About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review
Brent review
CSP: Brent
Published: December 2022
Year of death: 2018
Extracted: 29 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review identifies systemic failures in agencies' ability to recognise domestic violence indicators, particularly when co-occurring with substance misuse and pregnancy. It highlights gaps in multi-agency communication, record-keeping, and safety-netting for vulnerable individuals, alongside barriers to support for EEA nationals and Eastern European victims.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Home Office to review funding arrangements for the provision of specialist and expert advocacy for the families of victims who reside outside of the UK. | Home Office |
| 10 | The Safer Brent Partnership to work with neighbouring boroughs such as Barnet and Harrow, and MOPAC, to develop sustainable specialist provision for Eastern European communities at a regional level. | Safer Brent Partnership | Barnet Council | Harrow Council | Mayor’s Office for Policing and Crime |
| 11 | The Safer Brent Partnership to review its existing strategy and action plans in relation to domestic abuse, to explicitly identify the actions it will take to ensure that the needs of Eastern European victims are met, including ensuring: Staff can access single and multi-agency training, so they have appropriate skills and knowledge There are robust pathways in place locally. This recommendation should be implemented in consultation with the Brent LSCB and SAB. | Safer Brent Partnership | Brent Local Safeguarding Children Board | Safeguarding Adults Board |
| 12 | The Brent LSCB to review the learning identified in the case and develop an interim policy and procedure to ensure that no case is closed by health or children’s social are without consideration of safety netting options. | Brent Local Safeguarding Children Board |
| 13 | The Brent LSCB to escalate the learning identified in this case to the national Serious Case Review Panel for consideration. | Brent Local Safeguarding Children Board |
| 2 | The Safer Brent Partnership to review the local training offer to ensure all front-line practitioners have a good awareness of the barriers and support options for a person with NRPF. | Safer Brent Partnership |
| 3 | The Home Office to ensure that there is consistent access to immigration and/or benefits advice, support and pathways out of destitution, for EEA nationals who are victims of domestic violence and abuse but have NRPF. | Home Office |
| 4 | The Safer Brent Partnership to work with the Brent LSCB and Safeguarding Adults Board (SAB) to ensure all front-line practitioners are aware of the signs and indicators of Modern-Day Slavery as well as the NRM. | Safer Brent Partnership | Brent Local Safeguarding Children Board | Safeguarding Adults Board |
| 5 | WDP to work with its commissioners to ensure that female offenders can access a female member of staff as part of unscheduled ‘drop ins’. | Westminster Drug Project |
| 6 | The Brent LSCB to undertake a case audit to explore the issues identified in this case (relating to the undertaking of a Pre-Birth Assessment and identification of domestic valence risk) and identify any actions required to improve performance. | Brent Local Safeguarding Children Board |
| 7 | Brent CYP to ensure that mandatory domestic abuse training is undertaken by all staff to ensure they are familiar with indicators of domestic abuse, as well as the need to speak to people separately. | Brent Council - Children and Young People |
| 7.1.10 | Develop an online platform for child safeguarding referrals that will enable clinicians from the Trust to complete a single form with information regarding their concerns that can be shared with different professionals (depending on the case) from Social Care, the Trust’s PMLS team, the Trust’s Safeguarding Midwife, the Trust’s IDVA, the Adult Psychiatric Liaison Service, the Children’s and Adolescent Mental Health (CAMHS) team and local Substance Misuse teams. This will reduce the number of different forms clinicians need to complete for a single patient, reducing time away from direct clinical care and produce a simpler system which will be easier to train staff members on then the current very complex system. | London North West Healthcare University NHS Trust |
| 7.1.11 | The online platform will also enable a robust method for the PMLS to identify all Child Safeguarding referrals sent from the ED (as well as the rest of the Trust) to ensure they are appropriately actioned, information shared as required and establish a clear governance structure for these cases. | London North West Healthcare University NHS Trust |
| 7.1.12 | Independent Domestic Violence Advisor (IDVA) worker – It has been identified that a specialist Domestic Violence Practitioner would be beneficial within the service. A Criminal Justice Practitioner has been identified to complete the IDVA qualification to commence in their specialised role. | Westminster Drug Project |
| 7.1.13 | Review of Safeguarding Standard Operating Procedure (SOP) – The local Safeguarding SOP has recently been developed and expanded. It now directs staff to ensure they scan all referrals made to safeguarding (children and adults) onto the case management system. They also need to follow up the outcome once the referral has been made before being able to discharge the service user. | Westminster Drug Project |
| 7.1.14 | Audit of procedures and guidance compliance – The organisation will be undertaking an internal audit aimed at ensuring local compliance with organisational policy and procedure within an agreed timeframe are taking place. | Westminster Drug Project |
| 7.1.15 | Risk management – A guidance tool on how to write a comprehensive risk management plan has been developed, discussed and distributed amongst staff. We will be developing a workshop for staff on how to identify and assess risk, and then write an effective risk management plan. | Westminster Drug Project |
| 7.1.16 | Case notes – A case note format and guidance has been devised and implemented. Staff have been advised on when and how to document case notes correctly and efficiently through a workshop that was mandatory for all staff to attend. The template has been shared to all staff, and it will be included in any new staffs’ induction, so the good practice continues. | Westminster Drug Project |
| 7.1.17 | Criminal Justice ‘Follow up appointment’ – The criminal justice team have been advised that all service users who come through the Criminal Justice route should be offered both the compulsory ‘Initial Assessment’ and a ‘Follow Up Appointment’. Service users will be breached if they fail to attend either of these appointments. This gives staff the opportunity to engage and build a relationship with service users, so they feel more comfortable to disclose their life situations. | Westminster Drug Project |
| 7.1.2 | Awareness raising with multi-agency partners that referrals to the Brent Family Front Door should be as complete as possible (a correct address and contact details are needed to progress referrals). | Brent Council - Children and Young People |
| 7.1.3 | Establish a standardised screening tool for use by Emergency Department clinicians in patients presenting to the Emergency Department routine enquiry will identify those experiencing domestic violence, with a particular focus on those that have not presented as a result of suspicious injuries or after a disclosure of domestic violence. | London North West Healthcare University NHS Trust |
| 7.1.4 | Ensure training to Emergency Department clinicians (doctors and nurses including bank/agency/locum staff) on use of the tool and actions to be taken if the patient is screened positive, with training to be repeated at regular intervals. | London North West Healthcare University NHS Trust |
| 7.1.5 | Aim to implement this screening tool within the next 3 months and regularly audit its use, with training adapted to the results of this audit. | London North West Healthcare University NHS Trust |
| 7.1.6 | ED staff to be reminded of the importance of mini booking that it is essential in all un-booked pregnant women wherever they attend in the Trust and a referral to maternity should be made. | London North West Healthcare University NHS Trust |
| 7.1.7 | ED staff to familiarise themselves with the ‘Non-Obstetric Emergency Care: Guideline for the Care and Management of Maternity Admission to the Emergency Department. | London North West Healthcare University NHS Trust |
| 7.1.8 | Adult patients should be seen alone during their attendance in hospital if there is a safeguarding concern. | London North West Healthcare University NHS Trust |
| 7.1.9 | Staff to be reminded of the importance of completing documentation appropriately. | London North West Healthcare University NHS Trust |
| 8 | The Safer Brent Partnership to develop a comprehensive engagement and communications strategy. This should identify the actions the partnership will take to deliver both a sustained awareness raising campaign and community outreach (including developing resources to meet the needs of Eastern European communities and ensuring access to interpretation where appropriate). | Safer Brent Partnership |
| 9 | The Safer Brent Partnership to scope the requirement for specialist provision for Eastern European communities in the borough. | Safer Brent Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||