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
Somerset review
CSP: Somerset
Published: October 2024
Year of death: 2021
Extracted: 20 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 fragmented interagency communication, a lack of professional curiosity, and insufficient trauma-informed responses to the victim's complex needs, including domestic abuse, mental ill-health, substance misuse, and homelessness, which hindered effective safeguarding.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Increasing awareness among professionals on the links between and impacts of mental health, self-harm and/or suicidal ideation, with domestic abuse. | Somerset Community Safety Partnership |
| 2 | Responding to domestic abuse, so that agencies and professionals are equipped and confident to exercise professional curiosity, in a meaningful, empathic, and trauma-informed way. | Somerset Community Safety Partnership |
| 3 | Identifying and responding effectively to vulnerabilities, resulting from the intersection of protected characteristics, such as gender and disability. | Somerset Community Safety Partnership |
| 4 | Recognising co-occurring family violence, as a risk factor for domestic abuse, specifically, the parallels between domestic abuse of intimate partners with the abuse of other relatives. | Somerset Community Safety Partnership |
| 5 | Recognising disclosures of problem-gambling by prior/current domestic abuse victims as an important opportunity to provide support and to refer to specialist agencies, | Somerset Community Safety Partnership |
| 6 | For any provider with a Local Authority issued contract to have a domestic abuse policy and procedure in place, as well as confirmation that training on domestic abuse will be provided to staff. | Somerset Community Safety Partnership |
| 7.2.10 | To have a more robust transfer/move-on plan, to safeguard client | Arc Inspire |
| 7.2.11 | Liaise with the Local Authority, re DV concerns for place of safety. Rationale To Safeguard the client | Arc Inspire |
| 7.2.12 | Improvement with Multi Agency meetings. Rationale Communication/Sharing Information / Safeguarding client | Arc Inspire |
| 7.2.13 | Better communication / sharing of information with external agencies. Rationale To support the clients’ needs. Sharing of information. | Arc Inspire |
| 7.2.14 | Domestic abuse staff training. Rationale To improve/gain knowledge and skills of their awareness of domestic abuse and violence. | Arc Inspire |
| 7.2.15 | Closer link with housing provider. Rationale: We may have been able to reduce the risk for the victim by raising with housing. | Somerset Drug and Alcohol Service |
| 7.2.16 | At the start of a new treatment episode, the most recent treatment episode to be reviewed by keyworker. Rationale: Highlight identified risks or safeguarding concerns that may warrant further action | Somerset Drug and Alcohol Service |
| 7.2.3 | Remind GP practices to ensure a request for counselling is accompanied by a review of mental health and any risks e.g., of self-harm. | NHS Somerset ICB | GP practices |
| 7.2.4 | When dealing with sleep problems there should be evidence of a more holistic assessment e.g., including mental health and social circumstances as well as a pain review. | NHS Somerset ICB | GP practices |
| 7.2.5 | When someone with complex presentation does not return initial attempts to make contact for a medication review that may impact on the risk that person may be exposed to as a result of lack of the review, further attempts to establish contact should be evidenced by the GP practice. | NHS Somerset ICB | GP practices |
| 7.2.6 | Somerset NHS Foundation Trust to continue to move forward with embedding routine enquiry within mental health services, including how and where this is recorded. | Somerset NHS Foundation Trust |
| 7.2.7 | Continue to embed a focus on the absent parent, as there is evidence of a lack of curiosity regarding the victim as the absent parent. | Somerset County Council Children Social Care |
| 7.2.8 | To look at reconfiguring the system for free text in addition to tick boxes. | Somerset Council |
| 7.2.9 | Report Safeguarding (not assuming another professional is taking lead), for safety of client. | Arc Inspire |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||