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
Portsmouth review
CSP: Portsmouth
Published: September 2024
Year of death: 2019
Extracted: 25 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 systemic failures in multi-agency responses to domestic abuse, including inadequate risk assessment, missed opportunities for routine screening by health professionals, and a lack of understanding of coercive control and complex needs. Issues with social media platforms retaining criminal content were also noted.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | All referrals made by 111 and the emergency operations centre to be referred electronically. | South Central Ambulance Service |
| 1 | The Domestic Abuse Strategy Group will monitor a repeat audit for all single agency actions in twelve months to check all actions have been completed. | Domestic Abuse Strategy Group |
| 1 | The panel supports the author to approach the Home Office to legislate for the removal of proven criminal content on social media platforms. | Home Office |
| 10 | Although the IMR author has confirmed that the auditing of this new process will commence in Spring of 2022, the panel will further recommend that the Portsmouth Safeguarding Adult board will take responsibility to oversee this change. | Portsmouth Safeguarding Adult Board |
| 11 | Raise Awareness of the referral process for adults experiencing or at risk of Domestic Abuse. Training has been commissioned to promote Pan Hants guidance referencing raising safeguarding concerns. | Adult Social Care |
| 12 | Primary Care to consider a review of their routine screening questionnaires to ensure it includes a question relating to the patient experiencing domestic abuse. | GPs – Surgeries Portsmouth |
| 13 | Review of processes/policies/training in relation to patients requiring support with drug and alcohol misuse to ensure potential safeguarding issues are considered for all GPs surgeries in Portsmouth. | GPs – Surgeries Portsmouth |
| 14 | In both Police and Probation services, domestic homicide reviews are dealt with by a central team whose role it is to compile IMR reports and liaise with review panels. This should be considered for health services so that professionals can retain their specialist focus where it is needed most, and future panels can receive high quality reports. | Universal Health Services |
| 2 | Highlight through internal communications SCAS responsibility when dealing with DA incidents and the interface with police. | South Central Ambulance Service |
| 2 | Universal health services revisit training and share information with health professionals regarding the importance of routine screening and asking the question of patients whether they are experiencing domestic abuse, as set out in the NICE guidelines. | Universal Health Services |
| 2 | The panel supports the author to request government consider the recommendations within the Femicide Census in relation to the national VAWG strategy. | Government |
| 3 | The author recommended the use of internal reviews for SCAS teams to learn from this incident. The author suggested receiving permission from family and staff and when complete, seek authorization from an Assistant Director to cascade learning to SCAS teams. | South Central Ambulance Service |
| 3 | Using the victim’s story as a case study, Portsmouth’s multi-agency domestic abuse practitioner’s forum to consult with professionals on what needs to be done to change the culture within their own organisations and as coordinated partners in responding to domestic abuse. Particular attention will be given to unconscious/conscious bias with regards to the victim’s case and how she presented in relation to both her multiple and complex needs and the care she was afforded. | Domestic Abuse Practitioners Forum |
| 4 | Audits of DA Safeguarding referrals for SCAS. | South Central Ambulance Service |
| 4 | Audit content and frequency of training provided to individual agencies involved in this case to ensure training includes: • DASH risk assessment training • Homicide Timeline training • Trauma informed responses • Substance misuse and complex needs • Image based sexual abuse awareness • Counter allegations • Professional curiosity • Intersectionality | Domestic Abuse Strategy Group |
| 5 | Hampshire Constabulary to ensure clear internal comms are repeated after the review to ensure officers are clear of the force policy with regards to mandating a timeframe for what constitutes a non-current domestic abuse report and remind officers the arrest/positive action policy is applicable in a non-current domestic abuse report. | Hampshire Constabulary |
| 5 | The panel recommends individual agencies involved in this review consider the Femicide Census recommendations in strategies and commissioning. | CSP |
| 6 | Hampshire Constabulary's crime data integrity scrutiny panel regularly check that reports of domestic abuse include reference to any counter-allegations. Hampshire Constabulary agreed to feedback provide regular evidence from the DA scrutiny panel to the CSP in relation to Portsmouth specific DVA data. | Hampshire Constabulary |
| 6 | The CSP considers whether to recommend the promotion of Report Harmful Content Charity for specialist commissioned services responding to domestic abuse and sexual violence. | CSP |
| 7 | The CSP would like to receive confirmation that the DA Matters training includes the impact of substance misuse in cases of domestic abuse. | Hampshire Constabulary |
| 7 | The CSP to consider awareness raising campaigns with regards to technology related abuse for the general public and ensure that information on help seeking organisations is disseminated amongst professionals through training programmes and on communication portals. | CSP |
| 8 | Feedback to the CSP on the effectiveness of training related to domestic abuse, including the effectiveness of SafeLives DA Matters training. | Hampshire Constabulary |
| 8 | The CSP to consider the recently launched service, Findaway which supports family and friends when they are concerned about a loved one who is experiencing abuse. | CSP |
| 9 | Hampshire Constabulary as a part of ongoing Continuous Professional Development for custody officers and staff emphasise the significance and importance of a thorough pre-release risk assessment and that they routinely consider the impact of a domestic abuse incident for both victim and offender at point of release. | Hampshire Constabulary |
| 9 | Training to be multi-agency wherever possible to assist in making learning 'system wide' | CSP |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||