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
Braintree review
CSP: BraintreePublished: December 2022Year of death: 2017Extracted: 5 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identifies critical gaps in inter-agency information sharing, particularly between police and mental health services, leading to an incorrect incident grading and delayed emergency response. It also highlights issues with mental health care handover and risk management during the perpetrator's service transfer and medication changes.
Home Office classifications
23 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - was a carer
Victim - carer for perpetrator
Victim - carer assessed
Victim - serious or life limiting illness
Perpetrator - case heard in court
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - panic attacks
Perpetrator - psychosis
Perpetrator - self harm
Perpetrator - suicidal thoughts
Perpetrator - attended drug and alcohol services
Perpetrator - supervised by mental health services
DHR process - family contributed to dhr
DHR process - family received draft report
DHR process - police recommendations
DHR process - health services recommendations
DHR process - technology systems recommendation themes
DHR process - multi agency working recommendation themes
DHR process - other recommendation themes
Extracted recommendations
5 recommendations pulled from the report · 5 matched to organisations in the index
That a formal process should be developed by which the police can notify mental health professionals of an individual’s deteriorating mental health where it does not meet the threshold for Section 135/136 of the Mental Health Act 1983 or the Mental Capacity Act 2005. The review reiterates the recommendation made in previous DHRs published in 2017.
That Essex Police and EPUT consider basing a mental health practitioner in the force control room with access to mental health records. Had this been in place on the night of the incident, then the force control room would have been able to assess the concerns of the perpetrator’s parents alongside the perpetrator’s mental health history.
Addressed to
NHS England | Mid Essex Clinical Commissioning Group
That NHS England and CCGs remind primary care services to complete a transfer summary in the electronic medical records (regarding patients with mental issues) when a surgery becomes aware that a patient is moving to a new locality.
Addressed to
EPUT | Mid Essex Clinical Commissioning Group | Open Road
That all health agencies are reminded of the significance of information sharing with primary care services (GPs) to ensure clarity of information and continuity of care. It would be helpful if GPs are made aware when patients do not attend (DNA) appointments with other services.