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
West Cumbria review
CSP: West Cumbria
Published: October 2024
Year of death: 2021
Extracted: 14 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 an overreliance on parental decision-making without adequate mental capacity assessments, leading to ineffective monitoring of the victim's health and a lack of escalation when interventions were declined. Communication challenges and a lack of professional curiosity also hindered effective multi-agency support.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| R1 | Increase practitioner understanding and awareness of coercive controlling behaviour, including the definition of ‘personally connected’ and how people with learning disabilities might be affected. | West Cumbria Community Safety Partnership | Cumberland Community Safety Partnership |
| R2 | Research to be undertaken into the prevalence of coercive control for people with a learning disability and prevalence in carer/cared for relationships. | National |
| R3 | Strengthen the knowledge and application around the Mental Capacity Act 2005 | North Cumbria Integrated Care Board |
| R4 | Highlight the offer of external safeguarding supervision. | North Cumbria Integrated Care Board |
| R5 | Ensure that all complex cases of patients with a learning disability are brought to the attention of the practice learning disability nurse. | North Cumbria Integrated Care Board |
| SAR1 | Cumbria Safeguarding Adults Board to survey practitioners on the application of the Mental Capacity Act 2005, exploring challenges in practice. | Cumbria Safeguarding Adults Board |
| SAR2 | Cumbria Safeguarding Adults Board to use the findings of the above survey to inform the Mental Capacity ‘week of action’. | Cumbria Safeguarding Adults Board |
| SAR3 | Cumbria Safeguarding Adults Board to seek assurances that agencies are aware of the role and types of advocacy, and the circumstances in which a person is entitled to advocacy support. | Cumbria Safeguarding Adults Board |
| SAR4 | Cumbria Safeguarding Adults Board to seek assurances that health professionals understand the importance of Hospital Passports and know to ask for them. | Cumbria Safeguarding Adults Board |
| SAR5 | Cumbria Safeguarding Adults Board to raise awareness with agencies of the need to offer a further carer’s assessment to a family carer on an annual basis, or when needs and/or circumstances of the carer, or cared for person, change. | Cumbria Safeguarding Adults Board |
| SAR6 | Cumbria Safeguarding Adults Board to seek assurances from all relevant providers within the agencies in Cumbria that weighing, and management of underweight adults is supported by guidance, which aims to cover recognition of malnutrition; management of nutrition and diet; referral to specialist services and multi-agency coordination. | Cumbria Safeguarding Adults Board |
| SAR7 | Cumbria Safeguarding Adults Board to seek assurance from partners of effective care co-ordination for adults with a learning disability and complex health needs. | Cumbria Safeguarding Adults Board |
| SAR8 | Cumbria Safeguarding Adults Board to seek assurances that health agencies are aware of their role in Deprivation of Liberty Safeguards and that they are preparing for the implementation of the Liberty Protection Safeguards. | Cumbria Safeguarding Adults Board |
| SAR9 | Cumbria Safeguarding Adults Board to seek assurances that agencies creating contingency plans do so in a multi-agency forum and that the plans detail: the agencies involved and contact details, a detailed plan and arrangements for review, identified risks and risk management, and the process for escalation. | Cumbria Safeguarding Adults Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||