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How can we learn the lessons from Domestic Homicide Reviews?

Domestic Homicide Reviews (DHRs) and Serious Case Reviews (SCRs) frequently identify a lack of good information sharing amongst agencies, and frequently find that professionals have not identified different forms of risk within families.  Information sharing is about more than just passing on information; it’s about how agencies understand risk and collaborate to reduce it. In his blog, James Rowlands discusses how we can best utilise DHRs to prevent repeated mistakes.

James Rowlands is a Doctoral Researcher at Sussex University, where he is researching the part that Domestic Homicide Reviews (DHRs) play in the Coordinated Community Response. He is also an Independent Consultant, and in that capacity chairs DHRs. James originally trained as a Social Worker and an Independent Domestic Violence Advisor (IDVA). James set up the first advocacy service for gay, bisexual and heterosexual men in Wales (the Dyn Project) and he has 14 years of experience in the domestic abuse sector having worked in a range of frontline and strategic roles. Most recently, James was the Strategic Commissioner for Domestic and Sexual Violence for Brighton & Hove and East Sussex. He also serves on the Board of Respect, the United Kingdom’s membership organisation for work with domestic violence perpetrators, men and young people.  

A Domestic Homicide Review (DHR) is an important part of the coordinated community response, albeit after a tragedy. There are understandable criticisms of DHRs. Why do we invest so much money, time and energy into a case after someone has died? Why do they take so long? What actually changes as a result? These are all good questions, some of which I have wrestled with in other blogs. But perhaps put those questions aside for a moment. Consider instead what a DHR is trying to do. The promise of a DHR is to try and understand the experiences of a victim. In the words of the Statutory Guidance: to ‘articulate the life through the eyes of the victim (and their children)’. That includes talking with, and being guided by, the questions and concerns of family and friends. A DHR is also about learning lessons by considering how professionals and agencies individually or collectively worked together, as well as thinking more generally about responses to domestic abuse including what might help or hinder access to support. And lastly, a DHR should make meaningful recommendations. All this with the goal of bringing about meaningful change and trying to reduce the likelihood of future homicides.

But problems with information sharing are a recurring theme in DHRs. In a 2016 report by the Home Office, communication and information sharing were identified as an issue in 76% (25 out of 33) of the DHRs sampled. For anyone familiar with other kinds of reviews, including those relating to children and adults, that finding won’t be a surprise.

In my experience as a DHR chair, there are two common issues with information sharing. Sometimes information just isn’t shared. During a DHR in Bexley, which considered the death of Nargiza, we found that an agency considered making a Marac referral but for various reasons hadn’t. Consequently, when Nargiza’s case was later heard at a Marac, critical information was missing. It’s not possible to know if that additional information could have changed the ultimate outcome; but it’s fair to say that if it had been available the Marac would have had a starkly different understanding of Nargiza’s experiences, risks and needs.

Other times, information is known but isn’t acted upon. In a DHR in Lambeth, the victim (Sophia) was contacted by Children’s Services as a result of an allegation by her ex-partner. The complaint itself was likely an example of ‘abuse of process’. That wasn’t recognised, in part because Children’s Services took an incident-based approach. But it was also clear that Children’s Services didn’t draw on the information known to other agencies – including the police, a domestic abuse service and schools. That was significant because those other agencies had part of the bigger picture of Sophia’s experiences, as well as the behaviour of the perpetrator. The result was that the case was assessed as low risk and closed.

While these two cases were very different, they have something in common. In the first, information wasn’t shared. In the second, information wasn’t acted on in the way we might have expected. For both Nargiza and Sophia, it meant that their needs (and the risks they faced) were not understood and there were missed opportunities to intervene.

What frustrates me is we keep having the same conversation about information sharing.

Spin those two issues about information sharing on their head for a moment. What happens when a victim doesn’t share information? Or doesn’t act on in information the way we might have expected? All too often, they get blamed. I have seen that in some DHRs which focus on what a victim did or didn’t tell professionals, while others set out what services were offered and then explain that a victim ‘declined to engage’ or ‘didn’t take up support’.

That’s just not good enough. We are holding victims to one standard but often find ways to explain away the same scenario if a professional or an agency does it. Worse than that, even when we recognise that information sharing wasn’t good enough, the lesson doesn’t seem to be getting learned. 

Of course, it’s easy for me to write this. There are a whole range of other factors at play, from the role of services through to demand. But frankly, we shouldn’t be having this conversation time and time again. It extracts too great a toll on victims and their loved ones, including those who are murdered.

We need to stop victim blaming, reflect on our own practice, and be open to challenge – whether that comes from service users, other professionals or the families and loved ones of those who have been murdered.

So, what’s my closing thought? Well, ultimately DHRs are about trying to improve the response to domestic abuse and to prevent future homicides. It’s still too difficult to find published DHRs, although the government has committed to building a national repository in its response to the recent consultation on the Domestic Abuse Bill. In the meantime, look at your local or regional Community Safety Partnership website, read the Home Office report I mentioned earlier or check out Standing Together’s DHR Case Analysis

Ask yourself, which findings are relevant to me or my team or agency? How can I apply the learning, whether that’s in frontline practice or the commissioning of services? We shouldn’t have to keep learning the same lessons. Unfortunately, that’s not going to change overnight. But change it can. To get there – and in doing so, to honour those who have died, hold perpetrators accountable, and hopefully prevent future homicides – each of us needs to play our part in making sure the lessons really are learned.

Visit our Spotlight page for more blogs, podcasts, guidance and survivor stories over the coming weeks

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Children's social workers, domestic abuse and collaborative working

Vashti Wickers works as an independent consultant and trainer, providing improvement consultation and completing safeguarding auditing programmes for local authorities. Previously, Vashti spent 20 years practicing statutory social work, including working as Head of Service. Within this post Vashti held operational responsibility for the Multi Agency Safeguarding Hub as well as the frontline child protection teams.   

Vashti’s expertise in the field of domestic abuse stems from working within a Safer Community team – which included managing a team of Idvas as well as being the first team to be trained in and deliver the Recovery Toolkit programme for domestic abuse survivors. 

The facts 

Domestic abuse remains one of the most significant issues within statutory social work practice today. It features in over 50% of Serious Case Reviews and makes up a significant proportion of casework across all Children’s Services departments. 

Whilst recently undertaking a thematic audit looking at repeat child protection plans, I found that 64% were as a result of domestic abuse. 

Most social workers will agree that the overall approach is not effective for most families. As a profession we are passionate about getting this right, as the damage to the children and young people we work with is evident. 

Notwithstanding some pockets of excellent practice, there is more that needs to be done. 

Who knows? 

This is not only a matter of too little time and resource, although this clearly contributes to an ineffective response at times and frustrates progress with families. But just as critical is the lack of consistency in terms of knowledge provided to social workers to allow them to develop the attitude and approach that is required in responding to domestic abuse. 

In talking to newly qualified social workers and students, many report little or no input around domestic abuse at university. Social workers therefore may enter the profession understanding only the physical incident model, or simply that domestic abuse is harmful to children. 

Once in the statutory world, it is then somewhat of a lottery. Some local authorities offer a robust training package including coercive control, stalking and working with perpetrators. However others offer little or nothing. The availability and consistency of specialist agencies and programmes is also variable, meaning that access to expertise is not always there.  

Of course, there are social workers who have a vast amount of experience and knowledge – but the system should not be reliant on this alone. 

There should be a mandatory expectation for all child protection social workers to undertake domestic abuse training, and specifically coercive control. Without this, we cannot expect them to understand the complex dynamics, the lack of control a victim has, the inability to choose whether to stay or go, the pervasive fear, the interrelatedness of mental health and substance misuse and the reason why victims so often do not live up to the expectations placed on them. 

Instead, all too often we continue to see the non-abusive parent (still largely mothers) having to take full responsibility for protecting the children, a lack of focus on the perpetrator’s behaviour, and therefore the pattern of blame and shame continuing leading to a re-traumatisation of the victims through the system itself. 

There remains a focus by professionals on parents separating – ignoring the fact that 76% of women killed by their partners were killed in the first year following separation (Brennan, 2016). 

Social workers also need to understand the impact of coercive control on children, an area where research is growing. Emma Katz (2016 and 2019) tells us that children are active, not passive, participants in these dynamics – and that if we continue to focus on the harm caused via the physical model then we are likely to misunderstand levels of risk. 

Social workers must be curious about the individual situation. There will always be cases where the risk is severe and immediate and that necessitate the child to be removed for their own protection; but even in these circumstances the approach is critical to reduce potential re-traumatisation. 

Collaborate and participate 

The second issue is a lack of coordination and collaboration between agencies. 

Families require a group of experts to wrap around them, given the complexity of need here. There needs to be a collective understanding of risk (and consistent use of the Dash), a sharing of expertise, and an approach that is trauma-informed to give the optimum opportunity for the family to navigate their path to safety. 

Serious Case Reviews continue to identify misunderstandings, assumptions and blame between agencies in terms of who is working with whom, and what interventions are taking place.  

Professionals can provide the healthy support and challenge model to social workers, can be proactive in their engagement and participate in assessments and interventions. 

Social work is most effective when there is trauma-informed, relationship based work combined with collaborative practice. Nowhere is this more true than in cases of domestic abuse. Social workers need to get alongside the non-abusive parent, take the time to understand what has happened, listen and support them to increase their safety and regain control over their situation. All agencies need to see the situation through a trauma-informed lens, and use a strengths-based perspective to recognise the courage it takes to survive a coercive control relationship. 

What next? 

In conclusion I am reminded of Dr Gabor Mate as he describes the distinction between blame and responsibility. ‘Blame’ says that you did something that you could have done otherwise and so you are at fault. ‘Responsibility’ says that you did something, but not consciously or deliberately, but because you are programmed by your experiences. So therefore in becoming conscious of the reasons for our behaviours, we are able to take responsibility. 

It occurs to me that this applies equally to social workers. In the same way that we need to remove shame and blame when working with our children and their parents, let us remove the shame and the blame from social workers and instead properly equip them to be able to respond effectively to domestic abuse.

Brennan, D (2016) Femicide Census, profiles of women killed by men : redefining an isolated incident.

Katz, Emma (2016) Beyond the Physical Incident Model: How Children Living with Domestic Violence are Harmed By and Resist Regimes of Coercive Control.

Katz, Emma (2019) Coercive Control, Domestic Violence and a Five-Factor framework: five factors that influence closeness, distance and strain in mother-child relationships. Violence Against Women, online first.

Podcast:

How our childhood shapes every aspect of our health with Dr Gabor Mate.

#37 in series 'Feel Better Live More' with Dr Chatterjee. 21.11.2018.

 

Visit our Spotlight page for more blogs, podcasts, guidance and survivor stories over the coming weeks

Voices of experience: survivor reflections on Children's Social Care

Emma Retter is a Research Analyst at SafeLives, and previously worked as a lawyer in the family courts.

Survivor voice informs everything we do at SafeLives. In preparation for the new Domestic Abuse Bill, we created an online platform called Every Story Matters, so that as many people as possible could raise their voices and say in their own words what needs to change. Hundreds of people responded to that call in just a few weeks and, without being directly asked about it, many survivors recounted experiences of their interactions and involvement with Children’s Social Care. Alongside our Insights data, this blog will look at what survivors of domestic abuse who are also parents, have told us about how they’ve felt when Children’s Social Care have intervened with their family. 

First, to the data. Our 2017-2018 Insights national dataset[1] revealed that where there was abuse in the family home, 60% of these families were known to Children’s Social Services. Although this blog will focus on the 60%, it’s shocking to see that 40% of families are not on Social Services radar – and are therefore completely unknown and unsupported by Children’s Social Care.

Insights data from 2016-2017[2] showed that families known to Children’s Services were significantly more likely to have disclosed complex needs, including drug misuse (6% vs 2%), alcohol misuse (8% vs 3%) and/or mental health issues (36% vs 26%), compared to families with children who are not known to Children’s Services. This Insights dataset also suggests that families with Children’s Services involvement are more likely to be experiencing physical violence (71% vs 57%); one of the most visible forms of abuse.

In Every Story Matters, survivors told us they feel there is a lack of understanding of the more hidden abusive behaviours, such as coercive and controlling behaviour. Education and training on the complexities of domestic abuse, they felt, is the crucial change that is needed within Children’s Social Services and beyond. Survivors particularly felt that perpetrators used ‘tactics’ and ‘charming behaviour’ when social workers were involved and that these manipulative behaviours were not understood by Children’s Social Care. Here is an example of what one survivor feels needs to be done to better protect children where there is domestic abuse in the house:

Much better understanding and empathy through training from survivors for social workers and police as they are the initial point of contact when children are involved, I personally felt invaded and insulted by social services from the time they came on the scene…they had no understanding of the husband and his capabilities…’

The conflict between Social Services, Cafcass and the courts was also a common theme when survivors spoke about Children’s Social Care. Survivors found that Children’s Social Services had completely different views to that of the court and Cafcass and that they felt contradicted at every turn. When Social Services decided that there was to be no contact with the perpetrator, survivors would then be told by the courts that contact had to happen. Survivors found this confusing, worrying and dangerous for the children. One survivor wrote:

Yes. We had involvement from SS [Social Services]. Who said be a protective mother don't allow contact... So denied contact... Got ripped apart in court for being in contempt of court.... Police involved so there was bail conditions.... Got ripped apart in court for denying contact... Did police [or] SS [Social Services] back me up? No because they keep so out of it and seem to think family court will sort it.  These conflicts of same action creates gaps between services meaning my children remained unsafe and suffered further abuse…

Victim blaming by Children’s Social Services, alongside a fear of the children being removed from survivors’ care was another concern that was mentioned by more than one survivor. Survivors were frustrated that they were made to feel as though the abuse was their fault, with no responsibility being placed on the perpetrator. A strong fear of what Social Services would do if they found out about the domestic abuse was also expressed by survivors, from the stigma attached to having Social Services involved with the family to the removal of children from survivors’ care. One survivor, who was abused by their son, shared this story:

…I went to social services for help, and was blamed for their difficulties, to the point that the LA [local authority] took me and my husband to court to get a care order. We had asked for help with our sons' violence, destruction & aggression, been offered parenting courses, inappropriate therapy and plenty of ignorance. When the violence continued and support was refused, we had no choice other than to ask for our child to be accommodated by the LA, which triggered, not the help our child needed, but instead, Care Proceedings and our child returning to Care.

Survivors also told us that Children’s Social Care can and do make a difference to families. When Social Services provide survivors of domestic abuse and their children with the help and support they need, the experience of the intervention is dramatically different. A number of survivors told us that they chose to go to Social Services for help and one survivor wrote about how positive their experience with Children’s Social Care was, particularly the support their children received. When services work together, when there are domestic abuse advisors involved and when Children’s Social Care are supportive to the victim, the outcome for survivors and their children can be lifechanging as this final uplifting survivor story illustrates:

Although I still fear my ex I am so glad I left and went to court to fight for justice. I had so many worries about social services and how he would react if I reported him but none of it happened. Women's aid and rape crisis and my Isva have been my absolute lifelines. It's a long process but me and my son are moving forward with life and I am able to see a future free from abuse.

Hearing the voices of survivors and lifting up their experiences as individuals and as a collective voice is crucial to understanding how Children’s Social Care can really support survivors and their children. SafeLives will continue to listen to and share these voices to make sure survivors’ experiences influence everything we do to create a positive change. 

 

Visit our Spotlight page for more blogs, podcasts, guidance and survivor stories over the coming weeks

By emmar

Helping victims in Scotland become safer, sooner

Jen Douglas is our Scottish Engagement Lead. In this blog she talks about why it is so important to have the tools to make an accurate and fast assessment of the danger victims of domestic abuse face, so they can get the right help as quickly as possible. 

When someone is experiencing domestic abuse, it’s vital to make an accurate and fast assessment of the danger they're in, so they can get the right help as quickly as possible. Our Scottish Dash checklist is a tried and tested way to understand risk and is based on extensive evidence taken from homicide reviews, ‘near misses’ and lower level incidents.

Dash stands for domestic abuse, stalking and ‘honour’-based violence. What this tool does is provide a common language between organisations so that we can all assess risk in a more joined up, coherent way. The Dash cannot replace vital professional judgement or the need for training. It is guidance only.

The simple series of questions makes it easy to work out the risk someone is facing, and what they might need to become safe and well. A high score means the victim is at high risk of serious harm or murder and needs urgent help. These victims should get help from an Independent Domestic Abuse Advocate (Idaa), and all the relevant local agencies should come together at a multi-agency risk assessment conference (Marac) to make a plan to make them safe and well.  

We know from our Whole Lives dataset that it can take 4 years on average before victims of domestic abuse get the support they need to become safe and well. Any additional barriers, such as language, increase this time. At the point at which they accessed help, over half of victims said that the abuse was escalating in either in frequency, severity or both. Resources and evidence-based guidance like the Dash are essential in capturing the risk and reducing serious harm or fatality and have become embedded in the Scottish response to domestic abuse.

We believe every person living with domestic abuse needs to be supported to be safe, wherever they live, whoever they are. In order to do this, it is imperative that our risk checklist is accessible to as many survivors as possible and it is now available to Gaelic speakers and Gaelic speaking services. With approx. 57,000 speakers in Scotland this necessary tool will support in the management of risk and referral to local Marac provision.

In time for the introduction of the new Domestic Abuse Scotland (2018) Act we have updated and produced toolkits (including our Scottish Marac toolkit) to ensure that professionals are supported, and the scope of the new legislation is reflected within practice and our response to domestic abuse. It is only with a co-ordinated, systematic and evidenced approach that we will ensure the safety of survivors and their families; delivering the right support at the right time.

See our resources for professionals in Scotland 

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Challenging the stigma around mental ill-health in BME communities

Asha Iqbal is a mental health campaigner and founder of Generation Reform, an initiative that  aims to tackle head-on the stigma that Black and Ethnic minority communities face around the issue of mental health. Calling upon her own lived experience of coercive control and ‘honour’-based abuse, Asha has been featured in publications such as Women’s Health, where she’s spoken about her struggles with PTSD and anxiety. Find Asha on Twitter

Working in a mental health hospital as a call handler, I used to see patients from South Asian communities, whose families would rather pretend that their relative was abroad than in hospital, because they were so ashamed. There was a complete silence around mental health within these communities. Shame and stigma can really affect patient treatment; it can impact on their engagement and the speed of recovery. As an Asian woman, it was something that completely shocked me, and it inspired me to write a blog post regarding my mental health problems growing up.

The blog attracted 30-40,000 views within a few hours and I had hundreds of messages in response. I didn’t realise how much impact it would have. And that’s how Generation Reform started. Because of the interest that I got I thought there was a need for an open conversation. I was probably one of the first people from the South Asian community and with a Muslim background to talk openly and publicly about these issues.

I felt that different generations had different experiences of stigma, shame and barriers and that each generation needs different approaches to help them reform, that’s why I named it Generation Reform. I am not a professional in mental health, so I thought with my media and marketing background, the best way for me to tackle this issue was by creating an open conversation and using social media the way I knew how. I thought, let’s use my skills and try and tackle this issue.

There’s quite a lot of different issues associated with mental health for some communities. One would be reduced marriage prospects and the shame attached to that. Having mental health problems can reduce your chance of finding a suitor because some people believe that mental ill-health would be passed on to any children and so wouldn’t see you as marriageable. Of course in some communities, there is a danger of forced marriage and so being seen as unmarriageable is a risk factor.

Unfortunately, severe mental health problems can sometimes be associated with either black magic or the ‘Jinn’; supernatural and sometimes demonic beings. People brush severe mental health problems under the carpet so a lack of understanding and education about mental health creates further barriers.

I got told many times that the answer to my mental health issues would be through prayer and that this would cure it. Even when I was feeling suicidal that was the only response I got. As you can imagine this leaves a lot of people without the support and medical care they need.

Within South Asian communities, the older generation hold a lot of the power. The knowledge that they have on any topic will be the advice that’s given and usually what they say goes within the household. However, a lot of the older generation do not use social media so for me a way to reach younger generations and spread better knowledge and awareness of mental health was through social media.

Two years ago when I actually started campaigning I found it a struggle, because I couldn’t see mental health campaigners that I could relate to. None of them faced the same struggles with ‘honour’ abuse that I did. None of the public campaigners were from South Asian communities orfrom a Muslim background. That gap in representation is what inspired me to keep going.

That’s the feedback that I got from other young Asian people; that it was amazing for them to see someone from the community, not sensationalising anything but being quite open and honest about their own experience. 

A lot of people face mental health problems; one in four is the current figure. It needs to be normal conversation, it needs to be something that we tackle on a daily basis. It can’t be something that we’re surprised to be asked about.  My wish is for it to just be part of daily talk so that people aren’t afraid of reaching out for help. 

Even if you’re not experiencing mental ill health, you can help. It’s always great to have a discussion about mental health, to know what services are out there and to be non-judgemental. That’s one of the most important things; don’t be judgemental. Just listen but also do your own research, start your own conversations as well. That’s what helps break down the barriers and the stigmas.

 

For more information and support with forced marriage, mental ill health and ‘honour’ abuse please refer to the following organisations:

Mental health:

Mind

Young Minds

 

Forced marriage and ‘honour’ abuse

Karma Nivana

Forced marriage unit

 

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