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
East Sussex review
CSP: East Sussex
Published: March 2024
Year of death: 2018
Extracted: 34 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 systemic failures in multi-agency risk assessment and information sharing regarding domestic abuse, mental health, and offender management. Key concerns include missed opportunities for routine enquiry in health settings, inadequate use of disclosure schemes, and insufficient management of the perpetrator's high-risk behaviour by probation services.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | East Sussex Community Safety Partnership should seek assurance that all health services in their area have implemented policies, pathways and staff training to support routine enquiry in domestic abuse. | East Sussex Community Safety Partnership |
| 2 | Health agencies in East Sussex should ensure that all clinicians are readily identifiable in case notes and in the decisions they have made. | Health agencies in East Sussex |
| 3 | East Sussex Community Safety Partnership should raise awareness amongst partner agencies of the benefits and opportunities of the Domestic Violence Disclosure Scheme and the process of applying for safe disclosure to victims of their abuser’s history of violence and abuse | East Sussex Community Safety Partnership |
| 4 | MARAC Steering Group • all MARAC partners to send a representative from the relevant service/team to take part in the MARAC where there is significant involvement (current or historic) that impacts on current risk management and safety planning • to take pro-active steps to take further actions or alternative actions to address the risk/issue identified at MARAC, including all realistic means of managing the offender • to consider how MARAC action plans and case management can be overseen and by whom • An information sharing mechanism to be developed between GP Practices and the MARAC The MARAC Support Team • to consider how to identify the relevant social housing provider so that they are invited to MARAC for cases where their tenants are featured • to ensure that records of MARAC meetings accurately reflect the sources of information received | MARAC Steering Group | The MARAC Support Team |
| 5 | East Sussex Safer Communities Partnership should seek assurance from agencies that they are capable of harnessing multi-agency action to effectively manage and constrain perpetrators of domestic abuse. | East Sussex Safer Communities Partnership |
| 6 | East Sussex Health and Wellbeing Board seeks assurance from its agencies that they are delivering their responsibilities to carers under the Care Act 2014. | East Sussex Health and Wellbeing Board |
| 7 | That the report is shared with the Ministry of Justice in order that: • the implications of shortages of probation officers on professional standards are noted • consideration is given, within the restructure of the probation services, to the professional registration of probation officers to ensure that individual standards of professional practice can be regulated • consideration is given to providing a list of internationally commensurate probation qualifications | Ministry of Justice |
| CGL1 | Where there is a discrepancy to a risk assessment based on a further assessment or professional judgement, it is first discussed with the referring agency, before implementing service processes relevant to that risk level. | Change Grow Live Domestic Abuse Portal |
| CGL2 | Creative engagement should still be a consideration, whilst following safe practices. Joint visits especially in services where the victim already attends is considered good practice, e.g. GP or Probation. If engagement is not possible the Portal will offer consultation to other professionals where the victim is likely to attend. This must also be balanced and in accordance with GDPR. | Change Grow Live Domestic Abuse Portal |
| CGL3 | Services to bring creative suggestions to MARAC, ensure that DVPO/DVDs and community and statutory services are considered for victim and offender. | Change Grow Live Domestic Abuse Portal |
| ESCCASC1 | Ensure affected staff are accessing both IT systems as agreed | East Sussex County Council Adult Social Care |
| ESCCASC2 | Ensure all communication/ risks discussions at MARAC are appropriately updated onto both ESCC & SPFT IT systems ASAP but no longer that 24 hours following MARAC discussion. | East Sussex County Council Adult Social Care |
| ESHT1 | Develop a health pathway and embed into routine enquiry & NICE standards in A&E. | East Sussex Healthcare NHS Trust |
| ESHT2 | Demonstrate that efforts to improve staff awareness and responses to domestic abuse in recent times are proving successful. | East Sussex Healthcare NHS Trust |
| ESHT3 | As well as training to identify signs and indicators of domestic abuse, training, procedures and pathways need to be embedded about how practitioners/clinicians respond effectively to domestic abuse. | East Sussex Healthcare NHS Trust |
| KSSCRC1 | KSS CRC to meet the expected standards for pre-release contact. | Kent Surrey and Sussex Community Rehabilitation Company |
| KSSCRC2 | KSS CRC Senior Probation Officers to demonstrate professional curiosity and effective management oversight. | Kent Surrey and Sussex Community Rehabilitation Company |
| KSSCRC3 | KSS CRC to ensure that the competencies of temporary and/or agency staff are checked. | Kent Surrey and Sussex Community Rehabilitation Company |
| SCCG1 | That codes on the case recording system are used to flag people at risk of domestic abuse. This will aid GPs and nurses in the identification of people at risk and prompt accessing historical records to allow previous concerns to be address on subsequent consultations | Sussex Clinical Commissioning Groups |
| SCCG2 | That GPs and nurses refer to historical records during consultations to enable any outstanding health issues to be identified and discussed | Sussex Clinical Commissioning Groups |
| SCCG3 | Following significant events at the surgery, where risk to individuals has been identified, that a review is undertaken to ensure all relevant information is shared around identified risks. | Sussex Clinical Commissioning Groups |
| SCCG4 | That the practice implements a domestic abuse policy outlining the roles and responsibilities of staff, as well as resources to support people using and working for the practice. | Sussex Clinical Commissioning Groups |
| SCFT1 | Uckfield SCFT Minor Injuries Unit to raise awareness of the signs of domestic abuse and the appropriate pathways to seek support for the victim | Sussex Community NHS Foundation Trust |
| SCFT2 | Wider East Sussex SCFT Minor Injuries Units (Lewes and Crowborough) to raise awareness of the signs of domestic abuse and the appropriate pathways to seek support for the victim | Sussex Community NHS Foundation Trust |
| SCFT3 | Wider SCFT Minor Injuries and Urgent Treatment Centres: • To raise awareness of the signs of domestic abuse and the appropriate pathways to seek support for the victim • Raise internal awareness of SCFT IMR findings | Sussex Community NHS Foundation Trust |
| SP1 | The Head of Public Protection should ensure that a review of DASH risk assessment is incorporated within the ongoing force DA Improvement Plan to ensure that the level of risk is being appropriately identified / graded by officers and staff. This review should be undertaken as soon as practicable. | Sussex Police |
| SPFT1 | Lack of known and understood legal restrictions gave the perpetrator the choice to disengage with services and decline depot medication. His Care Plan and engagement was reliant on the perpetrator making contact and attending appointments when he was clear that he did not believe that this was necessary, there was no contingency for disengagement despite a history of disengaging and becoming unwell. All patients deemed at risk of disengagement from services will have a risk management plan. | Sussex Partnership NHS Foundation Trust |
| SPFT2 | Positive plans for engagement to be clearly documented with any restrictions or alerts to be discussed with Multi-Disciplinary Team. | Sussex Partnership NHS Foundation Trust |
| SPFT3 | Ensure that patients that have been de-registered from a GP are supported to re-register and that prescriptions are delivered to a community pharmacy so assurance can be sought re collection. | Sussex Partnership NHS Foundation Trust |
| SPFT4 | Where engagement is an issue, consideration of use of mental health act should be discussed and documented with a rationale for decision making. | Sussex Partnership NHS Foundation Trust |
| SPFT5 | HCR20 risk assessment to be completed for all forensic inpatients | Sussex Partnership NHS Foundation Trust |
| SPFT6 | Protocol to be put in place to ensure that all eligible patients receive a Section 117 discharge meeting. | Sussex Partnership NHS Foundation Trust |
| SPFT7 | Triangle of care to be fully implemented with all patients | Sussex Partnership NHS Foundation Trust |
| SPFT8 | Protocol to be developed to ensure that information shared by MARAC is accessible, checked by all Lead Practitioners and incorporated into risk management plans. | Sussex Partnership NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||