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

Croydon review

CSP: Croydon Published: December 2022 Year of death: 2017 Extracted: 31 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 identified a lack of inter-agency information sharing regarding the perpetrator's history of domestic abuse and missed opportunities to identify the victim's vulnerability to abuse. Gaps in safeguarding processes and the need for agencies to better understand clients' protected characteristics were also highlighted.

Extracted recommendations

31 recommendations pulled from the report

#	Recommendation	Addressed to
1	All agencies that had sustained contact with the victim and the perpetrator to reflect on their agency approaches and responses to the protected characteristics of their clients/patients to ensure that they are not just recording data but are having meaningful discussions to ensure they understand the experiences and needs of individuals; including ensuring staff are supported in these discussions with adequate training.	Croydon Health Services NHS Trust \| London Borough of Croydon Housing Services \| Metropolitan Police Service \| South London and Maudsley NHS Foundation Trust \| Turning Point \| Victim Support
2	This learning from the Domestic Homicide Review to be shared across the member agencies of the Community Safety Partnership, Local Safeguarding Children’s Board and Adult Safeguarding Board.	Community Safety Partnership \| Local Safeguarding Children’s Board \| Adult Safeguarding Board
3	Croydon Domestic Abuse and Sexual Violence Board to review the previous pilot Specialist Domestic Violence Court and why it came to an end; and to take action where required including any training requirements for court staff and magistrates on domestic abuse.	Croydon Domestic Abuse and Sexual Violence Board
4	This learning from the Domestic Homicide Review to be shared across the member agencies of the Community Safety Partnership, Local Safeguarding Children’s Board and Adult Safeguarding Board.	Community Safety Partnership \| Local Safeguarding Children’s Board \| Adult Safeguarding Board
6.1.10.aa	ACTION 4: Ensure service explanation, confidentiality/information sharing, and subject access rights are clearly explained and explanations clearly recorded. This will be included in briefings to VCOs with immediate effect. A script will be developed to ensure the phrasing of this is consistent. The script will then be cascaded to all services and reinforced through case review and auditing. Briefings and script to be completed by end of February 2018; rollout through case management to be completed on an ongoing basis and reviewed in March 2018.	Victim Support
6.1.10.x	ACTION 1: Until the new call and IT programme is introduced Victim Support should consider Victim Support Officers (VCOs) self-emptying their pipelines at the end of their own shift to ensure the pipelines are fully emptied and prevent the loss of cases from view. To be discussed at the next Victim Assessment and Referral Service (VARS) management meeting in January 2018 and implemented if agreed.	Victim Support
6.1.10.y	ACTION 2: Victim Support should ensure that services are resilient to pressures from restructure and resource limitations, and that business continuity plans are in place that account for IT failures, staff turnover and vacancy/absence cover, and that contact is prioritised in relation to risk as well as contact Service Level Agreement (SLA). This action is already under way. The learning from this DHR should be fed back to the VARS management team meeting in January 2018 and action points developed around improving triaging processes and built into the business continuity plan by January 2018.	Victim Support
6.1.10.z	ACTION 3: Ensure present-day Victim Support practice is adhered to through continued use of dip-sampling and case review and feedback to VARS staff. This is already being actioned through the introduction of an improved case review and auditing process throughout the organisation on a national level. The VARS should be included in this explicitly. This should be taken forward by Heads of Service with discussion points issued to the VARS management meeting for January 2018, to be developed into the next stage of rollout with input from service teams.	Victim Support
6.1.3.a	AIR Network to ensure that referrals to Turning Point are made as soon as possible after engagement has started. Outcome: An individual’s substance misuse and other complex needs are assessed and treatment and support delivered as soon as possible.	AIR Network
6.1.3.b	AIR Network to review their internal processes regarding the sourcing of external risk information. Outcome: To assess the need to have access to information that would make staff more alert to potential risks. Access to formally recorded known risk information would provide staff with a more holistic picture of an individual’s risk. This would enable staff to be more vigilant about behaviours which could indicate an escalation in risk or deteriorating mental health.	AIR Network
6.1.3.c	AIR Network to set up processes to receive risk information from referring external organisations. Outcome: same as point above.	AIR Network
6.1.3.d	Implement AIR Network’s Risk recording process. Outcome: To capture risk information in a standardised process. Will make staff more aware of potential risk factors.	AIR Network
6.1.3.e	Complete internal review of level of contact detail recorded. Outcome: To ensure that AIR Network records sufficient level of information to more effectively support and review an individual’s progress and record any untoward or concerning behaviours that may indicate an increase or deterioration in mental health.	AIR Network
6.1.3.f	AIR Network to assess the need for basic mental health training. Outcome: To have made a decision about the need for mental health training and sourced relevant training for staff.	AIR Network
6.1.4.a	Curiosity regards impact of mental health on physical health and vice versa and to ensure follow up recommendations regards physical health check requests.	Croydon Clinical Commissioning Group
6.1.4.b	The practice must update their knowledge and understanding of adults at risk.	Croydon Clinical Commissioning Group
6.1.4.c	The practices should both review their safeguarding policies with the support from the CCG Safeguarding Team and incorporate Domestic Abuse including referral pathways.	Croydon Clinical Commissioning Group
6.1.4.d	Named General Practice should identify a Domestic Abuse and Sexual Violence Lead.	Croydon Clinical Commissioning Group
6.1.4.e	The practice must attend CCG Safeguarding Training, Updates and Workshops and other learning opportunities within the borough.	Croydon Clinical Commissioning Group
6.1.5.f	Complete audit of ‘local’ procedures and guidance. As part of best practice, Croydon Housing Needs will undertake an audit of local procedures and guidance documents with the express purpose of withdrawing those that do not comply with organisational procedure. I would recommend that this process is project managed to ensure completion of the audit and completion of follow up actions aimed at ensuring local compliance with organisational policy and procedure within an agreed timeframe.	London Borough of Croydon Housing Services
6.1.5.g	Review Croydon Housing Needs procedures for eviction of leaving care clients. In this case, Croydon procedures were followed, however it is recommended that Croydon Housing Needs carries out a further review of procedures for eviction of vulnerable clients to ensure procedures are up to date and comply with current procedures.	London Borough of Croydon Housing Services
6.1.5.h	Training: Tenancy staff have attended domestic abuse and adult safeguarding training. However it is important that refresher training is provided to all housing staff on a regular basis. It is recommended that regular staff training should be provided to support staff members working with victims and perpetrators of domestic abuse to include: safe enquiry; responding, recording, reporting; safety planning; multi-agency working; working safely with perpetrators; legal remedies.	London Borough of Croydon Housing Services
6.1.6.i	We were emailed with concerns regarding domestic violence and a young child via a MARAC lead and there is no evidence of follow up action. Recommendation: MARAC process for the internal sharing information and follow up to be reviewed.	London Community Rehabilitation Company
6.1.6.j	As an organisation we now have a process for safeguarding checks to be completed and followed up, requiring management oversight. Safeguarding training was also rolled out to all staff. We are also in the process of updating our safeguarding training guidance and training as a result of REACTA, a new model. This is going to be rolled out across the organisation imminently. Recommendation: roll out and evaluate impact of REACTA.	London Community Rehabilitation Company
6.1.6.k	Case records were not always updated on this case. Our organisational plan, meet and record directive ensures that all appointments have a clear outcome with regards to an appointment and staff have to report to their line manager if contacts are incomplete or not actioned. Recommendation: Fully embed Plan, Meet and Record.	London Community Rehabilitation Company
6.1.6.l	London CRC has clear Offender Management practice standards for case management that practitioners manage their cases in line with.	London Community Rehabilitation Company
6.1.6.m	All appointments and contacts with Offenders are now managed and evidenced under the following format. CRISSA – Checking, Review, Intervention/Implementation, Summarise/Set Tasks and Appointment. This format ensures clear and evidential recording of appointments and discussions. Recommendation: Clear quality assurance activity to assure use of Practice Standards, CRISSA etc.	London Community Rehabilitation Company
6.1.7.n	NPS London to ensure that Probation Sentence Notification results undertaken at court are verified against LIBRA (Magistrates Court) XHIBIT (Crown Court) recording systems.	National Probation Service
6.1.7.o	NPS to ensure that in all Community/Suspended Sentence Orders imposed by the courts an order is held on NDelius our data recording system	National Probation Service
6.1.8.p	SLaM to review the domestic violence aspect of the adult and child safeguarding level 3 training in order to ensure it covers identification and how to respond to domestic abuse and violence concerns. There is an e-learning module on domestic violence and abuse for all Trust staff and this will be further advertised within teams to ensure compliance. The Trust produced a short article in the SLaM News at the end of 2017 to re-advertise the website and training, and reinforce the need for clinical staff to be aware of their responsibilities in routine enquiry and safety planning. This will be revisited once this Review is finalised.	South London and Maudsley NHS Foundation Trust
6.1.8.q	Named CMHT to incorporate the discussion of any adult or child safeguarding concerns and required actions into their monthly complex case formulation meeting.	South London and Maudsley NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗