Combined review published following the death of Phillip Nicholson

A combined Safeguarding Adult Review and Domestic Homicide Review has been published following the death of Poole resident, Phillip Nicholson in May 2015.

Mr. Nicholson died in Bournemouth on 26 May 2015 and the two perpetrators were convicted of his murder and sentenced to life imprisonment.

Following his death, a decision was made for Poole Community Safety Partnership to carry out a Domestic Homicide Review (DHR) due to the intimate relationship between the victim and one of the perpetrators. A Bournemouth and Poole Safeguarding Adult Review (SAR) was also commissioned by the Bournemouth and Poole Safeguarding Adults Board to determine whether agencies involved with Mr Nicholson’s care could have worked more effectively to protect him.

The combined review has now been published following the conclusion of the Inquest Hearing on Friday 8 March 2019. It is established practice that names are anonymised in such reviews. Mr Nicholson is therefore referred to as ‘Harry’ and the perpetrators as ‘Karen’ and ‘John’.

Barrie Crook, Chair of the Bournemouth and Poole Safeguarding Adults Board, said: “It was tragic that Harry lost his life in these circumstances and I would like to express the Board’s sincere condolences to his parents and wider family.

 “It was crucial that this combined independent review was carried out in order to fully examine the events leading up to Harry’s death and explore each agency’s involvement during that time.

 “This was a very complex case and through this independent and very detailed process, all agencies involved have identified areas for learning. Actions have been taken as a matter of priority to ensure that circumstances leading to deaths such as this are prevented from happening again in the future.”

The overall conclusion of the combined review, which was completed in 2017, stated that there were key opportunities to intervene which seem likely to have afforded Harry greater protection and may have restrained the behaviour of Karen and John for a time.”

Following an inquest, which reviewed all the evidence presented in person by witnesses, a conclusion of unlawful killing was recorded.

The Safeguarding Adults Review report made 13 recommendations for the Safeguarding Adults Board and Community Safety Partnership. There were also a number of important themes highlighted throughout the review:

  • Information sharing
  • Risk assessment and management
  • Mental capacity
  • Engagement with the perpetrators
  • The impact of social media
  • Mate crime
  • Steps have been taken to improve information sharing through an improved Personal Information Sharing Agreement between agencies, strengthening staff authority to reveal key information with partners.
  • Better information sharing and gathering through the Multi-Agency Risk Management (MARM) process.
  • Measures have been put in place to ensure that an individual’s mental capacity during a safeguarding enquiry is fully considered.
  • Relevant policies have been updated to reflect the expectations of staff around Consent and Capacity
  • Changes in legislation for Care Leavers and Special Educational Needs and Disability (SEND) means better transition for young people to adulthood. Legislation requires authorities to have a transition plan and maintain contact.
  • Risks of social media are being highlighted and addressed through the Learning Disability Partnership Board working with advocates and carers and through additional training by agencies. An event is also planned for later this year focussing on social media exploitation and domestic abuse
  • A specialist adult social care safeguarding team has been created which reviews all safeguarding referrals, manages the most complex cases and provides advice, information and support to other teams.
  • Multi-Agency Risk Assessment Conference and Adult Safeguarding meetings are now more closely integrated.
  • An independent audit has been commissioned to look at cases where someone with a learning disability has experienced domestic abuse.
  • Police have invested in training of frontline officers to be able to identify and respond to vulnerable adults
  • A new system of Public Protection Notices is in place by which the Police share information concerning adults at risk
  • Additional resources have been invested to identify and respond appropriately to incidents of financial and sexual abuse involving vulnerable adults.

The organisations involved in the review have accepted the conclusions of the SAR/DHR. Each has developed its own improvement plan to seek to prevent further tragic events occurring.

Actions taken since the review include: 


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