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

Kensington and Chelsea review

CSP: Kensington and Chelsea Published: December 2022 Year of death: 2019 Extracted: 22 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 identifies concerns regarding the recognition and response to adult child to parent domestic abuse, particularly where coercive control is present and victims are vulnerable or have language barriers. It highlights the impact of fear of authorities and immigration status on help-seeking by migrant communities.

Home Office classifications

28 tags

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

  • Victim - was a carer
  • Victim - housing issues
  • Victim - serious or life limiting illness
  • Victim - immigration involvement
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Child - immigration involvement
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - housing issues
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - immigration involvement
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - housing services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

22 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation 9.1.i

Addressed to CLCH NHS Trust Safeguarding Team

To feedback learning from the DHR to CLCH staff using a 7-minute learning briefing sent directly to the Locality Leads and specific teams involved. Consideration given to also circulating via the Safeguarding Bulletin and CLCH Safeguarding Committee.

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

Recommendation 9.1.ii

Addressed to CLCH NHS Trust

CLCH to consider asking the following questions when carrying out assessments for the care of terminally ill patients in the home: • Who else lives in the home and whether there are any pets? • Whether there has been Domestic and/or other forms of abuse?

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

Recommendation 9.2.i

Addressed to RBKC Neighbourhood Management - Housing

To place on a minimum of a quarterly basis, notices/or articles in the tenant newsletter, on how to report concerns anonymously to Housing and Neighbourhood Management Services.

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

Recommendation 9.2.ii

Addressed to RBKC Neighbourhood Management - Housing

To include information about DA and access to support in the Residents Handbook and Housing Matters newsletter. This information to also draw attention to abuse from adult children to parents.

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

Recommendation 9.2.iii

Addressed to RBKC Neighbourhood Management - Housing

To put notice/display key messages on physical or digital noticeboards where present in blocks of flats, about DA and how to access support. Include information about abuse from adult children to parents.

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

Recommendation 9.2.iv

Addressed to RBKC Neighbourhood Management - Housing

Ensure that all relevant staff who enter RBKC properties are aware of processes on reporting concerns to Housing Management

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

Recommendation 9.2.v

Addressed to RBKC Neighbourhood Management - Housing

Put in place arrangements where there is no next of kin for belongings to be collected by a third party

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

Recommendation 9.2.vi

Addressed to RBKC Neighbourhood Management - Housing

Ensure that information is accessible to those who do not speak or read English with confidence.

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

Recommendation 9.3.ii

Addressed to RBKC Adult Social Care

Commission further courses on adult safeguarding and DA and review the learning outcomes to address risk indicators- to use the DHR as a case example

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

Recommendation i

Addressed to All key agencies

All key agencies to consider using an interpreter for initial assessments where the person is not fluent in, or prefers to speak in their primary language

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

Recommendation ii

Addressed to All key agencies

All key agencies in this review to consider how to ensure best practice in recognising and responding to Domestic Abuse when working with vulnerable adults. This should include: a) training in recognising linked patterns of coercive control between Intimate Partner Violence and other forms of domestic abuse and b) clear processes in place to support staff in recognising and responding to adult child to parent abuse.

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

Recommendation iii

Addressed to Safeguarding Adults Executives Board

The Safeguarding Adults Executives Board to carry out a review within 18 months to evaluate whether the response to vulnerable adults, experiencing domestic abuse, is being effectively managed with a focus on adult child to parent domestic abuse.

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

Recommendation iv

Addressed to Safeguarding Adults Executives Board

The Safeguarding Adults Executives Board to consider the value of a Multi-Agency Safeguarding Hub (MASH) to Adult Social Care and the placement of an Independent Domestic Violence Advocate co-located within that team.

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

Recommendation ix

Addressed to RBKC DHR Group

RBKC DHR Group to ask each agency involved in this review to provide feedback on their single agency recommendations.

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

Recommendation v

Addressed to Agencies

Agencies to consider how they assist people furthest from services to become better aware of their rights, including how to access support when they are fearful of DA. This should include SMART communication for example: publicity on notice boards and in welcome packs and handbooks. All communication should be developed with the recognition of the impact of the hostile environment on migrant communities and their uncertainty of the response they may get when reporting abuse.

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

Recommendation vi

Addressed to Home Office | Domestic Abuse Commissioner

Recommendation to the Home Office and the Domestic Abuse Commissioner, to further consider measures to identify adult child to parent abuse and to advise all (non-DA specialist) Helplines on training staff in adult child to parent abuse.

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

Recommendation vii

Addressed to Helplines

In responding to DA, including recognising, and giving safe and accurate advice. Helplines to include those for older people, general advice, and mental health helplines.

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

Recommendation viii

Addressed to Domestic Abuse Commissioner

Recommendation to the Domestic Abuse Commissioner to highlight the considerable fear some people have of reporting to the police, due to their history of a fraught relationship with the police either here or in other countries and the hostile environment created towards migrant communities, refugees and asylum seekers in this country. Also, to bring to the Commissioner’s attention the issue of the police being ‘weaponised’ by perpetrators leading to increased fear of victims in engaging with support. To ask the Commissioner to consider these issues in relation to increased police and public awareness of DV and access to support for Black, Minority and Ethnic and migrant communities.

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

Recommendation x

Addressed to Public Health England

Recommendation to Public Health England that they inform the public that coercive controlling behaviour needs to be reported to ensure vulnerable people are supported.

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