Practice blog

Near miss reviews: finding out what we can do better

Lots of us are (sadly) familiar with domestic homicide reviews (DHRs). Completed in the aftermath of a domestic abuse death, DHRs look for lessons to help prevent a similar incident in future.

But why wait? SafeLives has spoken to a local authority which ran a “near miss review”, after a victim of domestic abuse attempted to end her life, resulting in serious injuries.

We’ve kept the area anonymous. But the findings and recommendations have lessons for us all, as we try to implement better ways of working to help victims become safe.

Background to the case

Alice*, the victim, was discussed four times at two Maracs – one in the local authority leading the near miss review, and one in a neighbouring local authority which later participated in the review process. Alice had a history of substance use and mental health issues. She was known to a number of services.

What the review found

Alice was in touch with Idva services in both areas. But neither area knew about her contact with the other.

Alice experienced repeated abuse, but these incidents were not always referred back to Marac – despite meeting the criteria. When a repeat referral was made, the previous action plan wasn’t systematically reviewed, so the same actions were put in place without checking if they’d been successful before.

It wasn’t always clear how an action would address the risks Alice faced, and the team didn’t have a set process for keeping track of them. And little or no information was shared by mental health and substance use services, despite Alice’s complex needs.

What happened as a result

The local authority which led the review, together with other local partners - including the neighbouring authority - made a range of recommendations to services and professionals.

The recommendations for the Marac were:

  • To identify whether victims and perpetrators have received help in the past, including through other Maracs and domestic abuse services
  • To review how repeat cases are heard
  • To review how complex cases are managed
  • To review the risk identification and action planning stage of the meeting so it’s clear what each action will achieve
  • To review the training, resources and support available to Marac partners to help them take part to the best of their ability

The review has helped to re-energise the area’s approach. They’re introducing new training and guidance for professionals who come into contact with victims. Specialist services are working hard to stop victims slipping through the gaps. And commissioners have set out clearer expectations for engaging with victims with complex needs. Plus, steps are now underway to create a new city-wide action plan for every victim. Once launched, this will allow local agencies to co-ordinate any safety measures put in place.

What can my Marac do?

The issues faced by the Marac in the case study are common. Think about how the findings from the review match with your Marac. Could you implement any of the recommendations in your area?

You can also:

  • Research new services to link into the Marac, including those specialising in complex needs, LGBT clients or B&ME communities
  • Make sure everyone who attends is aware of the Marac-to-Marac referral process, and that they remember to notify the Marac co-ordinator when a victim moves to a new area
  • Seek out areas for development with a regular audit. Our self-assessment programme helps you to explore every aspect of the Marac process, and identify any areas for improvement
  • Reflect on common themes and issues like complex needs, responding to perpetrators and young people. Hold a scrutiny panel to go over old cases - how could the Marac respond better in future?
  • Help prompt representatives during meetings by putting together a list of information and potential actions each agency can offer
  • Think about any strategic changes that could strengthen your Marac. For example - are representatives supported by their managers to take part?
  • Enrol in specialist training. SafeLives offers a range of training options, suitable for everyone involved in the Marac process.

Find out more

For more tools and resources to support your Marac, visit the Practice support section of the site.

And don’t forget to look out for recommendations from the latest national Marac scrutiny panel, focusing on complex needs, coming later in the spring.


Working with young people in abusive relationships - and how it's different to helping adults

Claire Amans is a young people's violence advisor, trained through the young people's programme. The programme, funded for two years by the Department for Education, has now come to an end. Here Claire reflects on her role.

When I started working as a young people’s violence advisor, I was surprised to see how many young people were victims of high-risk abuse. I’d worked in youth justice previously, so I knew that there would be some high-risk victims, but I didn’t realise how many.

Now I look back on the past year and think “Who was working with these young people before?”  They get so much out of the service that there’s clearly a need. I’ve worked with 16-17 year olds who had used an adult service before, in the absence of anything else. They’ve said that it was really helpful for them to have that, but they felt that it didn’t meet all of their needs.

Adult services are different, and rightly so – what they do is right for adults. But at 16-17 you are still a child in the eyes of the law, so you need support beyond what an adult service might have the resources to offer.

And that’s where I as a young people’s violence advisor come in. I can offer young people personalised support and be a single point of contact for all the problems they face.

In South Tyneside we do a lot of one-to-one work. We do the core safety planning and healthy relationship work, but we also look at the individual young person and their specific needs – like building their social network and their confidence. That includes becoming safe from the abuse itself, of course, but also issues such as housing, finance and education to name just a few.

Our engagement with young people has been fantastic and we’ve had contacts reaching into the late hundreds. Weekly sessions are offered to all young people and can sometimes last for 2-3 hours per session depending on the intervention offered.  What we offer is very intensive, but it’s necessary at times to help the young person holistically. Spending that much time with them can also mean they’re more likely to open up to you around personal issues such as sexual health or substance use.

There are times when a young person can feel overwhelmed due to their circumstances and the different agencies involved, and may need you to advocate for them to make sure their voice is heard. For example, one referral we received last week was for a 16 year old who was homeless because of domestic violence, so it wasn’t safe for her to return home. We couldn’t just signpost her to the housing team and leave it at that. She wasn’t sure of the process involved and felt overwhelmed. Having someone to advocate for her when she got emotional or wasn’t sure how to answer the question was important. We needed to help them understand why it wasn’t safe for her to go home. Bridging that gap for her meant that she was taken seriously and supported – and she now is in emergency accommodation.

When she first moved in, I took her shopping. I explained about budgeting and then took her back to her supported accommodation. She’d not had to do any household chores like that prior to becoming homeless – even putting food in the freezer was something she didn’t know about. With adults you might be able to rely on them to understand basic things like shopping, managing money and so on. But for many young people, on top of dealing with an abusive relationship, this may be their first experience of the real world and it can be a very worrying and overwhelming time for them.

She told me afterwards that she wouldn’t have been able to manage alone on her own – she wouldn’t have known where to go or what to say. Without intensive support, she wouldn’t have had the confidence to deal with the situation and would have remained at risk.

Now that this young person has safe and secure accommodation, we can focus on  safety planning and healthy relationship work to help this young person stay safe from abuse.

It just goes to show that, with young people, you need to do more than just signpost. You need to go on that journey with them. Young people should be able to expect the support of a dedicated worker. They deserve not to have to live in chaos. Having that central co-ordinator to not just help them be safe, but also to understand their needs and champion their cause, is vital. 

Our young people’s programme was created to find new ways to help young people who suffer abuse from the people they are close to. It began in May 2013 and has now come to an end. It was a partnership with Barnardo’s, IKWRO, Leap, and the Marie Collins Foundation and was funded by the Department for Education.


Dragon's Den: James Rowlands, Brighton & Hove and East Sussex

James Rowlands was one of the experts who pitched their ideas for getting it right first time for victims and families to our Dragon's Den at our conference in February - his pitch was voted the winner by the audience. Here he explains how his idea would work to keep victims and their families safe.

James Rowlands pitching his idea to stop domestic violence

Most services, regardless of their core activities, will come into contact with victims of domestic abuse or other forms of violence against women.  That might be abuse which is experienced by someone using their service, but it might also be abuse that’s being experienced (or perpetrated) by a member of staff. Services need to be able to respond to this effectively, so making domestic abuse everyone’s business is a chance to make sure we really do get it right first time.

My proposal is to build domestic abuse (and other forms of violence against women) into contracts when commissioning services, so that commissioners make identifying and responding to violence & abuse a core requirement. This is sometimes called ‘horizontal commissioning’ – it means writing in an expectation around the type of response commissioners want from services when they are preparing and agreeing contracts.

Obviously the type of response depends on what is being provided. At its simplest, it might mean ensuring that there is a workplace policy, so that the service is able to respond appropriately to a situation where someone is affected by abuse and knows where to refer for help and support. If you take the example of a contract for a refuse service, you wouldn’t want them (nor would they be able) to check for domestic abuse in every house that they collect rubbish from. But what you can ask them to do is to make sure they have a policy in place in case one of their employees makes a disclosure, so that they can make sure that person is safe in the workplace and knows where to access support.

For those services with more targeted or specialist contracts – say providing financial advice, housing or working with people with substance misuse issues - you could have a greater level of expectation. So for example, as well as a policy for staff, they might be required to make provision for staff training, undertake opportunistic enquiry and play a part in a local care pathway (‘Ask and Act’), as well as contribute to data collection.

In Brighton & Hove, we’ve been working on guidance to this approach, and are looking to pilot it in contracts for housing-related support and public health. This is an opportunity to ensure domestic abuse (and other forms of violence against women) are consistently identified as a priority by commissioners, enabling in turn best practice to be cascaded to services and frontline practice.  So now it’s about working to get this embedded in local contracts, evaluating the impact and then working to make sure we can contribute to a wider change in culture through this small, practical step. It doesn’t really cost commissioners anything to put these conditions in place, and the response from commissioners, colleagues in procurement and local specialist services has been really positive so far.

James Rowlands is strategic commissioner - domestic violence & sexual violence and violence against women and girls - for Brighton & Hove and East Sussex.

Dragon's Den: Det Supt Paul Goundry, Durham Constabulary

Detective Superintendent Paul Goundry is one of the domestic abuse experts who pitched their ideas for getting it right first time for victims and families at our annual conference. Here, he explains why it's so important to listen to the victim's voice. 

The police service in its work with the Home Office is intent on improving its response to domestic abuse by improving its consultation with victims. Currently, every force has its own way of learning about the victim's feelings but, in the main, we have shied away from contacting victims directly. This means that we do not understand what officers did well and what could have been done better to allow us to improve practice.

A national pilot taking place in spring/early summer 2015 will look at surveying victims by speaking directly with them. The question set is being developed with the assistance of third sector and academia and will allow forces to understand satisfaction levels and identify where improvements can be made.

If the pilot is a success, I expect all forces will adopt it.

Dragon’s Den: Becky Rogerson, My Sister’s Place

SafeLives domestic abuse conferenceAt our conference last week, we asked leaders from across the sector to pitch their ideas for getting it right first time for victims and families. Becky Rogerson from My Sister’s Place in Middlesbrough told us about how she would prioritise work with perpetrators.

Doing nothing is no longer an option. 

We have been dealing with domestic abuse since 1975 when first refuges were established. We have developed our understanding over the last 40 years around prevalence, manifestation and, importantly, about the impact of abuse. We have learned that the impact is even more harmful than first realised - for the direct victim, for children, for families, and for communities. With this knowledge, we have set to work to find ways to alleviate the symptoms – and we have some effective strategies with which to do this – from refuges to outreach support, counselling, Idvas, specialist courts, Maracs, Mashs and other hubs. These approaches, I would argue, ‘work’ in identifying those most at risk and reducing the harm. Statistically, however, these approaches are measured against the prevalence of domestic abuse. In effect, this is measuring victim services against the behaviour of perpetrators – a large heterogeneous group of individuals that we apply, what I call, a ‘sandbag approach’ to. It’s like having a major leak and stacking sandbags to re-direct the flow whilst we get on with clearing up the harm.

Nationally, what do we have in place for perpetrators? Some prevention work happens in schools about positive relationships but provision is patchy – then a yawning chasm until the 'perpetrator' appears on a police report or safeguarding referral. By this time, the problem may be entrenched and the response is expensive – police, CPS, courts, probation, victim services, 30 week programmes, safeguarding plans, multi-agency meetings, prison. And even where all these options are used, the data still shows high repeat rates.

So what needs to happen? We need a community-based prevention approach. If we are to hold perpetrators to account, we need to know which ones and how, as the prospect of all perpetrators heading toward the Criminal Justice System is not realistic.

We need an accessible, flexible and responsive perpetrator service that provides:

  • Initial assessment: that informs agency action
  • Information sharing to support Marac and safeguarding processes
  • Practical help and support to perpetrators that seek help and/or are at risk of escalation
  • Education: for example on the powers of the courts, and likely consequences of breaching protective orders or further incidents (the slope that takes some perpetrators unwittingly into the criminal process).

We now have a broad definition of domestic abuse that covers a wide range of behaviours and we need to think about education, enabling perpetrators to make informed choices at an early stage (rather than assuming they have already made a choice to be abusive). We need to make use of some the techniques we use to encourage victims to seek help and start to engage with perpetrators more effectively – perpetrators do not live on Mars – they are with us in our workplaces, in our families, and in our social circles. There are numerous opportunities to understand and influence the direction of travel. I believe we have a range of different perpetrators that could be thought about as on a ‘spectrum’ in terms of their behaviour and risk; an early opportunity to change, to reflect on their behaviour and make informed decisions about their future is a gap that needs filling. If this approach could change the course of only 10% of perpetrators, we could reduce the human cost of domestic abuse in thousands of families, save lives, and save millions of pounds to the public purse.