Disseminating learning from
Domestic Homicide Reviews
Serious Case Reviews
and
Safeguarding Adults Reviews
Joint Learning Event
© Copyright Wolverhampton City Council 2016. All Rights reserved
Welcome
Simon Hill
Independent Consultant and
Chair of Domestic Homicide Reviews
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
Key Messages
Linda Sanders Strategic Director - People
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
The Local Message
David Jamieson
West Midlands Police and Crime Commissioner
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
COLLECTIVE RESPONSIBILITIES
To Protect those who are most vulnerable in our society – children, young people and vulnerable adults
Which we discharge through
• Prevention – engaging communities through awareness raising, early intervention and culture change
• Protection – safeguarding those at risk and supporting those affected
• Justice – holding offenders to account and preventing reoffending
APPROACH
This will be achieved through Integrated Working to
transform our delivery of core public services
Governance of the programme is through the Chief
Officers Leadership Board as well as the PVVP Board
chaired by CEO Nick Page and ACC Carl Foulkes
Reporting through regional and partnership networks
as well as the West Midlands Public Services Reform
Board
WORKSTREAMS
There are 5 work-streams
• Child Sexual Exploitation
• Female Genital Mutilation
• Public Protection
• Sexual Violence
• Schools and Communities
CHILD SEXUAL EXPLOITATION - CSE
Implementation of Regional Framework published 2015
Consistent development of transparent data on risk and impact
Development of website and effective engagement with young people, parents and communities
FEMALE GENITAL MUTILATION - FGM
Following the West Midlands FGM report published last year this taskforce additionally reports to the West Midlands Police and Crime Panel
Regional Screening Tool
Establishing core elements of level 1 awareness training
Build understanding and data on prevalence of FGM
Develop Guidelines to protect girls born to mothers who have undergone FGM
Community engagement – map provision
PUBLIC PROTECTION
Development of consistent and coherent delivery of Multi-Agency Safeguarding Hubs
Implementation of Region-Wide Domestic Violence Standards
Development of Integrated regional DV practice
Identification of effective practice and development of evidence based perpetrator programmes
Tackling other specific forms of violence e.g. forced marriage and “honour” based crimes.
SEXUAL VIOLENCE
Multi-agency, holistic and seamless service to victims
and survivors
Development of concise regional standards for
tackling sexual violence
Development of regional provision for Independent
Sexual Violence Advisers
SCHOOLS AND COMMUNITIES
Develop appropriate regional mechanisms and tools to support
safeguarding work within schools and communities
Identify and develop best practice to promote a consistent approach to
the delivery of safeguarding and public protection work within schools
and communities
Streamlining communications to schools of PVVP and safeguarding
materials
Regional learning of Early Help Implementation
An Overview; Domestic Homicide Reviews
Serious Case Reviews Safeguarding Adults Reviews
Simon Hill
Independent Consultant and
Chair of Domestic Homicide Reviews
Multi Agency Joint Learning Event 2016
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
Case Study – Part One
Multi Agency Joint Learning Event 2016
The Bibi / Khan Family Family Tree Fozia Bibi
Salman Khan Samia Khan
Tamwar Khan Ayesha Khan
© Copyright Wolverhampton City Council 2016. All Rights reserved
Multi Agency Joint Learning Event 2016
Case Study Family Household Genogram
Grandmother 72yrs Fozia
Bibi
Son - 50yrs Salman Khan
First Wife - Sajida Khan
(deceased)
Second Wife
26yrs – Samia Khan
Ayesha Khan –3 yrs
daughter
Tamwar Khan - 11yrs son
Previously married Current wife
Son from previous marriage Daughter from current marriage
Samia’s Sister
Son - 52yrs Naseer Khan
Son - 40yrs Javid Khan
Sister Parveen 32yrs – Khan
© Copyright Wolverhampton City Council 2016. All Rights reserved
Case Study January to June 2014
Early evidence of domestic abuse
Issues around depression
Birth of Ayesha
Role of the Health Visitor
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Case Study 28/03/14 to 09/04/14
Fozia’s community group
Salman’s problems at work
A&E attendance
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Multi Agency Joint Learning Event 2016
Case Study April to May 2014
The Housing Office
Salman is arrested and threats to the family
Children’s Social Care Assessment
Referral to addiction services
Salman self medicates
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Case Study July to November 2014
The district nurse’s concerns for Fozia
Fozia’s needs assessment
The Health visitor reviews Ayesha
Repairs to the home
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Case Study December 2014
Domestic abuse or accident?
The GP visit
Samia at work
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Case Study January to March 2015
Tamwar’s school have concerns
The Early Help Assessment
The home/ school liaison worker’s lead role
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Case Study April to September 2015
Samia is pregnant and visits her GP
Early Help concerns for Ayesha
The maternity appointment
Police are called to the family home
Salman is taken to Naseer’s home
Tamwar moves school
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Case Study October to November 2015
Samia gives birth to a baby boy born two months premature
The Nursery have
significant concerns Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
Case Study December 2015
An Ambulance is called as the baby
struggling to breathe having apparently rolled off the sofa onto the rug.
At hospital baby was examined and a significant bleed to the brain was identified and bleeds found to the back of both eyes. The baby is on life support.
Ambulance notes described household as very clean on the ground floor. Upstairs bedrooms raised significant concern.
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
Any incident of threatening behaviour, violence or abuse
between adults who are or have been intimate partners or
family members, regardless of gender or sexuality. Includes
coercive control, controlling behaviour, female genital
mutilation, forced marriage, and honour based violence
(Home Office)
Domestic violence
Substance misuse
Intoxication by, or regular excessive consumption of
and/or dependence on – psychoactive substances,
leading to social, psychological, physical, or legal
problems. It includes problematic use of both legal and
illegal drugs including alcohol (NICE)
Includes a range of conditions including:
Depression and anxiety, psychotic illnesses such as bipolar
disorder and schizophrenia, and may also be associated
with alcohol or drug use, personality disorder, and
significant physical illness (Working Together)
Mental ill-health
Domestic violence
IMPERATIVE – Where one toxic trio ingredient is
identified, practitioners must proactively look for the
other two since: •Rarely exist alone (Working Together); studies show 3/5 children’s cases have 2
toxic trio ingredients; all 3 toxic trio ingredients are present in ¼ children’s cases
•Complex interaction between the 3 toxic trio ingredients – need to understand the
root cause
•Toxic trio are the most common issues in SCRs (OFSTED) and highly prevalent in
DHRs (Home Office)
© Copyright Wolverhampton City Council 2016. All Rights reserved
Think Family and Carer Issues
Sandra Ashton-Jones and
Lorraine Millard
TJoinLearning Event 2016
Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved
Multi Agency Joint Learning Event 2016
Think Family
Don’t see people in isolation, think of the wider
family networks
Make the links with the people directly involved with
the individual e.g family members, carers,
professionals
Don’t make assumptions- check out each family
member’s circumstances
© Copyright Wolverhampton City Council 2016. All Rights reserved
Carer Issues
Carers’ Assessments must be offered to all informal
carers who are involved in providing support to an
individual.
The insights and information available from families,
carers and informal networks must be central to care
planning processes and risk assessment.
Need for realism as to the level of care that can be
offered
© Copyright Wolverhampton City Council 2016. All Rights reserved
36 © SafeLives 2015
DHR/SCR/SAR Learning Event
Wolverhampton
Information Sharing & Risk 3rd March 2016
Dawn Williams
& Judith Vickress
37 © SafeLives 2015
Risk identification is…..
… the process of looking at what the possible
outcomes might be from any identified hazard or threat, using a combination of known information
and informed judgment. (Regan et al 2007)
CAADA Risk Training
38 © SafeLives 2015
38
39 © SafeLives 2015
Risk Assessment
40 © SafeLives 2015
Methods to identify risk
Visible Risk
predicting from knowledge.
based on risk factors. uses a tool and evidence based approach. informs professional judgement.
Professional Judgement uses knowledge & professional experience. can be based on victims perception. utilises observation and assessment.
Escalation in severity and frequency
41 © SafeLives 2015
Professional judgement points:
• Is the person minimising?
• How frightened are they?
• Sadistic forms of abuse?
• Abuse not captured by RIC?
• Is diversity impacting on disclosure?
• Escalation?
• Lack of resources and wider needs?
• What is my gut feeling?
42 © SafeLives 2015
5 Steps to a Professional Judgment
43 © SafeLives 2015
CAADA MARAC Chairs Workshop
At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety. A victim identified at high risk of serous harm or homicide needs a coordinated, multi-agency response with all agencies sharing relevant information to develop an action plan that is comprehensive, robust and addresses the risk to all parties.
The Primary focus of MARAC
44 © SafeLives 2015
Safety Planning
• Collaborative process
• Identifying and increasing harm reduction
• Empower individuals
• Increasing resilience
• Identifying sources of support (professional and
personal)
• Evidence your actions
• Prepares victim for ‘worse case’ scenarios - DA
45 © SafeLives 2015
Marac – positive outcomes for victims
65%
21%
14%
65% of victims experienced a
reduction in police call outs. 45%
had a total cessation of police call
outs, 20% reduced from an
average of 6 callouts before the
MARAC to 2 after 21% of victims experienced no
change in the number of police call
outs. 10% had none before or after
the MARAC, 11% had an average
of 2 before and 2 after
14% of victims experienced an
increase in the number of police
call outs. 4% went from none
before the MARAC to 1 afterwards,
10% had an average of 3 before
and 6 after
46 © SafeLives 2015
A place of greater safety Key findings: outcomes of the high risk approach
63% of adult high risk
victims report a cessation of
abuse following support from
an Idva
69% of victims report that
their quality of life has
improved
The more intensive the
support, the better the victim
outcomes
47 © SafeLives 2015
No 61%
Yes 33%
Missing 6%
Yes 59%
No 41%
Mental health problems Specialist service
involved at intake
No 89%
Yes 6%
Missing 5%
Yes 51%
No 49%
Drugs misuse Specialist service
involved at intake
No 85%
Yes 10%
Missing 5%
Yes 45%
No 55%
Alcohol misuse Specialist service
involved at intake
Pressure on the system
• 31% of Maracs have caseloads above
the recommended 40 per 10,000 adult
females
• 20 Maracs are currently operating at ‘high
volume’ levels
• ‘High volume’ = either 50+ cases per
10,000 adult females or more than 520
cases per year
48 © SafeLives 2015
- Social Care
- Police
- DV specialist (Idva)
- Substance Misuse specialist
- Mental Health specialist
Family &
friends
Statutory
Agencies
Voluntary
Agencies
Local Assessment Framework - a Common Understanding of Assessment such as BRAG Assessment*
MAPPA
Marac
Any safeguarding concern One Front Door
Blue
Low or
No Risk
Red
High
Risk
Amber
Medium
Risk
Green
Standard
Risk
Safeguarding
Self -
referrals
* Highest risk takes precedence
Identification
Assessment
Action
Fluid assessment linking children and adults simultaneously at the earliest opportunity
With consent
Advice and
Information
With or without consent
Multi Agency /
Strategy meeting
Social Care
Substance
misuse
Police
Probation
Housing
Mental health Health
DV
Specialist
(Idva)
Without consent
Statutory or
Voluntary
Agencies
Troubled
Families
49 © SafeLives 2015
How we can move forward
Improve links between
safeguarding forums
Induct and train participants so they
continue working together
Hard-to-reach groups
0.9% of cases heard
involve LGBT victims
1.8% involve 16-17 year
olds
3.6% involve a victim with
a disability
Understand why there is
high volume in order to
reduce it
50 © SafeLives 2015
45% alcohol misuse
41% drug abuse
32% mental health problems
Ensure visibility of perpetrators – which
services might they use?
Targeted enquiry in
universal services
% 0.05…
½ Pay attention to the data!
How we can move forward (2)
Closing Remarks
Multi Agency Joint Learning Event 2016
Alan Coe Chair of Adults and Children's
Safeguarding Board
© Copyright Wolverhampton City Council 2016. All Rights reserved