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

Havering review

CSP: Havering Published: December 2022 Year of death: 2017 Extracted: 26 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 DHR identified failures in multi-agency working, risk assessment, and recognition of domestic abuse (coercive control) of an older person, compounded by unaddressed mental health and alcohol issues in the perpetrator, leading to inadequate safeguarding.

Extracted recommendations

26 recommendations pulled from the report

#	Recommendation	Addressed to
1	LFT must review their procedures for domestic violence against the 2016 NICE Quality Standard (QS116) 2016 and seek opportunities for specific multi-agency training in how to identify and respond to domestic violence, including the role of MASH and MARAC, and use the learning from this independent investigation to prevent recurrence.	LFT
1	LA must review their procedures for domestic violence against the 2016 NICE Quality Standard (QS116) 2016 and seek opportunities for specific multiagency training in how to identify and respond to domestic violence, including the role of MASH and MARAC, and use the learning from this IMR to prevent recurrence.	LA
1	Homecare Provider must ensure that an appropriate policy is in place for adult safeguarding, aligned with LA Safeguarding Adults Protocol and the London multiagency adult safeguarding policy, and assurance sought that staff understand the correct procedures for timely reporting and recording of concerns.	Homecare Provider
1	It is recommended that BOCU SLT dip sample ACN Merlin reports to ensure compliance in documenting reports for each individual where vulnerability has been identified using VAF (vulnerable adult framework) and re-inforce this by communicating this message to staff.	BOCU SLT
1	Domestic Abuse Governance Boards (Local Authority Community Safety Partnership) to monitor referrals and engagement of older people with domestic abuse services and action plan accordingly.	Domestic Abuse Governance Boards \| Local Authority Community Safety Partnership
10	NHS England along with the London Safeguarding Board are to ensure the learning from this case are widely distributed due to the complex and unusual circumstances.	NHS England \| London Safeguarding Board
11	That all agencies should support and encourage the development of professional curiosity within their staff groups, particularly in relation to engaging with the wider network of family and friends to inform decision making in complex cases.	All agencies
12	That LA and all agencies should ensure that there is effective managerial involvement in the case transfers between staff, particularly agency staff, to ensure that there is the continuity of understanding and that the key issues do not become lost at the point of case transfer.	LA \| All agencies
2	LFT must review the partnership arrangements with local Hospitals, and between substance misuse services and the LFT inpatient and community services. This is to ensure that discharges are coordinated appropriately with local hospitals where there are mental health concerns, and with regards to substance misuse services that risks associated with co-morbidity are recognised and responded to as an area for joint working.	LFT
2	LA must seek assurance that the policy requirements for assessing capacity, DoLS, safeguarding, care support planning and carer’s assessments are in place and meet the quality standards set.	LA
2	Homecare Provider must ensure that an appropriate operating and escalation procedure is in place for adult support initial and risk assessments and that assurance systems are in place to demonstrate that this is embedded in practice.	Homecare Provider
2	It is recommended that BOCU SLT debrief the attending officers involved in this investigation to remind them of the importance of documenting non crime DA CRIS investigations and to complete ACN Merlin reports for each individual where vulnerability has been identified using VAF (vulnerable adult framework).	BOCU SLT
2	Local Authority Adults Safeguarding Board to ensure specific training for all professionals on the incidences of abuse within a caring relationship and/or where dementia or other mental/physical disabilities are present.	Local Authority Adults Safeguarding Board
3	LFT must review the high-risk report process to provide assurance that staff understands how this can offer support, management advice and senior oversight, and to provide further assurance that the absence of a high-risk report is not a recurring theme in serious incident investigations.	LFT
3	LA must seek assurance that all appropriate staff receive MCA initial and refresher training and that this training impacts on day to day practice in terms of the application of defensible practice.	LA
3	Local Authority Adults Safeguarding Board to oversee and ensure professional development and training programmes regarding safeguarding and domestic abuse are in place; which are purposeful and set out how to apply the learning and understand what the barriers are for implementing change and can be applied systemically across the partnership.	Local Authority Adults Safeguarding Board
4	LFT must provide assurance that the requirements for assessing capacity, safeguarding, risk assessments, care plans and crisis plans are in place, up to date, and meet the quality standards set.	LFT
4	LA must ensure that the expertise of the Safeguarding Adults Team in relation to both MCA and safeguarding is promoted and a system for review of complex cases and, or cases where a number of safeguarding alerts have been raised is formally considered for development.	LA
4	LA Adults Safeguarding Board should ensure that where there are services in place for a carer e.g. mental health; risk of self-harm; substance abuse issues they should consider risk both to the ‘carer’ and the person being cared for; ensuring carers concerns and worries are heard and understood and contribute to the planning of service provision. LA ASB should also consider in complex situations how extended family or friends could be part of a supportive/protective network.	LA Adults Safeguarding Board
5	LFT must address the issues associated with the professional relationships between AABIT, ACAT and HTT and review the resources and operational arrangements between the AABIT, ACAT and HTT to ensure that they are able to undertake, where relevant, joint assessments and escalate concerns.	LFT
5	LA must ensure that opportunities are sought to expand the adult social care understanding of mental health issues through further promotion of joint working and by using the learning from this IMR.	LA
5	LFT and LA to ensure that domestic abuse is fully considered at adult safeguarding enquiries through the implementation of training to ensure recognition of the dynamics of abuse between intimate partners or family members.	LFT \| LA
6	Implement a multi-agency domestic abuse training programme for LFT Health Services specifically Mental Health Services and LA Adult Social Care that addresses aspects of domestic abuse including adults who require care in the home by a family member.	LFT Health Services \| Mental Health Services \| LA Adult Social Care
7	All agency Governance bodies to review Quality Assurance Frameworks and audit arrangements to include management and supervision arrangements; completion and outcomes of Section 42 Enquiries and planning including domestic abuse; frequency and quality of mental capacity assessments; care planning and overall to ensure each agencies employee’s understand the importance of joint partnership working.	All agency Governance bodies
8	All agency Governance bodies to ensure staff are aware of and understand ‘Quality Assurance’ and its relevance and importance in their day to day working.	All agency Governance bodies
9	Clinical Commissioning Group to enhance General Practitioner Training with regard to domestic abuse of older people.	Clinical Commissioning Group
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗