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

Croydon review

CSP: Croydon Published: December 2022 Year of death: 2016 Extracted: 15 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 highlights systemic failures in healthcare agencies to use independent interpreters and assess mental capacity for a vulnerable patient with dementia and language barriers. It also identifies missed opportunities to identify the perpetrator's undiagnosed mental illness and assess her role as a carer, contributing to the victim's death.

Home Office classifications

19 tags

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

  • Victim - physical disability
  • Victim - mental ill health
  • Victim - cognitive disorder (dementia or alzheimer's disease)
  • Victim - serious or life limiting illness
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

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

Recommendation 1

Addressed to Croydon Clinical Commissioning Group | Croydon Health Services

Croydon Clinical Commissioning Group and Croydon Health Services ensure that referral protocols between primary care, and specialist services include reference to the language needs of patients.

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

Recommendation 2

Addressed to Safer Croydon Partnership

Safer Croydon Partnership work with statutory healthcare agencies and local NGOs to implement an initiative raising awareness of mental health and consider the role of carers when safeguarding adults. This will include the promotion of Non-Government Organisations supporting older adults and people with disabilities.

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

Recommendation 3

Addressed to Croydon BME Women’s Project

Croydon BME Women’s Project work in partnership with local statutory healthcare providers and Non-Government organisations to support training for staff.

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

Recommendation 4

Addressed to Croydon Clinical Commissioning Group | Croydon Health Services | South London and Maudsley NHS Foundation Trust

Croydon CCG, CHS and SLaM ensure that the learning from this case is disseminated to practitioners.

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

Recommendation 6.1.3.1

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice should review the recording and consideration of the compliance with the Mental Capacity Act (2005) and Best Interest Decisions

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

Recommendation 6.1.3.2

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice must update their knowledge and understanding of adults at risk

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

Recommendation 6.1.3.3

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice to review their utilisation of interpreters

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

Recommendation 6.1.3.4

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice should update their knowledge on assessments of the needs of carers

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

Recommendation 6.1.3.5

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice should review their safeguarding policy with the support from the CCG Safeguarding Team and incorporate Domestic Abuse including referral pathways.

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

Recommendation 6.1.3.7

Addressed to Croydon Clinical Commissioning Group (on behalf of the General Practice)

The practice must attend CCG Safeguarding Training, Updates and Workshops and other learning opportunities within the borough.

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

Recommendation 6.1.4.1

Addressed to Croydon Health Services

The Trust must ensure the application of the Mental Capacity Act is embedded in all practice appropriately including fully documenting mental capacity assessments and Best Interest Decisions.

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

Recommendation 6.1.4.2

Addressed to Croydon Health Services

The Trust must ensure that all staff use the interpreters/language line when there is a language barrier, in line with Trust guidance.

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

Recommendation 6.1.5.1

Addressed to South London and Maudsley NHS Foundation Trust

The MHOA&D Clinical Academic Group should ensure that staff are aware of the process for booking an interpreter and that all non-English speaking patients to be offered the opportunity to meet clinical staff with a trained interpreter.

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

Recommendation 6.1.5.2

Addressed to South London and Maudsley NHS Foundation Trust

The Community Mental Health Teams have received additional training on identifying signs of domestic abuse and appropriate liaison with social services.

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