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
Merton review
CSP: MertonPublished: April 2023Year of death: 2017Extracted: 8 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified failures in medication management, significant delays in arranging Mental Health Act assessments, poor inter-agency communication during patient transfer, and inadequate family support, exacerbated by language barriers.
Home Office classifications
24 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - was a carer
Victim - carer for perpetrator
Victim - immigration involvement
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Child - primary address same as victim
Child - immigration involvement
Perpetrator - case heard in court
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - psychosis
Perpetrator - supervised by mental health services
Perpetrator - immigration involvement
DHR process - family contributed to dhr
DHR process - family consulted about terms of reference
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - health services recommendations
DHR process - technology systems recommendation themes
DHR process - identification of risk recommendation themes
DHR process - policy recommendation themes
DHR process - record keeping recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
8 recommendations pulled from the report · 6 matched to organisations in the index
Addressed to
South London and Maudsley NHS Foundation Trust
The SlaM Clinical Policy Working Group commission a discrete Trust-wide policy on clozapine monitoring, management and prescribing. This will help inform local protocols and best practice in both inpatient and community settings. It should include the following based on the learning from this incident: • Titration protocols • Registration with ZTAS or DMS • Prescribing pathways for inpatient and community settings including the monitoring requirements and action to be taken where a red/amber/green result • A robust system for overseeing pathology testing and to generate an alert when a patient has missed a monitoring blood test • Guidance on side effects and the risks associated with non-concordance with medication as prescribed • How to discuss risks with patients their families and carers, especially where English is not their first language • Training Needs Analysis for different staff groups involved.
Addressed to
South London and Maudsley NHS Foundation Trust
The LEO Operational Policy should be updated to provide guidance to care coordinators working with families and carers. How they can access needs assessment/support from Trust services and/or be signposted to the local authority for a carer’s assessment under the Care Act 2014. This should include guidance on sharing care plans and emergency contact information with the family, with the patient’s permission.
Addressed to
South London and Maudsley NHS Foundation Trust
Where it is likely that a family member will administer medication and monitor compliance an assessment should be prioritised and any gaps in understanding about the medication and its risks, resulting from language/educational differences, should be identified and responded to, to ensure that the individual is properly equipped and supported to undertake this task. For example, they must be provided with information about the possible risks associate with the medication, in their first language if required or an interpreter engaged to help explain the risks and benefits to them. There should be documented records of any education discussions with them with regard to pharmacology. This guidance should form part of the policy reviewed and updated in Recommendation 1.
Addressed to
South West London and St George’s Mental Health NHS Trust | South London and Maudsley NHS Foundation Trust
SWL&StG and SlaM early intervention services to develop guidance for referrers on what they can expect when transferring in and out of their respective boroughs. This guidance could form the basis for pan-London agreements on standards for transfers.
Addressed to
South West London and St George’s Mental Health NHS Trust
There is an evaluation undertaken by SWL&StG of the revised Merton AMHP system now in place to ensure there is: a. a robust and transparent system for taking referrals and communicating with the referrer agreeing crisis/contingency plans as required b. a clear framework for the AMHP service to collate and evaluate risks which will assist with prioritising assessments c. a process for escalation for all assessments that are delayed by more than 24 hours d. oversight of case progression at a senior level.
All agencies working with victim and survivors of domestic abuse should ensure they understand what is being said and if necessary arrange translation services. This will ensure the victim/survivors have the best knowledge available that they understand.
All agencies working with victims and survivors of domestic abuse should demonstrate professional curiosity in order to understand what is happening for the victim/survivor to offer the best support and service.