Issue 54 nobody learns anything

On 11th August 2024 Jess Philips, new Home Office Minister made the following comment in the Times,?“nobody learns anything” from Domestic Homicide Reviews. She questioned whether ?it would be more fruitful to learn lessons from cases where domestic deaths had been avoided.

There are 2 separate questions here for Domestic Homicide Reviews.

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1.Should the Criteria for a DHR be changed?

Current Home Office guidance is clear as to when a Domestic Homicide Review should be undertaken.??Domestic Homicide Reviews were legislated for in section 9(4) of the?Domestic Violence, Crime and Victims Act 2004?(DVCVA). A?Domestic Homicide Review (DHR) is a review of the circumstances in which the death of a person?aged 16 or over has, or appears to have, resulted from domestic abuse and instances where a victim has died by suicide.?New draft guidance has been published and there will be?a new section in the DVCVA providing for Domestic Abuse Related Death Reviews to replace Domestic Homicide Reviews. We know the new guidance will include:

• guidance and information for reviews that cover where a victim has died by suicide, neglect or in unexplained circumstances;
• introduce of a new ‘Scoping Review’ process to ensure all potential DHRs are progressed;

The guidance suggests the rationale / ‘the why’ for these reviews include:

• deaths are often hidden from view.
• they offer an opportunity for national and local agencies, local communities, and society as a whole to pay attention to each individual victim and to treat every death as preventable.

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These are important ideals. They are close to my heart. However, we should always ask whether there are other ways to raise the visibility of these deaths.?Are there other ways to nurture a culture of every death like this being treatable??If there are we should consider these, as reviews are resource intensive. This would free us up to use different & more useful approaches to the criteria for a review.

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In my opinion, if we were to follow the suggestion advanced by Jess Philips, ie to review the cases in which a death was prevented, we risk

[1] finding whether we have prevented a death or not very difficult to define

[2] opening the floodgates & overwhelming the system with reviews & recommendations

[3] missing important messages contained in poor & average outcome cases

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2.Should reviews learn from what went well?

We can choose to learn from what went well now without any change to the criteria for a review.?It’s the review methodology & the individual reviewer’s approach that determines whether a deficit focus or a solutions focus is applied to each set of circumstances.?

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I want to address separately why we seem to be learning the same old lessons. Contextual factors are not considered and how a lack of funding contributed to the situation should be part of the analysis. Do you want to learn to do this really well??

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On 4th September?I am delivering a FREE workshop called,'How to Establish an Independent Review Practice which Aligns With the Next Steps in?Your Career v2.0'. It’s a version 2.0, with new content based on comments & suggestion from those who attended last time. Have?a look at the details and use the link to save your seat.?

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Donna Ohdedar, CEO Review Consulting Ltd

Donna has 16 years public sector experience, including her last role as Head of Law for a leading metropolitan authority. Now a safeguarding adviser & trainer, Donna is involved in serious case reviews in both children’s and adults’ safeguarding, domestic homicide, and is a SILP Reviewer and Mentor. Donna offers ‘SILP School’ her university accredited training course, CPD for reviewers & a free online network for leaders in review practice. Click here to join. Click here to hear the latest episode of the Safeguarding & Domestic Abuse Sector podcast.

www.reviewconsulting.co.uk

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