This brief is based on the findings from a Joint Strategic Review (JSR) undertaken by Safer Leeds, Leeds Safeguarding Adult Board & Leeds Safeguarding Children Partnership. It was conducted based on the prescribed methodology for a Domestic Homicide Review (DHR) though with additionality to inform the learning.  The purpose of a DHR is to learn lessons and improve future responses to domestic violence and abuse.

What happened?

Jake (not his real name) was an 18-year-old White British male and the persons found guilty of his manslaughter were his mother and grandmother, sentenced to 4 years and 3 years imprisonment, respectively. His elder sister was convicted of allowing the death of a  vulnerable adult and sentenced to 18 months imprisonment.  They are all White British women.

Jake died of malnourishment which had occurred over a number of months prior to his death. The exact reason for this is unknown, however medical help had not been sought either by himself or his family members.  On the day he died his mother called for an ambulance on the 999 system and said he was unwell. The ambulance arrived, and paramedics found Jake lying on a mattress on the living room floor. He had a Glasgow Coma Scale score of 3 (totally unresponsive).   His life was pronounced extinct shortly afterwards.  At the time of his death he weighed 37 kg (5 stone 11 pounds).

What did the review tell us?

In his early years, concerns were raised in relation to Jake’s developmental delay and risk of neglect both pre and during his primary school education. As a result, Children’s Social Care became involved, and assessment processes were undertaken. The family received further support and as a result, in part because Jake and his mother were then living with his grandparents, it was felt that there had been improvements so there was no ongoing involvement from Children’s Social Care.  For the remainder of his time in mainstream education there do not appear to have been further concerns identified by any agency.

By the end of his second term at secondary school his mother decided that he would be educated at home. This continued until his 16th birthday when he reached the age whereby the requirement for statutory education ceased. He did not go into further education or employment.

Although a family who tended to keep themselves to themselves, at points there were professionals who visited their home or met with the family including workmen, housing officers, and Elective Home Education Officers. However at differing points throughout Jake’s life there was a pattern of missed health appointments and not seeking medical help

What can we do now?

The review acknowledged that over the course of time local and national  guidance and practice has changed and highlighted the importance of building upon and strengthening existing safeguarding approaches and work practices. The following summarises those key approaches / practice:

Think Family, Work Family

The needs of one individual within a family may impact on another, including their ability to care for or meet the needs of another, which may in term place that person at risk of harm, abuse, or neglect either intentionally or otherwise.

A Think Family, Work Family Approach helps to understand the unique circumstances of an adult or child, and the strengths and resources within the family to provide for their needs, but also identifies where additional support may be required.

Early intervention

Intervening early as issues arise can positively improve the outcomes for an individual and their family.

Within children’s services this approach is known as Early Help and is based on the following principles:

  • Early in the life of the problem – whatever the age of the child
  • Early to respond when problems emerge or remerge
  • Help to prevent concerns getting worse and avoid the need for statutory intervention
  • Support in school, home and community through a graduated approach

Within adult services this is referred to as the early intervention and prevention approach undertaken by Adult Social Care which enables individuals to access advice, guidance and information about the services and support that is available to prevent entry into and reliance on services.

Non-Attendance at Appointments/Meetings

Many children and adults are reliant on someone else to take them to meetings or appointments that relate to their welfare, care, or health and as a result they are sometimes not taken to them, or appointments are not made or cancelled. Over time this may have an implication for that person’s health or welfare.

Changing how non-attendance is recorded, and consideration for the implications of not attending is known as the Was Not Brought Approach.”


Neglect is a form of abuse. Neglect with regards to children and young people is defined as “the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development” (Working Together to Safeguard Children 2018).

The Care Act 2014 describes this as:

  • ignoring medical, emotional, or physical care needs,
  • failure to provide access to appropriate health, care and support or educational services,
  • the withholding of the necessities of life, such as medication, adequate nutrition, and heating.

Neglect may be intentional or unintentional and can be caused by anyone with a responsibility to provide care, including relatives and paid carers.  It rarely occurs as a one-off incident rather than a cumulative effect which can take place over a period of time. 

Professional Curiosity

Professional curiosity is where a practitioner explores and understands what is happening within a family or for an individual rather than making assumptions or taking a single source of information and accepting it at face value. It means:

  • testing out your professional assumptions about different types of families.
  • triangulating information from different sources to gain a better understanding of family functioning which, in turn, helps to make predictions about what is likely to happen in the future.
  • seeing past the obvious.
  • questioning what you observe

It is a combination of looking, listening, asking direct questions, checking out and reflecting on ALL the information you receive.

Safeguarding Awareness

Safeguarding is everybody’s responsibility, and everyone has a part to play.

Safeguarding is an umbrella term which refers to any activity that ensures the safety and welfare of an individual. There are specific definitions as to what constitutes abuse and neglect for children and young people and for adults with care and support needs, and associated legislation with regards to how abuse and neglect of individuals is responded to.

Being alert to the signs and indicators of abuse and neglect and knowing how to raise these / respond may enable a person to get the support and care that they need.

Get the full report and/or Executive Summary by emailing DHR@leeds.gov.uk

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