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

Middlesbrough review

CSP: Middlesbrough Published: September 2024 Year of death: 2019 Extracted: 12 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

Mental health services did not adequately address the victim's vulnerability or the perpetrator's historical violence, relying heavily on his self-reporting. GP practices also missed opportunities to identify and respond to domestic abuse and safeguarding concerns.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
1	Review the evaluation of the two-year pilot of IRISi in Middlesbrough and write to the Integrated Health Board and Cleveland Violence Reduction Unit to make them aware of the benefits of the pilot, improved outcomes, and the risks in relation to sustainability of IRISi without collaborative commissioning, long term investment, or ownership of the initiative.	Middlesbrough Community Safety Partnership
1	A process should be put in place to ensure that potential victims of violence and abuse are provided with the means to communicate any concerns to professionals.	Tees, Esk and Wear Valleys NHS Foundation Trust
1	Provision of domestic abuse help and support information should be available within the practice.	Kathleen’s GP Practice
2	Write to the Tees Esk Wear Valley to request written update and evidence that recommendations identified in this DHR have been addressed and that changes introduced in relation to policy and practice have been implemented.	Middlesbrough Community Safety Partnership
2	Patient’s care plans should accurately reflect the frequency of intended reviews and who is to conduct them.	Tees, Esk and Wear Valleys NHS Foundation Trust
2	Ensure staff are compliant with the Adult Safeguarding Roles and Competencies for Health Care Staff Intercollegiate Document and the Safeguarding Children, Young People and Adults at Risk in the NHS: Safeguarding accountability and Assurance Framework.	Kathleen’s GP Practice \| Trevor’s GP Practice
3	Identify partners in Community Safety Partnership and implement a communication plan on how learning and recommendations can be shared effectively across the partnership and monitor impact of this.	Middlesbrough Community Safety Partnership
3	Written update and evidence provided to Community Safety Partnership that a previous recommendation ‘an audit be conducted to ensure there is no evidence of ‘copy and pasting’ of entries in clinical records by Clozapine clinic staff’ has been adequately addressed.	Tees, Esk and Wear Valleys NHS Foundation Trust
3	Where Domestic Abuse markers are identified on patient records and/or concerns relating to potential domestic abuse are identified during consultations, appropriate enquires (for individuals aged 16 and older) should be considered to ensure that safeguarding concerns are identified and that correct procedure is followed.	Kathleen’s GP Practice \| Trevor’s GP Practice
4	Assurance should be provided that a previous recommendation that ‘The Trust must revise internal policies and procedures relating to the functioning of ‘Clozapine clinics’ in order to be satisfied that any function relating to formal assessment of attendees’ mental health status is clearly described and supported’ has been adequately addressed.	Tees, Esk and Wear Valleys NHS Foundation Trust
4	The GP practice should monitor appropriate safeguarding activity and policy compliance through record keeping audits and referrals.	Kathleen’s GP Practice
6	The learning and recommendations from this DHR to be shared with primary care providers across Tees valley	North East and North Cumbria Integrated Care Board
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗