Forest of Dean review

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.

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 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.

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.

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.

To ensure professional curiosity and asking direct questions about domestic abuse when indicators of domestic abuse are present.

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.

In cases of suspected or disclosed domestic violence, the Safeguarding Lead should be consulted to inform further steps.

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.

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.

Ensure that GPs are informed when patients have stopped taking prescribed medication.

Provide clear guidance on when operational teams should follow the Domestic Abuse Pathway.

Promote the use of the DASH tool within GHC.

Improve recording of household information and relationships on clinical systems.

Provide clear guidance on when teams must follow the CPA discharge process of a patient on a section 117.

Wider availability of Mental Capacity Act training, and increased clarity and a robustness when completing the recording forms on clinical systems.

Review of GHC Mental Health Services Bed Management Policy.

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.

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.

Review of direct work and intervention using trauma informed methods when working with children who have lived with domestic abuse in their homes.

Review of the support needs of Social Workers and their managers working with parents who present with suicidal ideation.

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.

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.

Essentials 3.0 on Domestic Abuse to consider the learning from this IMR in relation to coercive control and impact on children.

Explore the role of social workers in providing third party evidence for victims of domestic abuse.

Review of transfer policy.

Confirmation of staff training in Child Safeguarding and Domestic abuse.

Discussion with staff regarding the importance of liaison with other agencies in all domestic abuse cases.

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.

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 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.

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.

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.