Domestic homicide reviews and near miss reviews: Summary of learning in Brighton & Hove 2012 and 2013

1.1

In April 2011, the government implemented section 9 of the Domestic Violence, Crime and Victims Act 2004. This means that local areas are expected to undertake a multi-agency review, following a domestic homicide, to identify the lessons that can be learned with a view to preventing future homicides and violence.

This approach is set out in the Revised Statutory Guidance for the conduct of Domestic Homicide Reviews, which was published by the Home Office in March 2013.

1.2

The local Community Safety Partnership, the Safe in the City Partnership, is responsible for commissioning Domestic Homicide Reviews (DHRs) in Brighton & Hove.

Reviews are led by an Independent Chair, with support from the Partnership Community Safety Team and the cooperation of other statutory, voluntary and community sector partners.

1.3

The purpose of a DHR is to:

1. establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims
2. identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result
3. apply these lessons to service responses including changes to policies and procedures as appropriate
4. prevent domestic violence and abuse homicide and improve service responses for all domestic violence and abuse victims and their children through improved intra and inter-agency working

1.4

In some circumstances, a Community Safety Partnership can consider conducting a single agency individual management review or a smaller-scale audit.

For example, where there are lessons to be learnt or on how staff worked within one agency rather than about how agencies worked together. This could include those cases where a victim committed suicide.

In Brighton & Hove, this guidance has been interpreted to mean the Safe in the City Partnership may undertake a ‘Near Miss Review’ (NMR) in certain cases, using the same process as one would use in conducting a DHR.

The cases where a NMR would be considered are those where an incident did not result in a homicide, but where the circumstances are of particular concern.

For example where an individual had a significant experience of domestic violence and abuse or repeated contact with a range of agencies.

1.5

Once a review is complete, a Community Safety Partnership must consider its findings and recommendations and develop an action plan setting out how it will respond.

That might mean looking at how an individual agency, or a group of agencies, worked and making recommendations to improve practice.

It may also mean identifying issues which challenge practitioners and agencies to change practice.

1.6

Reviews must be published. While this report makes references to the findings of individual reviews, these are not discussed in detail.

Access the reviews in their entirety.

1.7

There is no requirement to bring together local reviews. However, while each DHR or NMR is a tragedy in its own right, there is value in drawing together the findings and recommendations.

The intention of such an exercise is to identify common learning, key messages for professionals, policy makers and commissioners (to inform practice and the shape of services locally), and to develop a single action plan, to ensure services are improved.

1.8

Developing a ‘Lessons Learnt’ document is an approach used in other review processes. For example Ofsted conducted an analysis of the evaluations of 147 serious case reviews that between 1 April 2009 and 31 March 2010.

1.9

Similarly, the Home Office produced a report, Domestic Homicide Reviews: Common Themes Identified as Lessons to be Learned, setting out the most common themes that were identified.

This was based on the 54 reviews received between 13 April 2011 and 31 March 2013. The findings from this report are addressed further in section 3 of this report.

Unfortunately, the Home Office report did not publish a detailed analysis of these 54 reviews, so it is not possible to compare the profile of the adults who were subject of the local reviews to any national data.

2.1

This report covers 3 DHRs (Mrs A, Mrs B and Mr C) and 1 NMR (Ms D) commissioned by the Safe in the City Partnership in 2012 to 2013 and 2013 to 2014, with these reviews summarised in section 2.3.

2.2

For each DHR, the Safe in the City Partnership was notified by Sussex Police of an incident that might meet the criteria for a DHR and subsequently agreed to conduct a review.

In the case of Ms D, Sussex Police gave notice of a serious incident where the victim/survivor had attempted suicide.

Subsequently, the Safe in the City Partnership agreed that a NMR be conducted because this was a life changing incident and the victim/survivor was known to have had an extensive history of domestic violence and abuse (which included assault and harassment as well as breach of bail) and contact with local services.

The victims

2.3

Of the 4 reviews, each concerned one adult. Each review was also concerned with one perpetrator, although in one case (that of Ms D) there was a known history of alleged previous abuse so a further individual was identified as being of interest to the review.

There were no children associated with the adult victims.

Profile of adults at the time of the incident that led them to be the subject of a review:

Name: Mrs A

Age: 70 to 74

Ethnicity and gender: White British female

Sexuality: heterosexual

Work status: retired

Relationship status: married and living together

Name: Mrs B

Age: 20 to 24

Ethnicity and gender: White British female

Sexuality: heterosexual

Work status: employed

Relationship status: married and separated

Name: Mr C

Age: 60 to 64

Ethnicity and gender: White British male

Sexuality: gay

Work status: not in employment

Relationship status: significant relationship, cohabiting

Name: Ms D

Age: 40 to 44

Ethnicity and gender: White British female

Sexuality: heterosexual

Work status: not in employment

Relationship status: significant relationship, periods of living together

2.4

All but one of the adults was female and in a heterosexual relationship, and all were White British. One adult was a gay male.

2.5

There was a wide age range, as well as differences in employment status.

2.6

Mrs A and Mrs B were married, while Mr C and Ms D were both in significant relationships.

2.7

Mrs A and Mr C were co-habiting at the time of their deaths. Mrs B had recently separated from her partner, moving out of the home they had shared.

Ms D’s residential status was more complex, with some periods when she and her partner lived together, although each maintained a separate address.

The perpetrators

2.8

The characteristics of the perpetrators were not the subject of the reviews and are therefore not considered in this report.

The incidents

2.9

Of the 4 adults who were subjects of reviews, 3 died as a result of the following:

• asphyxiation, although it was unclear if this was associated with a suicide pact or a murder-homicide (Mrs A)
• stabbing (Mrs B)
• blunt force trauma to the chest (Mr C)

2.10

The remaining adult (Ms C) attempted suicide by overdose; while she survived she sustained a life changing injury.

Contact with services

2.11

Prior to the incidents that led to their death or serious injury, the adults who were subject of the reviews had varying levels of contact with services.

Only one adult had extensive contact (Ms D), with the other adults only engaging with universal provision (principally health).

Contact with services by adults who were the subject of a review

Mrs A: 

• annual check up with GP

Mrs B:

• one historical 'domestic incident' reported to police, no further action
• stand alone appointment with GP and Secondary Health Care

Mr C:

• 3 contacts with Ambulance Service - leading to 2 conveyance to hospital
• 2 hospital admissions
• disclosure to professionals following an assault

Ms D:

• contact with 3 different GPs, multiple hospital admissions
• contact with police
• known to specialist DVA services, mental health and substance use services, including as a MARAC subject

2.12

The range of contact demonstrates the challenges of working with domestic violence and abuse. Particularly as in most of the cases the adults had routine but infrequent and low level engagement.

For example, as part of an annual health check-up or registration with a General Practitioner (in the cases of Mrs A, Mrs B) or intermittent engagement in response to specific health needs (for example, Mr C had been in contact with the Ambulance Service for advice, but had declined attendance).

There were also examples of previous, historical contact with services (Mrs B had been involved in a ‘domestic incident’ with the perpetrator, which had been reported to the police in another area of the country).

2.13

However, at the time of their death or serious injury, it is of note that both Mr C and Ms D had considerable contact with services.

In the case of Mr C, this involved a disclosure to professionals following an assault and contact with staff in both the Ambulance Service and Accident & Emergency.

Ms D was in contact with specialist domestic abuse workers, other services (including the police) and had been subject to a Multi-Agency Risk Assessment Conference (MARAC).

Needs and issues

2.14

There were a range of needs and issues identified for the adults who were subject of the reviews prior to the incidents that led to their death or serious injury. 

Needs and issues of adults who were the subject of a review

Mrs A:

• social isolation
• limited contact with family
• partner identified as 'carer'
• no evidence of domestic violence and abuse

Mrs B:

• separation/end of relationship

Mr C:

• partner identified as 'carer'
• problematic alcohol use
• abuse disclosed to family, including physical and financial abuse

Ms D:

• problematic alcohol use
• mental health issues
• abuse reported to police, including breach of bail
• disclosure to range of professionals, including physical and sexual abuse
• possible separation

2.15

The needs and issues of the adults were varied. While not were known to agencies at the time, it is of note that many would be identifiable by the CAADADASH risk identification checklist.

It is likely that if a checklist were used – and subject to the effective use of the tool, disclosure by the adult or use of third party information and the use of professional judgement – Mr C may have been graded as Medium or High risk, while Mrs A and Mrs B may have been graded as Medium Risk.

Ms D was known to be at High Risk.

3.1

This section focuses on the lessons to be learnt from the reviews. There are a broader set of lessons identified in the Home Office document ‘Domestic Homicide Reviews: Common Themes Identified as Lessons to be Learned’ which are also relevant.

The key themes included:

• awareness raising and communication
• awareness and training for healthcare professionals
• risk assessment
• information sharing and multi-agency working
• complex needs
• perpetrators and bail
• awareness of the safeguarding needs of children

3.2

Many of the lessons for Brighton & Hove are similar to those set out in the Home Office report.

There are 6 main themes which recur throughout the local reviews, each of which is summarised in more detail below:

• awareness raising and communication
• skilled workforce
• consistent care pathways
• assessing and responding to risk
• information sharing
• coordinated community response

Awareness raising and communication

3.3

Each review identified the importance of raising awareness of domestic violence and abuse, in order that people know how to access help and support.

While this would normally take the form of a public awareness campaign, it is of note that 3 of the 4 reviews identified specific issues for victim/survivors from particular communities (older people, gay men, adults with complex needs).

Any communications strategy will need to consider how to address and respond to the unique needs of individuals from these and other marginalised communities.

3.4

A further issue identified was the importance of providing information to victim/survivors at or following an incident or disclosure, where it is safe to do so.

This would be in order to encourage them to identify ongoing abuse and know where to seek help and support.

This was specifically relevant in one review where the police (albeit in another area of the country) had responded to a domestic incident, but did not provide follow up on this after the initial response (Ms B).

It would also have been relevant for health professionals to whom a disclosure was made in the case of Mr C.

Although advice was provided by professionals this was an opportunity to provide specific information to a victim/survivor even if the professionals had not been able to take any other further action.

3.5

The role of family members and friends was also identified in 3 reviews.

In these cases family members and friends knew about the domestic violence and abuse, and there are examples of those who knew trying to provide help and support.

However, it was also evident that family members and friends as ‘supporters’ or ‘responders’ were not necessarily aware of how domestic violence and abuse may impact on a victim/survivor, possible indicators of risk and how they might most effectively respond or seek help themselves.

This included how they could or should respond to the alleged perpetrator.

3.6

Similarly, employers were identified as significant. In 2 of the 4 reviews, the adult was or had been in employment.

While there is no evidence in these cases that the employer might have done something differently, it is a reminder that employers can help raise awareness and provide help and support in response to a disclosure.

They may also need to be aware of the indicators of domestic violence and abuse, where these affect someone’s employment, or have a role in ensuring that the workplace is a place of safety.

These lessons are addressing with the following recommendations:

Recommendation 1

Raise awareness about domestic violence and abuse and the help and support that is available, with targeted communications for victims (tailored as appropriate to specific communities of interest), as well as family and friends.

Recommendation 2

Provide guidance and support for employers and unions to develop employment policies that address domestic violence and abuse.

Recommendation 3

Provide information directly to victims of domestic abuse at or following an incident, crime or disclosure (where it is safe to do so) that might encourage them to identify abuse and know where to seek help and support.

Skilled workforce

3.7

The importance of ensuring that members of staff were aware of domestic violence and abuse, and had the appropriate skills and confidence to identify or respond appropriately to disclosures, was identified in all the reviews.

3.8

In particular, reflecting the context of the 4 reviews, the importance of awareness and training for healthcare professionals was identified.

As discussed above, each adult had contact with health professionals, albeit to varying degrees.

In this context, the reviews identified the importance of staff being able to recognise the (clinical) indicators of domestic violence and abuse, and being able to ask relevant questions to help people disclosure their past or current experiences.

Examples of relevant indicators include:

• symptoms of depression, anxiety, post-traumatic stress disorder, sleep disorders
• suicidal tendencies or self-harming
• alcohol or other substance use
• unexplained chronic gastrointestinal symptoms
• unexplained reproductive symptoms, including pelvic pain and sexual dysfunction
• adverse reproductive outcomes, including multiple unintended pregnancies or terminations
• delayed pregnancy care, miscarriage, premature labour and stillbirth
• unexplained genitourinary symptoms, including frequent bladder or kidney infections
• vaginal bleeding or sexually transmitted infections
• chronic pain (unexplained)
• traumatic injury, particularly if repeated and with vague or implausible explanations
• problems with the central nervous system – headaches, cognitive problems, hearing loss
• repeated health consultations with no clear diagnosis
• intrusive 'other person' in consultations

[Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively’ Public Health Guidance 50, National Institute for Health and Care Excellence, February 2014]

3.9

The ability of staff to recognise the impact of domestic violence and abuse more globally, rather than as a specific symptom to be treated is also significant.

The importance of ‘professional curiosity’ was explicitly identified in the case of Mrs A, but was equally relevant in other cases.

For example in the case of Mr C the review concluded professionals 'did not pick the signs of abuse or ask about it'.

Developing the confidence and competence of staff to ask the question is challenging, and the reviews recognised the importance of access to appropriate training to enable skills to have the confidence and skills to do this.

3.10

An addition factor in considering the skills required by the workforce is balancing a generic understanding of domestic violence and abuse with how the individual circumstances of a victim/survivor might impact on their level of risk, capacity to seek help or their visibility to services.

This includes Mrs A and Mr C (as older people), Ms D (as someone with a chaotic lifestyle, with a range of complex needs including mental health problems and alcohol misuse) and Mr C (as a gay man).

See also the discussion around ‘assessing and responding to risk’.

These lessons are addressed with the following recommendation:

Recommendation 4

Ensure that staff have the confidence and skills to be able to identify domestic violence and abuse.

Consistent care pathways

3.11

In addition to ensuring staff have access to training; they also need to be supported to make the appropriate response to a disclosure.

This could be by offering an appropriate intervention themselves or making an onward referral to other services (including specialist service).

In all 4 reviews, there were issues identified in relation to care pathways, where the panels raised questions about the response to a disclosure or concern within an appropriate time frame; if addresses differently, professionals may have been able to support the adult progressively through their experience and contact with that service.

3.12

Concerns related to care pathways also identified the importance of the recording of incidents and/or accurate documentation of contact.

For example, in 2 cases, specific issues were identified in relation to case management (Mr C and Ms D), whereby opportunities to respond to disclosure, or to provide a more support, were missed.

These are discussed further in relation to information sharing (with related recommendations 7 and 8 below).

3.13

While the development of consistent care pathways is a universal recommendation, specific actions were identified relating to provision of talking therapies (in particular in the context of clinical need such as depression or anxiety) and the South East Coast Ambulance Service (to continue a pilot that supported a response to disclosures, which was identified as good practice).

These lessons are addressed with the following recommendation:

Recommendation 5

Ensure that staff are able to deliver appropriate interventions as part of their routine practice and/or make onward referral to specialist services.

Assessing and responding to risk

3.14

In the case of Ms D, specific issues were identified in relation to risk management.

This included risk identification, as well as working practice between individual services and within the Multi-Agency Risk Assessment Conference (MARAC).

This included ensuring that actions at the MARAC need to be:

• SMART - Specific, Measurable, Achievable, Relevant, Timely
• relate to both the victim/survivor and the alleged perpetrator
• address the risks and needs of those involved, including others, like family members
• clear as to what is expected of individual agencies

3.15

It is of note that to ensure a consistent approach to risk identification, this would need to include the provision of appropriate training (with related recommendation 4 above) about how to use the standard tool, the CAADA-DASH risk identification checklist (RIC), and how to engage with multi-agency responses such as the MARAC.

The purpose of the RIC is to give a consistent and simple tool for practitioners who work with adult victims of domestic violence and abuse in order to help them identify those who are at high risk of harm.

This also includes the identification of risk to a child or children, and would trigger a referral to other safeguarding arrangements to ensure that a full assessment of their safety and welfare is made.

The tool identifies key risks and needs in relation to 6 areas:

• physical abuse
  • nature, range, severity and escalation
  • sexual abuse
  • use of threats, force or intimidation to obtain sex, deliberately inflicting pain during sex, or combining sex and violence and using weapons
• coercion, threats and intimidation
  • the fears of the victim/victims in relation to what the perpetrator/s may do; who they are frightened of, who they are frightened for
  • links to so-called honour based violence (HBV)
  • stalking, harassment and separation
• economic abuse
  • financial control
• emotional abuse and isolation
  • impact on victim in terms of minimisation, denial and blame
  • access to social networks
• children and pregnancy
  • presence of children (including step) can increase the risk
  • children can be caught up in the violence and abuse
  • physical violence can occur for the first time or get worse during pregnancy or for the first few years of the child's life
• the perpetrator may use the children, for example, contact

['CAADA Risk Identification Checklist (RIC) and Quick Start Guidance for Domestic Abuse, Stalking and ‘Honour’- Based Violence’, CAADA, 2012]

It also enables professionals to consider other factors using their professional judgement, including:

• impact on a victim’s vulnerability or risk, like:
  • age
  • disability
  • substance misuse
  • mental health
  • financial or social resources 
• barriers to victim engagement, like cultural/language barriers
• unique forms of abuse, like: 
  • harmful practices such as so-called honour based violence or forced marriage
  • identity abuse in Lesbian, Gay, Bi or Trans (LGBT) relationships

3.16

There is an established evidence base that has identified that the risk of experiencing domestic violence and abuse is increased in certain circumstances [‘Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively’ Public Health Guidance 50, National Institute for Health and Care Excellence, February 2014], specifically where an individual is:

• female (relevant to Mrs A, Mrs B and Ms D)
• aged 16 to 24 (women) or 16–19 (men) (relevant to Mrs A)
• has a long-term illness or disability – this almost doubles the risk (potentially relevant to Mrs A)
• mental health problem (relevant to Ms D)
• woman who is separated – there is an elevated risk of abuse around the time of separation (relevant to Mrs B)
• pregnant (although can offer protection) (not applicable in these reviews)

3.17

However, it is of note that Mr C was a gay man.

While there is a less well established evidence base in relation to LGBT people's experience of domestic violence and abuse, it is generally accepted that members of these communities experience domestic violence and abuse at a similar (if not higher) rate to the female heterosexual population.

This is likely to be a significant issue for Brighton & Hove, given the size of the local LGBT population.

3.18

In developing the use of the risk tool, the reviews also identified the importance of ensuring that this is embedded within consistent care pathways, so the use of such tools is part of routine practice (with related recommendation 5 above) and supported by a consistent information sharing process (with related recommendations 7 and 8 below).

These lessons are addressed with the following recommendation:

Recommendation 6

Ensure that risk management processes are fit for purpose.

Information sharing

3.19

In the cases of Mrs A, her contact with services was limited and the reviews did not identify any opportunities for improved information sharing between agencies.

3.20

In the cases of Mrs B, Mr C and Ms D, specific issues where identified at the point of contact with services following an incident that are relevant to the theme of information sharing:

Mrs B: the police did not consistently complete an accurate record of an incident (including what was known to staff at the time and the actions of staff).

Importantly, subsequent discrepancies were not resolved to ensure a full understanding of the situation and any further action required.

Critically, the panel noted that, had the situation been resolved it may have changed the assessment of risk (with related recommendation 6 above).

Mr C: the review identified a key practice episode where Mr C made a disclosure, but '...if professionals had recorded and shared key information so that Mr C was separated from Mr Y, fast tracked to medical help, and had the opportunity to make a safety plan and talk to someone about his options, it may be that he would have survived'.

Ms D: information sharing between agencies, in particular prior to and at the MARAC, was not complete, meaning 'the process as a whole failed to achieve the broader understanding that would have been required to coordinate a response to someone with so many needs as Ms D'.

3.21

This learning is not dissimilar to themes drawn from DHRs in Bedford Borough, Rochdale and Sheffield (2011), and Guilford (2013), which identified a range of issues relating to information sharing:

• timely risk assessment, including training and confidence in use of risk tools
• effective recording as a tool for communicating effectively
• making the connection
• timely information sharing
• acting on concerns

Recommendation 7

Ensure that there is a consistent information sharing process.

Recommendation 8

Provide guidance and training for health professionals on recording and sharing information, particularly in regard to domestic violence and abuse.

Coordinated community response

3.22

The range of needs and issues of the adults subject to the reviews demonstrate the importance of ensuring that there is a Coordinated Community Response (CCRM) to domestic violence and abuse.

This model acknowledges that, while each agency maintains its independence, all agencies involved must work in an integrated and coordinated way with each other to achieve:

• an increase in the safety of domestic violence survivors
• an increase in the safety of children who live with domestic violence
• holding abusers accountable for their actions
• effective prevention strategies
• a system where the onus of holding abusers accountable lies with service providers, and the wider community, rather than the survivor

3.23

All the reviews identified implications for commissioners in ensuring that services included appropriate provision in relation to domestic violence and abuse.

This included specific issues for commissioners in relation to practice (for example, in the case of Ms D), as well as considering how to develop or design service provision (all the cases made recommendations in relation to health responses to domestic violence and abuse, particularly around the implementation of provision to better support General Practitioners to identify and respond to domestic violence and abuse).

In addition, the approach to commissioning was most fully articulated in the case of Mr C, with made recommendations to ensure that when services are commissioned, their service level outcomes reflect the city wide VAWG outcomes.

'Brighton & Hove residents and communities to be free from VAWG crime types, by:

• increasing survivor safety
• holding perpetrators to account
• decreasing social tolerance and acceptance
• increasing people’s ability to have safe, equal, violence-free relationships'

3.24

Lastly, a CCRM requires services to have the capacity to engage in continuous quality improvement.

Outside of quality assurance and contact management arrangements, the process of a DHR or NMR is a critical way of ensuring that lessons are learnt.

The review process itself was a learning experience, as this group of DHRs and NMR were the Safe in the City Partnerships’ first experience of reviews since they were placed on a statutory footing.

As a result, the Partnership Community Safety Team developed its experience of managing these processes, and in particular, identified specific areas for development or improvement should a future review be conducted.

These lessons are addressed with the following recommendation:

Recommendation 9

Develop a consistent Domestic Homicide and Near Miss Review process across Sussex, including information sharing, in order to promote the sharing of learning and recommendations locally, regionally and nationally.

Recommendation 10

Ensure that commissioning as well as delivery of specialist services reflects issues identified from the review process.

Recommendation 11

The specifications for all services commissioned locally include provisions in relation to domestic violence and abuse, reflecting the City wide VAWG outcomes.

Recommendation 12

Implement the NICE guidance on domestic violence and abuse.

4.1

The Revised Statutory Guidance for the conduct of Domestic Homicide notes that the quality and accuracy of the review is likely to be significantly enhanced by family, friends and community involvement.

It sets out an expectation that review panels should therefore make every effort to include these parties.

4.2

Unfortunately, the Home Office report did not publish a detailed analysis of the 54 reviews, so it is not possible to compare the participation of family and friends in the local reviews to any national data.

4.3

In all of the reviews, a decision was made to involve the family.

In 3 of the 4 reviews, family members were involved. Contributions were made not only by parents (in 2 cases), but also by siblings (in 2 cases). In one case, a contribution was also made by the perpetrator (who was contacted after his conviction) and a member of his family

In 1 of the 4 reviews, family members (a sibling and a nephew) were identified through their contact with the Police Family Liaison Officers. Although invited to contribute, they did not respond.

4.4

In cases where participation by family members happened, it raised matters that were explored further in the review of the information provided by agencies and helped create a better picture of the adult and their experiences.

For example, questions put forward by the family members who participated helped to shape the questions that were considered as part of that review into whether support was effectively and appropriately offered.

4.5

In each review, attempts were made to explain the outcomes of the review to family members in advance of the publication of report and provided appropriate support during this part of the process.

In 2 of the 4 cases, this involved the review panel chair meeting with the family, as well as the offer of a named contact at the Partnership Community Safety Team who was able to provide support around any future issues.

In one further case, although there was no further meeting with contributors, there was further communication by letter, phone and email. Only one contributor did not respond to any attempts to contact.

For the family who chose not to participate in the review, one member of the family did subsequently ask to receive a copy of the report when he was contacted again prior to publication.

James Rowlands

Brighton & Hove Partnership Community Safety Team

VAWG Strategy Manager and Commissioner

September 2014