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

Enfield review

CSP: Enfield Published: December 2022 Year of death: 2016 Extracted: 8 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 significant failures in multi-agency coordination and information sharing, particularly regarding the victim's complex needs involving domestic abuse, mental health, and substance misuse. Professionals also underestimated the perpetrator's coercive control and manipulation, leading to inadequate risk assessments and support.

Extracted recommendations

8 recommendations pulled from the report

#	Recommendation	Addressed to
1	The key agencies within this review must consider how complex cases are managed and report back to the Community Safety Partnership and other senior level Boards by March 2018	Key agencies within this review
2	Within 18 months, the Community Safety Partnership should evaluate whether complex cases are being managed more effectively	Community Safety Partnership
3	The multi-agency risk assessment conference (MARAC) meeting should consider how to share any pertinent information with the relevant GPs	Multi-Agency Risk Assessment Conference (MARAC)
4	The individual management reviews in this case were particularly poor. The Violence Against Women and Girls Group should consider providing multi-agency training to improve agency's understanding of the process	Violence Against Women and Girls Group
5	Staff in Accident and Emergency Departments should receive training about self-harm and self-harm should be included in all local domestic abuse training. (This should ensure that staff have an understanding of unusual self-inflicted injuries (e.g. the victim's facial injury or 'accidental' injuries)	Accident and Emergency Departments
6	The Community Safety Partnership should consider funding a domestic abuse advocate/educator for the Accident and Emergency Department at North Middlesex Hospital	Community Safety Partnership
7	The victim's mother and daughter had a number of questions they wanted answered about the chain of events following the victim's death (see section 2.2.1.). The Metropolitan Police Service should consider how best to address those questions	Metropolitan Police Service
8	Enfield Community Safety Partnership should ask each agency involved in this review to provide feedback on their single agency recommendations.	Enfield Community Safety Partnership
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗