria Community Safety Partnership |
| 9 | North Cumbria Integrated Care Board and Recovery Steps Cumbria to develop and embed pathways and relationships between primary care and alcohol treatment services in the area. Pathways to ensure that clinicians in primary care have access to clear and concise guidance for assessing and managing patients with alcohol concerns and have access to locally agreed information to enable them to make effective decisions, together with patients, at the point of care, particularly for those with whom practitioners would otherwise struggle to engage. | North Cumbria Integrated Care Board | Recovery Steps Cumbria |
| Cumbria County Counc | Mothers experiencing domestic abuse are enabled to access specialist domestic abuse support | Cumbria County Council Children’s Services |
| Cumbria, Northumberl | To ensure professionals routinely enquire about domestic abuse when there are indicators of concern and staff need to understand their role when receiving disclosures of domestic abuse from perpetrators. | Cumbria, Northumberland, Tyne and Wear NHS Trust |
| Cumbria, Northumberl | To ensure staff consider history of domestic abuse and how this impacts on presenting risks at the time of initial assessments and future appointments. | Cumbria, Northumberland, Tyne and Wear NHS Trust |
| Cumbria, Northumberl | To promote the need to enable engagement with domestic abuse services, even when the police may be involved. | Cumbria, Northumberland, Tyne and Wear NHS Trust |
| Home Group R1 | To review Home Group’s internal procedure and ensure that the best practice highlighted above is captured and implemented. Mainly, that when DV and DA instances are reported or there are suspicions of DV/DA these incidents are reviewed by a Senior Manager (Operations Manager level). | Home Group |
| Home Group R2 | For Home Group to review their local procedures around outcomes and discussions at MARAC. Specifically focusing on; what visibility to Senior Managers have; What visibility do local Housing Managers have; How does the feedback process occur; What oversight and input do Senior Managers have. | Home Group |
| Lancashire and South | Liaison with other agencies, especially those that may be specifically addressing offending behaviours (such as the courts, probation services) assists in the wider understanding of the perpetrators’ risks and actions that other services have implemented to address these. The requirement to notify partner agencies when an individual is discharged from the Liaison and Diversion service will be incorporated into the service wide Standard Operating Procedure (SOP) and introduced as standard practice. | Lancashire and South Cumbria Foundation Trust |
| Lancashire and South | Communication with partner agencies including GPs should be strengthened by providing awareness about the Liaison and Diversion service to ensure an understanding of the service scope of practice. This will be achieved by sending a letter to GP’s and partner agencies describing the Liaison and Diversion service. | Lancashire and South Cumbria Foundation Trust |
| Lancashire and South | Information sharing and recording processes for MARAC for all LSCFT services to be consistent across all LSCFT localities. | Lancashire and South Cumbria Foundation Trust |
| Lancashire and South | Current LSCFT processes regarding domestic abuse are correctly victim focussed, however, it is not clear regarding the expectations of staff when working with suspected perpetrators of domestic violence. This would be especially useful for Liaison and Diversion who are an offender focussed service. | Lancashire and South Cumbria Foundation Trust |
| North Cumbria Clinic | To further promote with GPs the need for targeted routine enquiry about domestic abuse when indicators are present and to strengthen the disclosure pathway | North Cumbria Clinical Commissioning Group |
| North Cumbria Integr | to continue to improve awareness and responses to domestic abuse through the A&E and Domestic Abuse Improvement Plan, to include increased use of DASH and MARAC referrals and the ‘think family’ Screening tool | North Cumbria Integrated Care NHS Foundation Trust |
| North Cumbria Integr | Domestic abuse and substance misuse to continue to be included in mandatory training updates for all staff, with particular focus on routine enquiry and referral to support services. | North Cumbria Integrated Care NHS Foundation Trust |
| North Cumbria Integr | To complete a review to be completed of current pathway and follow up for patients who leave A&E prior to completing treatment. | North Cumbria Integrated Care NHS Foundation Trust |
| Probation Service R1 | Under the parallel Serious Further Incident review, the CRC were required to provide assurance to Her Majesty’s Prison and Probation Service (HMPPS) that they were managing domestic abuse alleged perpetrators to a sufficient standard. The Probation Service to provide this evidence to the Community Safety Partnership | Probation Service |
| Probation Service R2 | To develop a criminal justice pathway within substance misuse services through which to address the issues over self-referral and information sharing between probation and substance misuse services. | Probation Service |
| Probation Service R3 | To strengthen management oversight of staff in order to ensure adherence to policy and practice standards in assessments, planning, implementation and review of interventions in the future. | Probation Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||