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: CroydonPublished: December 2022Year of death: 2016Extracted: 15 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
Croydon BME Women’s Project work in partnership with local statutory healthcare providers and Non-Government organisations to support training for staff.
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.
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.
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.
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.