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 Lancashire review
CSP: West Lancashire
Published: November 2024
Year of death: 2021
Extracted: 33 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 challenges in inter-agency information sharing and follow-up, inconsistent victim engagement, and missed opportunities to assess risk, particularly concerning the links between domestic abuse, complex health needs, social isolation, and suicidal ideation. The impact of the COVID-19 pandemic on service delivery and victim vulnerability was also noted.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | West Lancashire Community Safety Partnership (WLCSP) encourages all agencies that have formed a part of this Panel to seek out training and education opportunities to become 'trauma informed' in their day-to-day practice and to develop a knowledge base and best practice procedures concerning the impact of Adverse Experiences on adult clients | Lancashire Constabulary | West Lancashire Community Safety Partnership | Lancashire County Council Safeguarding Adults | NHS Lancashire and South Cumbria Integrated Care Board | Wrightington, Wigan and Leigh NHS Trust | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust | Lancashire Victim Support | The Liberty Centre | North West Ambulance Service | Lancashire County Council - Intermediate Care Allocation Team | Lancashire County Council – Re-enablemen |
| 10 | WLCSP shares this learning with the Office of the Police and Crime Commissioner and health Sector commissioning services in Lancashire, including the NHS Integrated Care Board, so that they may explore the feasibility of developing an operating procedure to allow the co-location of these services within hospital based IDVA services | Office of the Police and Crime Commissioner | NHS Lancashire and South Cumbria Integrated Care Board |
| 11 | WLCSP to share the research undertaken by Safe Lives and Gentoo examining the role of housing providers in helping victims of domestic abuse with the WLBC Housing Service. | West Lancashire Community Safety Partnership |
| 12 | WLCSP to seek assurance from all partner agencies that have formed part of this Panel, that front line staff in all agencies are trained to recognise the indicators of domestic abuse and to ask relevant questions that enable people to feel safe to disclose their past or current experiences of such abuse and to know how to signpost victims of domestic abuse for suitable support. | Lancashire Constabulary | West Lancashire Community Safety Partnership | Lancashire County Council Safeguarding Adults | NHS Lancashire and South Cumbria Integrated Care Board | Wrightington, Wigan and Leigh NHS Trust | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust | Lancashire Victim Support | The Liberty Centre | North West Ambulance Service | Lancashire County Council - Intermediate Care Allocation Team | Lancashire County Council – Re-enablemen |
| 13 | WLCSP to request the NHS Lancashire Integrated Care Board West Lancashire locality re-emphasise and promote awareness of the safeguarding duty of independent clinical practitioners. | NHS Lancashire and South Cumbria Integrated Care Board |
| 14 | WLCSP to seek assurance from General Practice and the MARAC, that the template currently used to share MARAC information with General Practice, is effective and efficient; If areas of improvement are identified, to construct a means to deliver these changes. | NHS Lancashire and South Cumbria Integrated Care Board | Lancashire Constabulary |
| 15 | West Lancashire Borough Council to ensure that information is available, to ensure tenants are aware to contact the Council, if they have problems when maintenance jobs are undertaken at their property. | West Lancashire Borough Council Housing Team |
| 16 | WLBC Housing Services to encourage its maintenance contractors to make Housing staff aware of situations where they know or believe there is DA or a vulnerable adult. | West Lancashire Borough Council Housing Team |
| 17 | Lancashire County Council Safeguarding Team to have a system in place, to support safeguarding staff, who have concerns there is an increased risk to an individual, linked to their reluctance to engage with professionals. | Lancashire County Council Safeguarding Adults |
| 18 | WLCSP to seek assurance that Telecare referrals are not closed down if the service user did not answer a phone call particularly when poor telephone connection was the reason for the referral in the first place. | Lancashire County Council Safeguarding Adults |
| 19 | WLCSP to seek assurance from MARAC that the Lancashire Safeguarding team are aware of all MARAC meetings and are provided with the details of all those to be discussed at each meeting | Lancashire County Council Safeguarding Adults | Lancashire Constabulary |
| 2 | WLCSP encourages all agencies that have formed part of this Panel to consider developing policies and practices to achieve a standard of ‘Trauma Informed Practice’ in the delivery of their service to reflect the ambition of the LVRN | Lancashire Constabulary | West Lancashire Community Safety Partnership | Lancashire County Council Safeguarding Adults | NHS Lancashire and South Cumbria Integrated Care Board | Wrightington, Wigan and Leigh NHS Trust | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust | Lancashire Victim Support | The Liberty Centre | North West Ambulance Service | Lancashire County Council - Intermediate Care Allocation Team | Lancashire County Council – Re-enablemen |
| 20 | WLCSP to seek assurances that prompt contact is made between with Wrightington Wigan and Leigh Hospital and the Safeguarding Team | Wrightington, Wigan and Leigh NHS Trust | Lancashire County Council Safeguarding Adults |
| 21 | WLCSP to seek assurances that formal COVID written risk assessments should be recorded prior to all LCC Safeguarding visits during present COVID risks. | Lancashire County Council Safeguarding Adults |
| 22 | WLCSP to seek assurances that MARAC actions are being completed within the timescales agreed or are being followed up in a timely manner of not | Lancashire Constabulary |
| 23 | WLCSP to seek assurances through the ICB that all GP Practices operating within West Lancashire are reminded of key points which are already recommended practice. To include the following: Read coding and recording Dealing with incoming letters Dealing with non- attendances by adults with care and support needs (the “vulnerable”) The “Think Family” approach | NHS Lancashire and South Cumbria Integrated Care Board |
| 24 | NHS Integrated Care Board to consider providing staff West Lancashire Primary Care staff with bespoke DA update training that sits alongside the standard safeguarding update training | NHS Lancashire and South Cumbria Integrated Care Board |
| 25 | WLCSP to seek assurances that the process to ensure timely escalation of safeguarding concerns from other agencies, via letters are shared with GP leads via Practice administration staff regarding safeguarding risks/ vulnerability and DA | NHS Lancashire and South Cumbria Integrated Care Board |
| 26 | WLCSP to seek assurances from the NHS Integrated Care Board that the follow up of patients where there is a lack of engagement with services and where vulnerability is a feature is inherent within its policy | NHS Lancashire and South Cumbria Integrated Care Board |
| 27 | NHS Integrated Care Board (West Lancashire locality) to Develop a DA Grab pack which will be circulated to Primary Care services | NHS Lancashire and South Cumbria Integrated Care Board |
| 28 | NHS Integrated Care Board to share the lessons learned from the DHR with the individual practices across Lancashire and South Cumbria Primary Care Networks | NHS Lancashire and South Cumbria Integrated Care Board |
| 29 | WWLFT to consider how to raise staff awareness of how to facilitate the reporting of a crime following a patient's disclosure | Wrightington, Wigan and Leigh NHS Trust |
| 3 | WLCSP encourages all agencies that have formed part of this Panel to appoint a specific point of contact to report back to WLCSP on progress against the implementation of the above 'trauma informed' recommendations. | Lancashire Constabulary | West Lancashire Community Safety Partnership | Lancashire County Council Safeguarding Adults | NHS Lancashire and South Cumbria Integrated Care Board | Wrightington, Wigan and Leigh NHS Trust | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust | Lancashire Victim Support | The Liberty Centre | North West Ambulance Service | Lancashire County Council - Intermediate Care Allocation Team | Lancashire County Council – Re-enablemen |
| 30 | Southport and Ormskirk Hospital Trust to reinforce to staff the Importance of completion of the safeguarding questions in A&E and highlight this through safeguarding training | Southport and Ormskirk Hospital NHS Trust |
| 31 | Southport and Ormskirk Hospital Trust to seek assurances that the Provider Enquiry Report is completed and returned to Sefton Local Authority due to concerns regarding errors in reinstating a package of care | Southport and Ormskirk Hospital NHS Trust |
| 32 | West Lancashire Home Treatment Team to ensure that staff involved in the care of the service user have completed clinical risk training | Lancashire and South Cumbria NHS Foundation Trust |
| 33 | Completion of an audit by West Lancashire Home Treatment Team that focusses on the quality of risk assessments, with necessary further actions taken should there be evidence of further concerns in this regard | Lancashire and South Cumbria NHS Foundation Trust |
| 4 | WLCSP to share the 'suicidal ideation' learning opportunity for suicide prevention with all agencies that have formed part of this Panel, Lancashire and South Cumbria Health and Care Partnership: Start the conversation (healthierlsc.co.uk) | West Lancashire Community Safety Partnership |
| 5 | To share this (action 4) learning opportunity with the pan-Lancashire DHR Task and Finish Group, in order to encourage services to consider the possible links between 'suicidal ideation' and Domestic Abuse as part of the intelligence gathering process to identify “victim suicides” who should be considered for the DHR process. Lancashire and South Cumbria Health and Care Partnership:: Suicide prevention (healthierlsc.co.uk) | West Lancashire Community Safety Partnership |
| 6 | WLCSP to encourage all agencies that have formed part of this Panel to ensure a process is in place to identify domestic abuse victim suicides and ensure they are considered for a DHR | Lancashire Constabulary | West Lancashire Community Safety Partnership | Lancashire County Council Safeguarding Adults | NHS Lancashire and South Cumbria Integrated Care Board | Wrightington, Wigan and Leigh NHS Trust | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust | Lancashire Victim Support | The Liberty Centre | North West Ambulance Service | Lancashire County Council - Intermediate Care Allocation Team | Lancashire County Council – Re-enablemen |
| 7 | WLCSP to share this learning opportunity with the Lancashire Domestic Abuse Board and request they consider the findings of the Home Office Report with the aim of developing an assessment process that identifies any risk of victim suicide, i.e., where coercion and control (and according to the evidence – non-fatal strangulation) are present in the case they are reviewing | West Lancashire Community Safety Partnership |
| 8 | WLCSP to share the learning from this DHR review with Lancashire Constabulary and the Office of the Police and Crime Commissioner (OPCC) so that they may jointly consider the most appropriate Domestic Abuse Risk Assessment tool for improved risk identification | Lancashire Constabulary | Office of the Police and Crime Commissioner |
| 9 | WLCSP to encourage all agencies that have formed part of this Panel to consider the evaluation of the Wrightington, Wigan and Leigh NHS Trust IDVA service and to encourage the relevant partners, to build a case for replicating this good practice and expanding and/or enhancing the provision of specialist hospital based IDVA services where appropriate | NHS Lancashire and South Cumbria Integrated Care Board | Southport and Ormskirk Hospital NHS Trust | Lancashire and South Cumbria NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||