Home / Sources / Domestic Homicide Reviews / Waverley · Dec 2022
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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

24 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - was a carer
  • Victim - mental ill health
  • Victim - depression
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - suicidal thoughts
  • Perpetrator - supervised by mental health services
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - health services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

6 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

Addressed to Surrey and Borders Partnership NHS Foundation Trust

To ensure they have a robust SI review process in place that ensures SIs are tracked and subject to quality control before being released.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Surrey Heartlands CCG’s Safeguarding Team

To communicate findings of this review to GPs, to emphasise that all contacts including follow up telephone conversations are recorded.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Surrey and Borders Partnership NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Surrey and Borders Partnership NHS Foundation Trust

That Waverley CMHRS ensure that changes to decisions made at MDT should be fully recorded and endorsed by the consultant doctor.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Surrey and Borders Partnership NHS Foundation Trust

To report to the CSP when all SI recommendations are implemented, and changes made.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Surrey and Borders Partnership NHS Foundation Trust

Should promote a ‘Think Family’ approach to assessments.

Verified wording from the published review · Original review (PDF) ↗