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Recommendations from DHR 005

Overview recommendations

Recommendation number 1

The Department of Health to review the national ambulance response to dispatch codes with the view to trigger words which may be used to escalate the call to provide a more timely response.

Recommendation number 2

All agencies to provide assurances to the CSP that professional curiosity is included in their safeguarding training to staff.

IMR recommendations

East Midlands Ambulance Service

  1. A level 2 safeguarding book containing information on DVA has been provided to all staff. During 2017-2018 all staff will be required to complete an eLearning package and assessment around safeguarding and DVA. A training needs analysis will be taken from this eLearning package along with learning from this domestic homicide review and used in the education during 2018-2019.
  2. EMAS will take the multi-agency learning from the final review and ensure that it is implemented as part of EMAS continuing engagement with the safeguarding agenda’.

Northamptonshire Police

  1. The Northamptonshire Police Domestic Abuse procedures are to be regularly reviewed and updated to ensure that they remain fit for purpose.
  2. Northamptonshire Police should continue to regularly update officers and refresh training packages in relation to domestic abuse and vulnerable adults to ensure they are current and fit for purpose.
  3. Northamptonshire Police should remind officers of their responsibilities in maintaining contact with the victims of domestic abuse especially following referrals to the Sunflower Centre.
  4. In the main police officers and staff who had contact with ‘A’ followed the correct procedures and took the appropriate action, but officers should be reminded of the importance of completing a DASH risk assessment even if the victim refuses to cooperate.
  5. Northamptonshire Police should remind supervisory officer and staff of the importance of their role in domestic abuse investigations.

Health - CCG, NHFT, and KGH

CCG

  1. Practices should utilise the IT system tools available to them to support safeguarding by sharing information by a readily accessible route.
  2. Adults identified as being at risk of harm should be considered for discussion in practice multi-disciplinary team meetings.
  3. Accurate coding of each reproductive event will ensure any developing risk is identified in a timely manner and appropriate action taken to safeguard.

KGH

  1. Review of the TOP service guidance to ensure that this is followed with regard to due consideration of cumulative history for TOP requests, that Practitioners have awareness of how to ask questions around potential domestic and other abuse, that Practitioners are aware of and know how to refer to other support services where appropriate. This would give assurance and confirm positive practice regarding potential identification of cases of abuse and onward appropriate referral to other agencies and services. If any actions are identified within the TOP pathway, then these will be addressed via an action plan.
  2. Develop further examples of utilising known personal, medical and social history to explore current situation taking account of potential abuse or risks considerations. To deliver this within training. This would enhance existing training and highlight lessons learned from this and previous review findings with regard to exploring and considering cumulative and past history in relation to current hospital attendance. This may enable practitioners to offer further referral or actions regarding DA to victims.
  3. Re-enforce the need for professional curiosity within training, taking account of previous lessons learned and using local examples. This would give confidence to Practitioners regarding asking questions around DA and enable a dialogue with potential victims to take place leading to appropriate signposting where disclosure occurs.
  4. Re-enforce the need to consider making referrals to Adult Social Services.

Orbit

  1. Keyways should be encouraged to forward the original application to all third parties on every nomination or at least use the description that an applicant completes on Keyways for the nomination form.
  2. Orbit should ask all applicants whether they have ever suffered or are currently suffering from domestic violence as a matter of course.
  3. Orbit to remind practitioners of the need to consider making referrals to Adult Social Services.

MARAC

  1. Review mental health attendance at MARAC.
  2. MARAC to encourage Safeguarding adult’s attendance at MARAC.
  3. MARAC steering group and individual Chairs to work with BenchCRC and National Probation Service to try and ensure consistent attendance at an appropriate level.
  4. MARAC steering group to work with the core agencies to ensure that they actively volunteer actions to aid the risk management plan.
  5. MARAC steering group to work with chairs to organise chair’s training.
  6. Increase case audit process to ensure compliance.
  7. To remind staff of the need to consider making referrals to Adult Social Service.

Children’s Social Care

  1. All parents under the age of 18 years to be considered as a child in their own right when referrals are considered about them and their unborn children.
  2. Strategy discussions should be timely and quorate with other professional views recorded.

Last updated 19 November 2025