Independent investigation: Anita Bawtree, Southampton (2011)

All services involved in this review should ensure relevant staff are fully trained in identifying, assessing and responding to domestic abuse.

Southampton Safe City Partnership should ensure that the Pippa (Prevention, Intervention and Public Protection Alliance) project is implemented. This will provide a clear point of contact for workers seeking advice and information about domestic abuse cases and will provide a place to make referrals of domestic abuse cases that require specialist support.

NHS Southampton should ensure that the IRIS (Identification and Referral to Improve Safety) project is implemented and sustained in the City to work closely with GP practices to improve identification and referral of domestic abuse cases. The project should involve both Practice 1 and 2 as involved in this case within its first set of practices involved in the project.

Key services including Health and the Local Authority should require specific standards in training for providers so that all professionals and practitioners are able to ensure domestic abuse identification, assessment and appropriate referral.

The Vulnerable Victims group should consider how agencies can respond more effectively to the cumulative impact of standard and medium risk cases for adults with compounding issues such as mental health and substance misuse as well as domestic abuse. To include consideration of developing a triage system similar to Multi Agency Safeguarding Hubs used in other parts of the UK, or the triage used for children and young people cases in Southampton.

Force policies and procedures are amended to provide police officers with more guidance when dealing with suspects who have mental health issues.

Force control room standard operating procedures are amended to provide clear risk based guidance on how to respond to calls from people with mental health issues.

Increase GP and practice staff awareness and identification of domestic violence, the potential effects on relationships / families and the service provision available for support and intervention. Develop close working relationships with domestic violence services (e.g. IDVA – Independent Domestic Violence Advisors) and health services.

Increase awareness of GP role and responsibility in Safeguarding Adults with the development and implementation of individual practice Safeguarding Adult Policy. This policy should include recognising and managing Domestic Violence.

New patient registration forms to have a detailed section requesting information on the consumption of alcohol, over the counter medications, alternative medication and illicit drugs to facilitate lifestyle assessment and opportunistic signposting to appropriate drug and alcohol services.

A greater correlation between the data available in the form of easily identifiable read codes and the information contained in individual patient records. Increase performance management of Primary Care services to ensure practices are complying with this mandatory process in line with guidance using uniform read codes.

Validate the 2011 update of management of domestic abuse guidelines.

Ensure training re: management of domestic abuse is always included on the orientation for Emergency Department nurses and doctors.

Include training re: management of domestic abuse on forthcoming Vulnerable Adult Champions Programme.

Ensure that the record of referral from Emergency Department re: mental health problems is included on the patient’s electronic mental health records by the mental health team receiving the referral, regardless of whether the patient is seen in Emergency Department, the Mental Health team refuse to see or patient self discharges/absconds.

Disseminate learning from this review at key Trust groups.

Ensure clinical and non clinical staff have easy access to information and resources on all vulnerable adults issues.

Facilitate access to specialist services for victims of domestic abuse when they attended the acute hospital site.

Provide awareness for all staff groups of the recently developed domestic abuse policy including the availability of domestic abuse training throughout the trust.

Each service within the Society to ensure that at least one member of staff attends specialist domestic violence training each year, if this is appropriate to the role of the service. This is in order to keep teams up to date with the issues, and to maintain awareness of the issues over the longer term. This needs to be in line with the role of the service, so may not be considered relevant within the Registered Care Home, for example.

Refresher domestic violence training for all Customer Service Advisors and Housing Officers.

Improved access to relevant policy and procedures.

Review effectiveness of induction process for new starters.

Have a specific module within the Sovereign training framework covering domestic abuse.

To access Hampshire domestic abuse training programme.

Supervisors to attend DASH (Risk Assessment) and MARAC (Multi Agency Risk Assessment Conferences) training course.

To ascertain how long client files should be kept before destruction.

Refresher training for team on file management and codes of practice.