Recurring concern

Failure to reliably recognise and assess domestic abuse risks

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First reported 30 Oct 2013•Latest report 19 Sep 2025

Definition

What this concern includes

Includes failures in domestic-abuse policies, flowcharts and operational risk-assessment arrangements to identify, understand or assess material abuse risks and risk factors, including non-fatal strangulation, cultural risk, coercive control and other indicators, where the deficiency affects safeguarding or protective action.

Not included

Excludes the existing DASH-specific risk-assessment process when the assertion is confined to DASH forms, training or operation.
Excludes general domestic-abuse investigation, victim support or protective-order failures where risk recognition or assessment is not the unsafe condition.
Excludes generic police or healthcare training, communication or information-sharing deficiencies without a direct domestic-abuse risk-assessment connection.
Excludes isolated domestic-abuse incidents or outcomes where no continuing deficiency in risk recognition or assessment is asserted.

Reports: 12
Individual concerns: 17
Date range: 2013–2025
Stated actions: 30

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office4

Ministry of Justice3

National Police Chiefs’ Council3

Department of Health and Social Care2

Greater Manchester Police2

College of Policing1

Crown Prosecution Service1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

HM Prison and Probation Service1

Independent Office for Police Conduct1

Lancashire Constabulary1

Metropolitan Police Service1

Midlands Partnership University NHS Foundation Trust1

National Offender Management Service Equality, Rights and Decency Group1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Dec2013
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Recirculate the Adult Safeguarding Policy and Thresholds to all Telford and Wrekin GP practices.
  Stated by NHS Telford and Wrekin Clinical Commissioning GroupStated completed
2. Action
  Distribute domestic abuse leaflets and guidance to all Telford and Wrekin GP practices.
  Stated by NHS Telford and Wrekin Clinical Commissioning GroupStated completed
3. Action
  Fund and deliver a multi-agency safeguarding and domestic abuse education event for Telford and Wrekin GPs and practice nurses.
  Stated by NHS Telford and Wrekin Clinical Commissioning GroupStated planned
1. Action
  Provide all operational staff with a reminder to complete DASH, crime reports and vulnerable adult documentation.
  Stated by West Mercia PoliceStated planned
Respondent positions 2
1. Position
  Existing DASH training, policies, procedures and auditing are considered sufficient for domestic violence responses.
  Stated by West Mercia PoliceExisting arrangements considered sufficient
1. Position
  Recognising vulnerable adults is considered sufficient to trigger referral for specialised assistance, without individualised dementia training.
  Stated by West Mercia PoliceExisting arrangements considered sufficient
AI-generated summary

Christine Ann WILLIAMSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Christine Ann Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence
Wider context from the report
“(1) A referral and assessment should have been made that the deceased was a Vulnerable Adult at risk from her husband. Such a referral and assessment could have been made before or after April 2012, but most notably on or around the 2nd - 4th April 2012 when the deceased’s GP made a direct referral to social services. This should have led to an assessment as a Vulnerable Adult but if not as the victim of domestic violence. ”
Source location
Christine Ann WILLIAMSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recirculate the Adult Safeguarding Policy and Thresholds to all Telford and Wrekin GP practices.

Verbatim wording from the response
“1) The Adult Safeguarding Policy and Thresholds has been recirculated to all GP Practices in Telford & Wrekin to raise awareness of this guidance.”

Source location
2013-0371-Response-by-Telford-Wrekin-Clinical-Commissioning-Group
Page 1 · response
Published 18 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Distribute domestic abuse leaflets and guidance to all Telford and Wrekin GP practices.

Verbatim wording from the response
“2) Domestic abuse leaflets and guidance has been circulated to all GP Practices.”

Source location
2013-0371-Response-by-Telford-Wrekin-Clinical-Commissioning-Group
Page 1 · response
Published 18 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Fund and deliver a multi-agency safeguarding and domestic abuse education event for Telford and Wrekin GPs and practice nurses.

Verbatim wording from the response
“3) An education and training event for all Telford & Wrekin GPs and Practice Nurses will be funded and delivered with a focus on safeguarding requirements and domestic abuse. I have written to all GPs to request full attendance as far as possible. This event is part of the CCG’s Protected Learning Time Programme and will be delivered on 14th May.”

Source location
2013-0371-Response-by-Telford-Wrekin-Clinical-Commissioning-Group
Page 2 · response
Published 18 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide all operational staff with a reminder to complete DASH, crime reports and vulnerable adult documentation.

Verbatim wording from the response
“Response: This recommendation is not relevant to West Mercia Police as all operational staff are trained in the DASH risk assessment process. There are policies and procedures in place to guide staff and the DASH risk assessment process is regularly audited by the Business Assurance”

Source location
2013-0371-Response-by-West-Mercia-Police
Page 3 · response
Published 18 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing DASH training, policies, procedures and auditing are considered sufficient for domestic violence responses.

Verbatim wording from the response
“Recommendation 6 – Domestic Violence All agencies must ensure that there are improvements in service responses for all domestic violence victims (both adults and children), all relevant staff to attend multi-agency training programme based on the DASH model.”

Source location
2013-0371-Response-by-West-Mercia-Police
Page 3 · response
Published 18 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recognising vulnerable adults is considered sufficient to trigger referral for specialised assistance, without individualised dementia training.

Verbatim wording from the response
“Recommendation 7 – Support Services All agencies need to review their service responses to people who suffer from Alzheimer’s and other Dementia Diseases and their Carers. This should be done in partnership with groups such as the Alzheimer’s Society who have significant knowledge and understanding of the issues.”

Source location
2013-0371-Response-by-West-Mercia-Police
Page 4 · response
Published 18 December 2013
Open published response
30 Oct2013
Liverpool
Concerns raised1
1. Failure to identify domestic abuse risk factors during prison reception and risk assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Damion Anthony Andre Martin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify domestic abuse risk factors during prison reception and risk assessment
Wider context from the report
“During the initial prison reception and risk assessment, the domestic nature of Mr Martin’s alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified, notwithstanding it was considered to be a known suicidal risk factor. ”
Source location
Damion Anthony Andre Martin · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to identify domestic abuse risk factors during prison reception and risk assessment

Actions described in response 4

Respondent positions 2