Outline
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
Statutory context
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
Purpose
- 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
National learning
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
Local learning
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.
Reviews
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
Mrs A - Overview
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.
Mrs A - Lessons learnt
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”.
Mrs B - Overview
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.
Mrs B - Lessons learnt
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”.
Mr C - Overview
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.
Mr C - Lessons learnt
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”.
Ms D - Overview
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.
Ms D - Lessons learnt
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”.
Key themes
The key themes are:
- awareness raising and communication
- skilled workforce
- consistent care pathways
- assessing and responding to risk
- information sharing
- coordinated community response
Further information
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
Local services – women and LGBTQI people
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.
Other local services
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.
National services
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.