Home / Sources / Domestic Homicide Reviews / Doncaster · Oct 2024
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

Doncaster review

CSP: Doncaster Published: October 2024 Year of death: 2019 Extracted: 19 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
Agencies missed opportunities to pursue evidence-based prosecutions and apply protective orders. There was a failure to understand the victim's non-engagement, particularly regarding the perpetrator's coercive control, highlighting a need for improved multi-agency responses.

Home Office classifications

41 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - physical disability
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (between victims)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

19 recommendations pulled from the report · 10 matched to organisations in the index

Recommendation 1

Addressed to South Yorkshire Police | Lincolnshire Police

That South Yorkshire and Lincolnshire Police provide assurances and evidence to Safer Stronger Doncaster Partnership that all available evidence is gathered and considered during investigations into cases of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Doncaster Council IDVA Service

All IDVAs attend Safelives accredited IDVA training within the first twelve months of their appointments.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

Clinicians should consider: • The Trust’s ‘Engagement and Discharge of Patients Referred to and in Contact with Aspire Drug and Alcohol Services Policy’ • Complete Risk Assessments To mitigate the risk to patients who are vulnerable but have a propensity to not engage in a consistent manner despite their ongoing need.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Safer Stronger Doncaster Partnership

That all agencies provide assurances and evidence to Safer Stronger Doncaster Partnership that all known risk factors and vulnerabilities such as alcohol use, are taken into consideration, and that contact with victims of domestic abuse is undertaken in cognisance and with agreement of the victim.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Doncaster Clinical Commissioning Group

Training for primary care staff to raise awareness of suicide risk in domestic abuse and the importance of routine enquiry when a patient presents with indicators of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

ASPIRE Drug and Alcohol Services to provide awareness sessions to the Safeguarding Adult Board

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to South Yorkshire Police | Lincolnshire Police

That South Yorkshire and Lincolnshire Police provide assurances and evidence to Safer Stronger Doncaster Partnership of their processes to consider utilising a DVPO/DVPN to safeguard victims of domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

Services to explore ways in which to engage / communicate with patients of no fixed abode and consider how multi agencies can support in this.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Safer Stronger Doncaster Partnership

That Safer Stronger Doncaster Partnership ensures that the learning from this case is used to inform the ongoing workstreams in responding to domestic abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Doncaster Council IDVA Service | South Yorkshire Police

IDVA Chair training being facilitated with Safelives on behalf of SYP. (To be arranged

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

All staff to understand what the definition of Domestic Abuse is.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Safer Stronger Doncaster Partnership

That Safer Stronger Doncaster Partnership reviews the multi- agency response to victim engagement during DVDS and criminal investigations.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

All staff to ask patients about their relationships with their family

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to South Yorkshire Police

That South Yorkshire Police provide assurances and evidence to Safer Stronger Doncaster Partnership as to how they have embedded learning into practice in relation to DVDS applications and processes.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Rotherham Doncaster and South Humber NHS Foundation Trust

All staff to understand when a referral to Domestic Abuse services should be considered.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Safer Stronger Doncaster Partnership

That Safer Stronger Doncaster Partnership ensures that there are services and referral pathways in place for perpetrators of domestic abuse, in particular, for those perpetrators who are not being managed within the criminal justice system.

Verified wording from the published review · Original review (PDF) ↗