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
Lincoln review
CSP: Lincoln
Published: September 2024
Year of death: 2021
Extracted: 27 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 information sharing and risk assessment, leading to an underestimation of the perpetrator's escalating violence and coercive control. Opportunities to safeguard the victims, including the child victim's specific vulnerability to the perpetrator's animosity, were missed.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Safer Lincolnshire Partnership (SLP), Lincolnshire Domestic Abuse Partnership (LDAP) and the Lincolnshire Safeguarding Children Partnership (LSCP) need to coordinate the raising of professionals’ awareness, knowledge and understanding of: i) the Domestic Violence Disclosure Scheme, Domestic Violence Protection Notices and Domestic Violence Protection Orders (to be led by Lincolnshire Police). ii) The risks following separation of harassment and stalking. iii) Coercive and controlling behaviours iv) The fact that domestic abuse is always harmful to children. (Utilising the lives of the victim and the victim would help understand as a case study and each agency to support the learning by also delivering agency specific guidance.) | Safer Lincolnshire Partnership (SLP) | Lincolnshire Domestic Abuse Partnership (LDAP) | Lincolnshire Safeguarding Children Partnership (LSCP) | Lincolnshire Police |
| 2 | The Lincolnshire Domestic Abuse Partnership and the Local Safeguarding Children Partnership should seek assurance from partners that when they work with victims of domestic abuse, who are unable to or reluctant to engage, that they consider the best individual, or agency, who could facilitate this engagement, in order to ensure that any risk posed to the victims and their children in these families is properly assessed and the victim can be suitably supported. (As an example, this may be through Lincolnshire Children Social Care tool ‘Family Seeing’ as it may be a family member best placed as it was in this case to make more use of the victim’s mother or through the MARAC process and an IDVA.) | Lincolnshire Domestic Abuse Partnership | Lincolnshire Safeguarding Children Partnership |
| 3i | The Lincolnshire Safeguarding Children Partnership must seek assurance from Children Social Care that they have made changes to the local Child in Need processes which makes them more inclusive and that all relevant agencies, including those providing services to adults, are included more consistently in the process and meetings. This also includes the consideration for the meetings to have records taken. | Lincolnshire Safeguarding Children Partnership | Children Social Care |
| 3ii | The Safer Lincolnshire Partnership and the Lincolnshire Domestic Abuse Partnership should seek assurance from all agencies that their staff are aware of the impact that Domestic Abuse has on Safeguarding Children. That the agencies also ensure that any perpetrator risk assessments feed into the safety planning around any children in the family. | Safer Lincolnshire Partnership | Lincolnshire Domestic Abuse Partnership |
| 4i | The Lincolnshire Domestic Abuse Partnership must seek assurance from those agencies, who are working with perpetrators of domestic abuse, that they are able to co-commission with them services that will provide a robust response with perpetrators to try and alter their abusive behaviours and prevent future domestic abuse | Lincolnshire Domestic Abuse Partnership |
| 4ii | The Lincolnshire Domestic Abuse Partnership must also seek assurance that those supporting and working with perpetrators of domestic abuse are fully trained to ensure that interventions target and manage their abusive behaviours. | Lincolnshire Domestic Abuse Partnership |
| 5i | The Lincolnshire Domestic Abuse Partnership and Lincolnshire Safeguarding Children Partnership should engage with the Local Criminal Justice Board, to promote that they use the learning from the deaths of the victim and the victim as a case study to raise awareness and understanding of the domestic abuse risks involved in these cases. | Lincolnshire Domestic Abuse Partnership | Lincolnshire Safeguarding Children Partnership | Local Criminal Justice Board |
| 5ii | Lincolnshire Safeguarding Children Partnership & Lincolnshire Domestic Abuse Partnership to explore with the Local Family Justice Board, provision of the multi-disciplinary training recommended by the Harm Panel, with a particular focus on coercive and controlling behaviour, including the ways that perpetrators utilise private law children proceedings as part of this behaviour. | Lincolnshire Safeguarding Children Partnership | Lincolnshire Domestic Abuse Partnership | Local Family Justice Board |
| 6 | The Safer Lincolnshire Partnership and Lincolnshire Safeguarding Children Partnership should seek assurance from partners that their information sharing systems, ensure that in cases of domestic abuse, information is being shared in a timely and appropriate manner and that the voluntary sector are included as an integral part of information sharing for safeguarding adults and children. This should include the agencies reminding individuals of their duty to share information and ensure these individuals have an opportunity to be fully trained in information sharing. | Safer Lincolnshire Partnership | Lincolnshire Safeguarding Children Partnership |
| i | PNC checks submitted by children’s services practitioners will routinely seek disclosure to include all information relating to a person’s offending history and make clear this is not limited to just information from the preceding two years. | Lincolnshire County Council Children Services |
| i | A monthly audit is undertaken of all safeguarding referrals completed by LCHS Urgent Treatment Centre staff to ensure all safeguarding procedures have been followed. | Lincolnshire Community Health Services |
| i | The Trust to review how known risks and risk management plans identified within the Police custody environment translate from the CJL&D ‘Assessment of Needs and Outcomes’ into the ‘Clinical Risk Framework’ (where other LPFT services are involved or later become involved) to ensure the Clinical Risk Framework is a complete record and reflection of risk. | Lincolnshire Partnership NHS Foundation Trust |
| i | The names of those who attend appointments with patients should be asked as well as their relationship and recorded in the patients record. | GP Practice |
| i | Staff within the Hostel need to be confident in their responsibility to report disclosures of concern robustly and consistently. The service has evidence of regularly reporting safeguarding concerns appropriately, however, in this case staff felt reassured by (1) how the perpetrator presented within the service and (2) the response from the Police Officer which impacted the extent to how they reported the concern. | Salvation Army |
| i | Additional training has since been given to school staff on Domestic Abuse and the indicators for pupils and families. | Special School |
| ii | Children’s services staff to be supported to ensure attendance and contributions from all relevant agencies at multi-agency meetings and in children’s plans. | Lincolnshire County Council Children Services |
| ii | Professional curiosity has been included in further LCHS safeguarding mandatory training, and safeguarding supervision for all staff within LCHS. The LCHS safeguarding team also provides an advice hub for contacts from any LCHS staff members who have experienced concerns from a contact with a patient where their aggressive behaviour may be linked to possible domestic abuse and potential harm to others. | Lincolnshire Community Health Services |
| ii | For Steps2Change Service Manager, in consultation with the Trust Safeguarding team, to review their Referral Screening Protocol and consider if changes are required to improve consistency amongst the screening staff in identifying and recording safeguarding and risk history when it is recorded on the separate clinical system RIO. | Lincolnshire Partnership NHS Foundation Trust |
| ii | Recording the names of those who attend appointments, and the reason for this, is discussed within the level 3 safeguarding training delivered by the CCG safeguarding team. Clinical staff at the practice are in the process of booking on to sessions of this. | GP Practice |
| ii | Further training is being delivered to staff at the Hostel in reporting concerns and will be monitored through regular service reviews. | Salvation Army |
| ii | Safeguarding leaders have already improved procedures for sustaining routine contact with all parents whose children with special educational needs and disabilities travel independently to the school. | Special School |
| iii | Internal Children Services review of MOSAIC24 recording and reporting of CIN meetings and attendance of partner agencies. | Lincolnshire County Council Children Services |
| iii | The Trust’s Head of Safeguarding to meet with the Trust Named Doctors for Safeguarding and the Trust Medical Director to review the process of how a safeguarding concern disclosed within an outpatient’s appointment is cross referenced with the record and the care coordinator to ensure it has already been identified and actioned. | Lincolnshire Partnership NHS Foundation Trust |
| Implicit | It is accepted that there are gaps in front line Officers’ knowledge of DVDS, DVPN’s and DVPO’s and Lincolnshire Police have instigated further DA Matters 25training to all front line staff commencing in February 2022 where the use of DVPNs and DVDS will be covered. The subject of DVDS has been the subject of significant internal communications and recently been re-circulated to all front line Officers and staff via a formal briefing mechanism. | Lincolnshire Police |
| Implicit | The Safeguarding Midwives will continue to remind all Midwives via their annual Midwifery Mandatory Training Safeguarding sessions to document all safeguarding information on the Electronic Maternity system in addition to any paper documentation and inform the Safeguarding Midwives if they become aware of any domestic abuse within a relationship so that the appropriate flags can be placed on the pregnant woman’s records so that they would be visible to those accessing the system. | United Lincolnshire Hospital Trust |
| Implicit | Whilst learning has been identified in terms of how practitioner practice could be improved in terms of multiagency working; it remains unclear as to why Probation services were not involved in the Child in Need process or whether the concerns of the supported housing provider were shared and acted on. It is the view of the Reviewing Manager that these questions need to be answered, not as a means of blame, but so that lessons can be learnt, and any necessary improvements made, in terms of how agencies can work together more effectively to protect potential victims, particularly in domestic abuse cases which are not subject to formal multiagency arrangements such as MARAC, MAPPA or Child Protection. | Probation Service |
| Implicit | A review of training needs in Public Sector Partnership Services and the Councils has begun. | East Lindsey District Council |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||