Gloucestershire review

That the Home Office consider research into the risk of suicide after separation for vulnerable victims where high level coercive control is present. If appropriate this could be included in domestic abuse risk assessments going forward.

That the Department and Health and Social Care and Home Office draft guidance on how to effectively manage joint Safeguarding Adult Reviews and Domestic Homicide Reviews.

That Safer Gloucestershire ensure a thematic review is undertaken. The aim of the thematic review should be to bring together the learning from all suicide reviews in the county and ensure links are made with the GSPPF to develop a multi-agency plan for local activity to respond to common themes and share learning. This work should link to the recent publication of the “Suicide Timeline” by the University of Gloucester.

That Safer Gloucestershire consider raising awareness with housing providers, including private landlords, on domestic abuse. This should include information on coercive and controlling behaviour and economic abuse. This would alert landlords that abusers may exploit tenants and sabotage housing. Landlords should be encouraged to make Third Party reports where appropriate.

That the Gloucestershire Criminal Justice Board establish a process to independently review the quality of police investigations to ensure that Evidence Led Prosecution policy is being used in appropriate cases.

That Gloucestershire Domestic Abuse Local Partnership Board ensure the findings from this review are considered in the ongoing review of the local training pathway to ensure appropriate training on economic abuse is available and that the county DA communications plan include measures for awareness raising.

That the Gloucestershire Safeguarding Adults Board review Safeguarding Referral Protocols to ensure that Domestic Abuse cases involving people in need of care and support are effectively risk assessed, reported, investigated and supervised in a timely manner. This must include a robust supervision and audit model to ensure that all actions in s. 42 Care Act 2014 enquiries are addressed within the agency designated to make the enquiry; and then supervised before case is closed at County Council level.

Targeted training for key partner agencies to increase knowledge about housing and homelessness services. Particularly focusing on issues around domestic abuse and homelessness and when to make an approach. Partner agencies to be targeted as a result of this DHR are: mental health services, supported accommodation providers within community (not commissioned by City Council).

Domestic Abuse specific training (including competition of DASH, MARAC and GDASS services) to be delivered by MHIDVAs to Wotton Lawn Hospital Teams, Recovery and AOT Teams.

Development of Trust wide Domestic Abuse Training Package. MHIDVAs to identify and train Domestic Abuse champions across mental health services. GHC to establish a joint clear process with GCC for the management oversight/supervision of section 42 enquires caused to be made by GHC and their relevant recommendations.

Re-introduce Trust Domestic Abuse Lead role that sits within the Safeguarding Team.

GHC to develop a robust system of support/oversight with Section 42 enquiries. This has been developed in communication with the GCC Safeguarding Team, and is now up and running.

To record the name of the person a patient attends hospital with, and the role of that person in the patient’s life.

To record the name of ‘boyfriends’ (or other significant others) who have allegedly assaulted patients.

To review the VIST to ensure appropriate risk assessment submissions utilising the new DARA tool and to ensure officers are provided with appropriate training.

Improvement on Domestic Violence Investigative Standards of Custody Sergeants. Custody Sergeant provided a training input around investigation standards, rationale recording and the importance of investigative excellence.

NFA Rationale to be recorded on the Custody Log. All Custody Sergeant and Supervisors provided an input around any custody decision to be recorded on the custody log prior to release. This will help negate any questions around disposal.

Refresher Training on Domestic Abuse Evidence Led Prosecutions. Training inputs and guidance to be rolled out to ensure awareness of all Officers and Supervisors is raised.

DVPN Training. Training inputs and guidance to be rolled out to ensure all Officers and Supervisors awareness raised.

Practices will consider the vulnerabilities of patients with mental health issues when receiving a letter from the mental health teams and flag a patient as vulnerable when necessary.

GP practices to ensure that mental health and other vulnerability issues are considered as part of their DNA policy and appropriate contact made and support offered if necessary with the patient.

When a patient with vulnerabilities is to be discussed at a practice vulnerable adult/safeguarding meeting, the mental health practitioner working with that patient should be invited to attend.

Request that letters coming from secondary care (including mental health teams) clearly note concerns arising and any increase in risk assessment levels in BOLD and in the summary include GP actions.

Ensure mechanism by which urgent concerns can be shared between Primary Care and Mental Health teams.