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
Northumberland review
CSP: Northumberland
Published: February 2024
Year of death: 2015
Extracted: 41 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 fragmented care, inadequate risk assessment and management of adolescent-to-parent violence and abuse (APVA), and a failure to recognize the victim's vulnerability and emerging psychosis in the perpetrator. There was also a lack of multi-agency coordination and information sharing.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The CYPS service will review their safeguarding responsibilities to assure themselves that they are fulfilling their requirements within trust safeguarding and public protection policies and are receiving advice supervision and support when required. | Northumberland Tyne and Wear NHS Foundation Trust |
| 1 | Children’s social care and adult safeguarding to raise awareness and widely distribute the Home Office guidance regarding Adolescent to Parent Violence and Abuse (APVA) and request that this is disseminated within teams, discussed at team meetings, team briefs and referenced at relevant training. The Home office document will be available on the NSCB and Adult Safeguarding websites. | Northumberland County Council (Children’s Social Care) | Northumberland County Council (Adult Safeguarding) |
| 1 | It is not clear whether staff at the school were aware that domestic violence may have been taking place. Training staff in spotting the signs of domestic abuse (APVA) may mean that in future cases appropriate agencies can be informed more quickly and with greater certainty. | Northumberland County Council (Education & Skills) |
| 10 | To ensure that appropriate training is available and the systems for escalation are understood. | Northumberland Tyne and Wear NHS Foundation Trust |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The threshold for undertaking an Early Help Assessment; to include an escalation policy, for all professionals, linked to the updated multi-agency Thresholds Document. The escalation policy should cover the opening, stepping up/down and closing of the case and should include seeking guidance/supervision and exercising professional judgement. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The role of the Lead Professional and the contribution and expectations of the Team Around the Family. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: Agreement that NTW, where appropriate, will take on the role of the Lead Professional. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The visiting frequency of the Lead Professional and other relevant professionals, to include planned and meaningful direct work with the child or young person. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The Early Help Assessment, plan and reviews, to include: the duration of the Early Help Assessment, linking with the escalation policy. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The role of the Team Around the Family meeting, including multi-agency attendance, information sharing, professional contribution, timely and smart actions and the distribution of minutes. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The formal supervision arrangements in place for the Lead Professional and members of the Team Around the Family to include: the frequency of formal supervision, reflection and professional challenge, the role of the Lead Professional’s line manager in chairing Team Around the Family meetings, where progress is not being achieved or sustained within 6 months. | Northumberland Safeguarding Children Board |
| 1 (sub-point) | The NSCB will review and revise the early help procedures and guidance to include the following key elements: The Early Help Module: to ensure that this is fully compatible with the statutory social care module, so information can to be accessed and reviewed between the Early Help and statutory social care elements of ICS. The Early Help Assessment template and Early Help module on ICS should incorporate a chronology that is used in order to capture and analyse the key events and the child’s journey and experience. | Northumberland Safeguarding Children Board |
| 2 | Review current practice with regard to the Early Help agenda. | Northumberland Tyne and Wear NHS Foundation Trust |
| 2 | Children’s social care and adult safeguarding to implement a clear procedure and pathway to ensure that all referrals regarding adolescent to parent violence and abuse are responded to appropriately and consistently, identifying the risks around domestic violence, to ensure that the adult victim is safeguarded and protected and that the most appropriate assessment, intervention and multi-agency support is in place to safeguard, protect and support the child or young person and their family. | Northumberland County Council (Children’s Social Care) | Northumberland County Council (Adult Safeguarding) |
| 2 | To review the single and multi-agency training that is available to Children’s Services staff regarding domestic violence, to ensure that this includes adolescent to parent violence and abuse, mental health and self-harm to ensure that lessons learned from this case are incorporated. | Northumberland Safeguarding Children Board |
| 2 | Whilst the record-keeping of the school was very detailed the school should ensure that a single management system is used to collect all information regarding incidents linked to students, rather than in separate behaviour logs. This may aid the spotting of behaviour patterns in future. | Northumberland County Council (Education & Skills) |
| 3 | A clinical review of a sample of x cases of children, who are seen within the ADHD clinic and have additional needs that require Care Co-ordination have a care co-ordinator who has the skills to meet their needs. | Northumberland Tyne and Wear NHS Foundation Trust |
| 3 | The Home Office guidance regarding Adolescent to Parent Violence and Abuse (APVA) to be incorporated into the Single Point of Access (SPA) procedure and pathway to reflect the learning from this review and support a consistent, timely and appropriate response regarding adolescent to parent violence and abuse. | Northumberland County Council (Children’s Social Care) |
| 3 | To explore multi-agency training with NTW to ensure a greater understanding of the role of professionals and interventions within NTW. | Northumberland Safeguarding Children Board |
| 3 | The school should also ensure that relevant information is shared systematically between staff within school and with outside agencies through the use of Safeguarding Children processes. A multi-agency approach to the most suitable way to achieve this is required. Consideration of who is responsible for collating such information is necessary. | Northumberland County Council (Education & Skills) |
| 4 | Specialist Care Triumvirate Management Team should further review the clinical practice of those individuals identified by the Investigating Officer and clinical advisors to ensure that the early interventions already initiated in the process of undertaken the review are sufficiently robust to ensure patient safety. | Northumberland Tyne and Wear NHS Foundation Trust |
| 4 | The Disabled Children’s Team should review the role of the Enquiry and Referral Administrator and duty Social Worker within the team, to include clarity and expectations around the duty Social Worker role in attending Team around the Family meetings and Transitional School Review meetings. | Northumberland County Council (Children’s Social Care - Disabled Children’s Team) |
| 4 | Once the current review of the Suicide and Self Harm Pathway is complete, key messages from this DHR and for the Suicide and Self Harm pathway to be re-launched with training for all Children’s Services staff. | Northumberland Safeguarding Children Board |
| 4 | The school should consider a formal recording of conversations with parents/carers to aid the transfer of relevant and timely information between staff within school and outside agencies. | Northumberland County Council (Education & Skills) |
| 5 | All community CYPS practitioners will be offered a specific workshop with a focus on assessing and managing risk to others and factors impacting on decision making. | Northumberland Tyne and Wear NHS Foundation Trust |
| 5 | To review the purpose of the Transitional Database held within the Disabled Children’s Team. | Northumberland County Council (Children’s Social Care - Disabled Children’s Team) |
| 5 | On two occasions (10 December 2014 and 10 July 2015) the school did not receive any formal communication regarding outcomes from multi-agency meetings that had taken place. Whilst the responsibility for distributing those outcomes lies with the host of the meeting, the school may consider an internal process that follows up missing communications. This would ensure the school always has a full picture of activities undertaken by other agencies which may impact upon the school. | Northumberland County Council (Education & Skills) |
| 6 | The CYPS service will review their responsibilities to support parents in their caring role to assure themselves that parents’ needs are met and that staff responsibilities to report acts of domestic violence are understood. | Northumberland Tyne and Wear NHS Foundation Trust |
| 6 | The school may wish to instigate a process by which they ask parents for a summary of how each child has been during the school holidays. This may flag up any changes in behaviour or attitude that may impact upon school performance. | Northumberland County Council (Education & Skills) |
| 7 | Review current practice with regard to prescribing within team and adherence to guidance. | Northumberland Tyne and Wear NHS Foundation Trust |
| 8 | NTW should review their position relating to post incident contact with family members following homicide with immediate effect to ensure consideration and decisions on a case by case basis. This should have regard for the police support framework provided through Police liaison officers. | Northumberland Tyne and Wear NHS Foundation Trust |
| 9 | The outcome of this investigation should be made available to the patient’s grandparents and an apology offered regarding shortfalls in the provision of appropriate standards of care and treatment. | Northumberland Tyne and Wear NHS Foundation Trust |
| CSC_F1 | Within the review of training, outlined with the IMR recommendations, CSC should ensure that staff are aware of the need to act upon reported incidents of violence and abuse through the undertaking of appropriate risk assessments, referral to appropriate risk management procedures, and consideration of the need to share such information with other agencies. | Northumberland County Council (Children’s Social Care) |
| CSC_F2 | To review procedures relating to the feedback of information following multi-agency meetings, including TAF, to ensure that feedback is disseminated to all those actively working with the case. | Northumberland County Council (Children’s Social Care) |
| EDU_F1 | Where concerns are known regarding the home environment, the school should identify how this can be addressed within the school environment and attempts made to engage the young person and his family. | Northumberland County Council (Education & Skills) |
| Recommendation 1 | NTW re-acquaint staff with the existing policy on Care Coordination in order to understand the organisation’s and their own professional responsibilities in the assessment, planning and implementation of an appropriate package of care. An essential pre-requisite of this recommendation is an assurance that all staff fully understand what the policy advises with regards to Multi-agency assessment, specialist interventions and the practice of Care Coordination. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendation 1 (su | Agreed interventions within care plans are evidence based and fulfil SMART criteria. For this to be inclusive it is imperative that all professionals are aware of the importance of involving the family / Carers at all stages of the process. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendation 1 (su | NTW provide assurance that recording and communication practices are adhered to most notably in the context of updating records, developing and communicating formulations, care plans, risk management plans and review processes. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendation 2 | At the very least staff are reacquainted / re-trained in the various elements of the Clinical Risk Assessment and Management Strategy with particular reference to understanding the principles of a structured clinical approach to risk behaviours. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendation 2 (su | NTW plan how they intend to provide staff with the knowledge to practice in the area of Risk assessment and management with special regard to not only the processes but the current evidence base related to Assessment, Management and mitigation of risk behaviours. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendation 2 (su | In line with the above recommendations, communication practices reflect the need to constantly reassess and re-evaluate risk management practices and that professionals practice should reflect these. This, it is recommended would contribute to reviewing and improving the quality of care provided. | Northumberland Tyne and Wear NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||