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
Forest of Dean review
CSP: Forest of Dean
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 systemic failures in multi-agency information sharing and risk assessment regarding the perpetrator's domestic abuse history and the victim's complex mental health. Agencies missed opportunities to identify and respond to indicators of abuse, economic abuse, and gaslighting, alongside shortcomings in child protection.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Forest of Dean Community Safety Partnership to recommend to Gloucestershire Children’s Services that the final report of this review is attached to the child’s social care records. This is so that, if the child wishes to read the report of the domestic homicide review when they are older, it will be available to them. | Forest of Dean Community Safety Partnership | Gloucestershire Children’s Services |
| 2 | Gloucestershire Domestic Abuse Local Partnership Board to receive assurance from Gloucestershire Police on their implementation of the Police, Crime, Sentencing and Courts Act 2022 and its impact upon domestic abuse offenders subject to bail over the 12 months following the Act coming into force. | Gloucestershire Domestic Abuse Local Partnership Board | Gloucestershire Police |
| 3 | Gloucestershire Domestic Abuse Local Partnership Board to raise professional’s awareness of the need to identify mental ill-health, substance misuse and suicide as symptoms of domestic abuse and promote trauma-informed approaches to work with victims. | Gloucestershire Domestic Abuse Local Partnership Board |
| 4 | The Home Office is asked to consider consulting with the Department of Health and Social Care and the Royal Colleges over whether stand-alone domestic abuse training should be made mandatory for all front-line health professionals. | Home Office | Department of Health and Social Care | Royal Colleges |
| 5 | The Home Office to review access to the Police National Database for domestic abuse cases where there is information that a perpetrator of domestic abuse has had police contact in another force area. | Home Office |
| 5.2.1a | To ensure professional curiosity and asking direct questions about domestic abuse when indicators of domestic abuse are present. | Primary Care |
| 5.2.2a | For any newly admitted patient, the admitting nurse and doctor should make an entry on Carenotes at the point of admission, with some detail of mental state, and a risk assessment and management plan. | Elysium Healthcare |
| 5.2.2b | In cases of suspected or disclosed domestic violence, the Safeguarding Lead should be consulted to inform further steps. | Elysium Healthcare |
| 5.2.2c | The Acute Risk Matrix is a dynamic tool and should be updated whenever there is a significant event of concern, as it informs the Risk Management plan for the patient. Patients should have full multidisciplinary reviews, such as Ward Round meetings, at least once a week. Where possible, particularly if discharge is being considered, this should involve the Consultant Psychiatrist. | Elysium Healthcare |
| 5.2.2d | The NHS Mental Health Service that will take over the care of the patient following discharge should be involved in the discharge planning process, as far as is practicable, particularly for non-detained patients who are not being managed under the Care Programme Approach. The Discharge Planning meeting should include discussion of the patient’s presentation, identified risks and the level of support required post-discharge. | Elysium Healthcare |
| 5.2.3a | Ensure that GPs are informed when patients have stopped taking prescribed medication. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3b | Provide clear guidance on when operational teams should follow the Domestic Abuse Pathway. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3c | Promote the use of the DASH tool within GHC. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3d | Improve recording of household information and relationships on clinical systems. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3e | Provide clear guidance on when teams must follow the CPA discharge process of a patient on a section 117. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3f | Wider availability of Mental Capacity Act training, and increased clarity and a robustness when completing the recording forms on clinical systems. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.3g | Review of GHC Mental Health Services Bed Management Policy. | Gloucester Health and Care NHS Foundation Trust |
| 5.2.4a | To review the use of PND for domestic abuse cases where there is information that the perpetrator has had police contact in another force area. | Gloucestershire Constabulary |
| 5.2.4b | To provide assurance to the Community Safety Partnership that the changes that have been made to improve the standard of investigation and victim contact have resulted in positive outcomes for domestic abuse victims. | Gloucestershire Constabulary |
| 5.2.5a | Review of direct work and intervention using trauma informed methods when working with children who have lived with domestic abuse in their homes. | Gloucestershire County Council Children’s Social Care Services |
| 5.2.5b | Review of the support needs of Social Workers and their managers working with parents who present with suicidal ideation. | Gloucestershire County Council Children’s Social Care Services |
| 5.2.5c | Support Social Workers to be fully informed about the range of local support available for victims of Domestic Abuse, including the mental health IDVAs and the vulnerable women’s project. | Gloucestershire County Council Children’s Social Care Services |
| 5.2.5d | Work with the Nelson Trust and Children’s commissioning to review how accessible the vulnerable women’s project is across the county. This is especially a challenge to access for women living in rural areas. | Gloucestershire County Council Children’s Social Care Services | Nelson Trust | Children’s commissioning |
| 5.2.5e | Essentials 3.0 on Domestic Abuse to consider the learning from this IMR in relation to coercive control and impact on children. | Gloucestershire County Council Children’s Social Care Services |
| 5.2.5f | Explore the role of social workers in providing third party evidence for victims of domestic abuse. | Gloucestershire County Council Children’s Social Care Services |
| 5.2.6a | Review of transfer policy. | Hereford, Shropshire and Telford Probation Service |
| 5.2.6b | Confirmation of staff training in Child Safeguarding and Domestic abuse. | Hereford, Shropshire and Telford Probation Service |
| 5.2.6c | Discussion with staff regarding the importance of liaison with other agencies in all domestic abuse cases. | Hereford, Shropshire and Telford Probation Service |
| 5.2.6d | New partners and their children are informed, protected and supported throughout a case and there is an appropriate response to all new information about the risk of harm. | Hereford, Shropshire and Telford Probation Service |
| 6 | Gloucestershire Domestic Abuse Local Partnership Board to seek assurance from its partner agencies that its position statement on anger management has been cascaded throughout their organisations and that anger management does not feature as a response to domestic abuse within its services. | Gloucestershire Domestic Abuse Local Partnership Board |
| 7 | Gloucestershire Domestic Abuse Local Partnership Board to recommend to the Safeguarding Children Board that a domestic abuse focussed review of multi-agency responses to child protection be undertaken to ensure that: the impact of coercive control on both child and non-abusing parents is explored and understood; domestic abuse perpetrators are not invisible to child assessments and that the threat they pose to families informs risk assessments and responses to protecting the child and their non-abusing parent; robust safety planning is undertaken, alongside multi-agency protective interventions. | Gloucestershire Domestic Abuse Local Partnership Board | Safeguarding Children Board |
| 8 | Within its forthcoming Perpetrator Strategy, the Home Office is asked to include guidance to social workers and other professionals on providing evidence to support criminal and civil action against perpetrators of domestic abuse, particularly in the context of child protection. | Home Office |
| 9 | Gloucestershire Domestic Abuse Local Partnership Board to continue to work with health and local authority commissioners to review whether gaps remain and whether there is a need for specialist domestic abuse services for children and young people if not already available. | Gloucestershire Domestic Abuse Local Partnership Board | health and local authority commissioners |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||