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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

15 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	Croydon Clinical Commissioning Group \| Croydon Health Services
2	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.	Safer Croydon Partnership
3	Croydon BME Women’s Project work in partnership with local statutory healthcare providers and Non-Government organisations to support training for staff.	Croydon BME Women’s Project
4	Croydon CCG, CHS and SLaM ensure that the learning from this case is disseminated to practitioners.	Croydon Clinical Commissioning Group \| Croydon Health Services \| South London and Maudsley NHS Foundation Trust
6.1.3.1	The practice should review the recording and consideration of the compliance with the Mental Capacity Act (2005) and Best Interest Decisions	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.2	The practice must update their knowledge and understanding of adults at risk	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.3	The practice to review their utilisation of interpreters	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.4	The practice should update their knowledge on assessments of the needs of carers	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.5	The practice should review their safeguarding policy with the support from the CCG Safeguarding Team and incorporate Domestic Abuse including referral pathways.	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.6	The practice should identify a DASV Lead	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.3.7	The practice must attend CCG Safeguarding Training, Updates and Workshops and other learning opportunities within the borough.	Croydon Clinical Commissioning Group (on behalf of the General Practice)
6.1.4.1	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.	Croydon Health Services
6.1.4.2	The Trust must ensure that all staff use the interpreters/language line when there is a language barrier, in line with Trust guidance.	Croydon Health Services
6.1.5.1	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.	South London and Maudsley NHS Foundation Trust
6.1.5.2	The Community Mental Health Teams have received additional training on identifying signs of domestic abuse and appropriate liaison with social services.	South London and Maudsley NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗