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
Wokingham review
CSP: Wokingham
Published: July 2025
Year of death: 2017
Extracted: 23 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 highlights significant pressures on an elderly, ill carer supporting a spouse with advanced dementia, noting the carer's reluctance to accept help. It identifies a need for more holistic assessments of carer stress and improved multi-agency coordination to better support such complex situations.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | A review of whether assessments of people caring for those with mental health difficulties, be undertaken by a specialist mental health practitioner or a generalist practitioner should be undertaken. | Wokingham Borough Council |
| 1 | In cases where patients with significant health needs of their own are carers the mechanism of interagency assessment at the time of diagnosis should be reviewed to ensure a more holistic process involving health care providers, adult social care, other relevant agencies, the patient and family | Royal Berkshire NHS Foundation Trust |
| 1 | In cases where elderly carers with significant health needs of their own and are responsible for providing support to vulnerable adults who may not have capacity to make their own decisions about care and support, consent to share information should be sought for the purposes of ensuring that the dependent adults needs are prioritised and care act assessments are sought from adult social care partners for carers and their dependents. This recommendation should inform multi-agency partnership work to provide joined up approach to meeting the needs of people who access dementia services | Berkshire Healthcare NHS Foundation Trust |
| 1 | To make the whole risk assessment process for supporting people living with dementia more robust. As previously described in the IMR, the risk assessment process encompasses an assessment of the person, their environment and their physical and mental capacity. However, our risk assessment process also needs to evaluate potential risks to the main family carer arising from the behaviours of the client and the change in their relationship. | Home Instead |
| 1 | We recommend that a system be put in place for a multi-disciplinary case conference to be held to review and plan care needs where the carer of a person with a life limiting physical or mental illness, in particular dementia, also experiences a life limited or potentially life ending physical or mental illness. Wherever possible, family members should be present at this conference to gain a full understanding of the needs and potential issues. | Wokingham Community Safety Partnership |
| 2 | Undertake an audit of cases open to adult social care which have a similar domestic profile to the case of the victim and the perpetrator, and those of the couple in the first DHR. This audit will include a risk analysis of cases and provide recommendations for further operational review. | Wokingham Borough Council |
| 2 | That an interagency pathway and pathway document should be developed with the support of patient representatives e.g. Alzheimer’s Society so that early assessment and referral taking into account the needs of the carer and the vulnerable adult and recognising the emerging vulnerability of the carer is developed | Royal Berkshire NHS Foundation Trust |
| 2 | A new risk form has been developed by the Trust to identify risks to vulnerable adults due to carer stress. This new risk form has been supported with staff training and a recommendation from this IMR is that learning from this IMR will be included in risk management and adult safeguarding training and shared with partner agencies to enhance safeguarding adult practice and learning across partner agencies. | Berkshire Healthcare NHS Foundation Trust |
| 2 | We recommend that health and social care professionals receive clear guidance about how to effectively engage with those carers who are reluctant to accept support and reiterate the importance of clearly and accurately documenting those conversations. | Wokingham Community Safety Partnership |
| 3 | Develop joint working arrangements for couples with this domestic risk profile. | Wokingham Borough Council |
| 3 | That the learning from this case should inform the development of the RBFT Carers Strategy as part of the Berkshire West Carers Strategy being led by the CCG | Royal Berkshire NHS Foundation Trust |
| 3 | Develop consistent partnership approach to MCA training which includes practitioners from a variety of health and social care disciplines in order to improve our shared knowledge and skills in mental capacity act practice . | Berkshire Healthcare NHS Foundation Trust |
| 3 | We recommend that the local NHS and Adult Social Care engage with representatives of independent and voluntary sector organisations to agree protocols for ongoing communication and involvement in multi-agency care planning that will encourage more effective joint working across sectors. | Wokingham Community Safety Partnership |
| 4 | That the learning from this DHR be disseminated to all Adult Social Care and COAMHS staff, drawing attention to the similarities with the first DHR. This learning should include training on any changes to practice resulting from the previous three recommendations. | Wokingham Borough Council |
| 4 | That learning from this case should inform the RBFT Strategic Safeguarding Priority already identified for 17/18 – ‘In line with the Care Act and the principles of Making Safeguarding Personal new evidence review our approach to ensuring the knowledge and competency of our staff in practice in relation to the Mental Capacity and Mental Health Acts, DoLS, best interest assessments and consent’. | Royal Berkshire NHS Foundation Trust |
| 4 | Healthcare professionals should advise the adult social care team so that a Care Act assessment can be offered or completed to determine level and appropriateness of care input required regardless of funding arrangements for care and support needs for patients in the community, especially when a patient lacks capacity to make a decision regarding these needs. | Berkshire Healthcare NHS Foundation Trust |
| 4 | We recommend that the findings, conclusions and recommendations of this DHR be disseminated widely and used to directly inform service change and practice improvement processes. In particular the similarities between this case and DHR1 should be reviewed and used to inform the approach to assessments and service delivery to older people and specifically those with caring responsibilities. | Wokingham Community Safety Partnership |
| 5 | RBFT discharge letters to GPs should include referrals made but also if and what referrals were declined | Royal Berkshire NHS Foundation Trust |
| 5 | The need to establish the legal representative for patients who lack capacity to make decisions about their care and treatment to be incorporated in BHFT mental capacity act training. | Berkshire Healthcare NHS Foundation Trust |
| 6 | Berkshire Cancer Centre (BCC) will improve assessment documentation and interagency sharing of documentation. | Royal Berkshire NHS Foundation Trust |
| 6 | Review and improve record keeping systems in memory clinic to ensure that administration staff taking calls from patients record the call and identify a staff member to return the call in a timely manner. | Berkshire Healthcare NHS Foundation Trust |
| 7 | This case should be used to explore opportunities for peer support within the therapies team and the learning included in Adult Safeguarding, Dementia and risk management training | Royal Berkshire NHS Foundation Trust |
| 8 | Feedback learning from this case within the RBFT to Oncology Clinical Governance, Planned Care Clinical Governance, Patient Experience Committee and Quality Assurance and Learning Committee. | Royal Berkshire NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||