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

Waverley review

CSP: Waverley Published: December 2022 Year of death: 2017 Extracted: 6 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 significant failures in mental health service provision for the perpetrator, including inadequate risk assessment, poor inter-agency communication, and a lack of care coordination, which left him vulnerable during a period of rapidly deteriorating mental health.

Extracted recommendations

6 recommendations pulled from the report

#	Recommendation	Addressed to
1	To ensure they have a robust SI review process in place that ensures SIs are tracked and subject to quality control before being released.	Surrey and Borders Partnership NHS Foundation Trust
2	To communicate findings of this review to GPs, to emphasise that all contacts including follow up telephone conversations are recorded.	Surrey Heartlands CCG’s Safeguarding Team
3	That Waverley CMHRS have process in place, that will ensure that letters are prepared and sent to GPs (or other services) when decisions are made to discharge.	Surrey and Borders Partnership NHS Foundation Trust
4	That Waverley CMHRS ensure that changes to decisions made at MDT should be fully recorded and endorsed by the consultant doctor.	Surrey and Borders Partnership NHS Foundation Trust
5	To report to the CSP when all SI recommendations are implemented, and changes made.	Surrey and Borders Partnership NHS Foundation Trust
6	Should promote a ‘Think Family’ approach to assessments.	Surrey and Borders Partnership NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗