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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.

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