Learning from domestic homicide and near miss reviews - implications for practice

This document has the following sections:

• welcome and introductions
• introduction to the Domestic Homicide Review process
• overview of key learning nationally
• consideration of local reviews and lessons learnt
• reflections on practice
• questions
• feedback forms and close

Implemented through section 9 of the Domestic Violence, Crime and Victims Act 2004.

Following a homicide, local authorities should conduct a ‘Domestic Homicide Review’ (DHR) into what happened.

In some circumstances, local authorities may decided to conduct a ‘Near Miss Review’ (NMR):

• into those cases that did not result in a homicide but are of particular concern, e.g. because of a life changing incident and/or extensive contact with local services
• not a statutory requirement
• in Brighton & Hove the Safe in the City Partnership is responsible for commissioning reviews

• identify what lessons can be learned about the way in which local professionals and organisations work individually and together to safeguard victims
• identify how these lessons will be acted on, and what is expected to change as a result
• apply these lessons to service responses including changes to policies and procedures as appropriate
• prevent domestic violence and abuse homicide and improve service responses through improved intra and inter-agency working

Home Office published ‘lessons learnt’ based on 54 DHRs which had been received between 13 April 2011 and 31 March 2013.

Key themes included:

• risk assessment
• information sharing & multi agency working
• complex needs
• perpetrators and bail
• awareness of safeguarding needs of children

Brighton & Hove Partnership Community Safety Team has prepared a ‘Summary of Learning in Brighton & Hove 2012 & 2013’.

Based on three DHRs (Mrs A, Mrs B and Mr C) and one NMR (Ms D).

Aim is to identify key learning for:

• professionals - in order to inform practice
• policy makers and commissioners - to inform the shape of services locally

Supported by a single combined action plan, to ensure services are improved.

Mrs A:

• 70 to 74 years old
• White British female
• heterosexual
• retired
• married
• living together

Mrs B:

• 20 to 24 years old
• White British female
• heterosexual
• employed
• married
• seperated

Mr C:

• 60 to 64 years old
• White British male
• gay
• not in employment
• significant relationship
• co-habiting

Ms D:

• 40 to 44 years old
• White British female
• heterosexual
• not in employment
• significant relationship
• periods of living together

Unlawful killing of Mrs A by her husband in 2012.

No specific weaknesses or errors identified.

Limited information about Mrs and Mr A:

• there was an absence of information from Mrs A herself
• unable to rule in or out the presence of DVA

Questions relating to contact with services, Mr A’s as a ‘carer’, interagency work, social isolation, vulnerability and capacity
Identified the broader learning relating to older women.

The lessons learnt are:

• access to information about support services
• challenge of working with individuals where help is not sought, particularly where there is no other information at the time that might have lead to a safeguarding referral or concern
• the importance of timely discharge notifications
• better understanding of the issues for older women, including barriers to disclosure and service responses
• the importance of professional curiosity

“In their contact, albeit limited, with a range of professionals, no one had any sense of Mr and Mrs A as real people. For example, no one was aware of their likes, history or interests or a broader context to their engagement with services”.

Unlawful killing of Mrs B by her husband in 2013.

No specific weaknesses or errors identified.

Neither Mrs B or Mr B (the perpetrator) was well known to services:

• engagement with statutory services was limited
• no contact with any DVA services

Mr B had sought psychological support in the past, (possible) prior abuse by Mr B.

The lessons learnt are:

• accurate record keeping, including response
• how information on psychological interventions is made available to members of the public
• availability of clear, accessible information
• clear referral pathways to ensure that help and support are available - in particular, from health
• importance of wider societal awareness and understanding of domestic abuse, inc. employers and support for family & friends

“This illustrates the complexity of identifying relatively minor situations that may occur often, but have the possibility of becoming, or indicating, something more serious”.

Unlawful killing of Mr C by Mr Y in 2012.

Assaulted at least over a period of months and probably years. He was physically, emotionally and financially abused.

Mr C had a history of alcohol use and was isolated.

Many health professionals saw Mr C in the last year of his life did not pick up the signs of abuse or ask about it.

When Mr C did disclose, professionals did not respond pro-actively. This was a key practice episode: a different response may have changed the outcome. 

The lessons learnt are:

• Mr C’s reluctance to talk about the abuse limited the opportunities to help
• being an older gay man may have made it difficult for Mr C to seek professionals to identify domestic abuse
• professionals did their specific job, but without an understanding of their role in the coordinated response and of health to include safety
• this included responding to disclosure, risk identification and subsequent information sharing

“They [health professionals] responded with a narrow set of options or discounted what he said and did not take pro-active steps to help him. They addressed his immediate health needs but did not prioritise his safety”.

Complex and chaotic lifestyle:

• a range of needs including mental health problems, alcohol misuse and other health problems

Agencies struggled to retain Ms D in services:

• like many other victim/survivors of DVA, she would resort to a number of strategies to minimize the difficulties she was facing

Agencies had an ‘event’ based approach.

Multi-Agency Risk Assessment Conferences (MARACs), did not construct sufficiently robust action plans.

The lessons learnt are:

• range of lessons were identified, with these relating to the response to complex cases by a range of services locally, with regard to risk assessment, information sharing and case management
• a key lesson was that services were - unconnected in many ways, no agency or professional took the initiative to step up and provide a central role in overseeing the care that Ms D needed

“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”.

The key themes are:

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

Go to http://www.safeinthecity.info/domestic-homicidereviews to access:

• a more detailed report ‘Domestic Homicide Reviews and Near Miss Reviews: Summary of Learning in Brighton & Hove 2012 & 2013'
• the individual, published review for each case

Rise

Crisis and ongoing support for women and LGBTQI people.

They provide the following services:

• helpline
• refuge
• advocacy
• counselling
• housing
• legal and financial help
• support for children and young people

Contact Rise via the website or phone 01273 622 822.

Survivors’ Network & Independent Sexual Violence

Advisory service (ISVA), help and support for survivors (women and men) of sexual violence, rape and childhood sexual abuse.

Contact Survivors network via the website or phone 01273 203 380.

Victim Support

Emotional and practical help and support for heterosexual men.

Contact Victim Support via the website or phone 0845 38 99 528.

Mankind

Support for men who have been sexually abused.

Contact Mankind via the website or phone 01273 911 680.

Domestic Abuse Surgery

A private, safe space to talk through concerns & find out more about the options available locally. Every Wednesday morning between 9am and 12 noon at the Customer Service Centre at Hove Town Hall.

Sussex Police

Safeguarding Investigation Unit: Ring 101 and ask to be put through to the unit. In an emergency ring 999.

The Saturn Centre (SARC) – Crawley

Services to women and men who have who has been raped or sexually assaulted.

Contact The Saturn Centre via the website or phone 01293 600 469, 9am to 5pm. 

24hr National Domestic Violence Helpline

Phone 0808 200 0247

National Stalking Helpline

Phone 0808 802 0300

Men's Advice Line

For male victims, phone 0808 801 0327

Respect Phone Line

For anyone concerned about their violence and/or abuse towards a partner or ex-partner, phone 0808 802 4040.

Broken Rainbow Domestic Violence Helpline

For LGBT victims, phone 0300 999 5428

Further information on these services and other help and support is also available from the Safe in the City website at http://www.safeinthecity.info/getting-help.