Lambeth review

The Safer Lambeth Partnership should liaise with Buckinghamshire and Lewisham Children’s Social Care respectively and satisfy itself that Child A and Child B (as well as their families) are in receipt of trauma informed support to cope with both the aftermath of the homicide and the publication of the DHR.

After publication of this DHR, the Safer Lambeth Partnership should liaise with Buckinghamshire and Lewisham Children’s Social Care respectively and ensure that this report is attached to Child A and Child B’s social care records. This is so that, if they wish to read the DHR when they are older, it will be available to them.

The Home Office to work with other government departments to develop a cross-government definition of AFV/CPV. This should include developing policy and practice guidance for AFV and refreshing the current CPV guidance.

The Lambeth CCG to further promote the Living Well Network Hub to ensure that all GPs are aware that mental health referrals should be made via this route.

The MPS to undertake a training needs assessment to identify the skills and training that police officers require to respond to AFV/CPV.

The MPS to audit the ‘Strengthening Local Policing’ programme’ to ensure it enables a consistent and robust process for the supervision all of domestic abuse incidents / crimes.

The MPS to identify the root cause of the delay in the response to Mia’s report and ensure that this is addressed in its IT ‘Changes Project’ in order that such excessive delays cannot occur in the future.

The Safer Lambeth Partnership to work with local partners to review the findings from this DHR and develop the response to AFV / CPV locally. This should include identifying the actions that agencies can take individually and collectively, as well as completing a training needs assessment to identify the skills and training that professionals require to respond.

Lambeth Together to consider the learning from this DHR in relation to meeting the needs of local communities, including the provision of culturally appropriate services, a diverse workforce and creating opportunities to build trust with communities.

The Practice Domestic Abuse policy needs to be amended to include how the practice will respond if a perpetrator discloses or is registered with the practice, as well as clarifying details of the Practice Domestic Abuse Lead, the local referral pathway and Domestic Abuse training resources.

The Safer Lambeth Partnership to use the learning from this DHR, as well as other local and national research, to work with the MPS to identify how to improve relationships between Black communities and the police.

LEO CMHT to develop a local protocol to state that once an initial assessment has been done, the outcome of the assessment should be discussed at the next MDT meeting and any plans put in place to address the key issues relevant to risk

LEO CMHT to develop a protocol to state that relatives and patients are to be given a copy of the treatment care plan on the day of the assessment including crisis contact details

The LEO CMHT induction package to highlight how to access medical members of the team for advice

LEO CMHT to develop a consistent approach and framework for conducting assessments including consideration of collateral sources of information

A Trust-wide piece of work to be done to share the learning from other domestic homicide cases that have taken place in the Trust

The Trust should assure itself that all practitioners are sufficiently aware of the need for domestic abuse routine enquiry as part of full needs and risk assessment. The Think Family approach demonstrates that this should not solely focus on service user’s vulnerability, but also carers and other family members, if relevant. Staff should also consider the needs of male victims of domestic abuse

The Trust should assure itself that staff are aware of the MARAC referral processes, local borough arrangements and the standards expected when there are high risk domestic abuse concerns.