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: Merton Published: April 2023 Year of death: 2017 Extracted: 8 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 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.

Extracted recommendations

8 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	South London and Maudsley NHS Foundation Trust
2.1	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.	South London and Maudsley NHS Foundation Trust
2.2	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.	South London and Maudsley NHS Foundation Trust
3	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.	South West London and St George’s Mental Health NHS Trust \| South London and Maudsley NHS Foundation Trust
4	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.	South West London and St George’s Mental Health NHS Trust
5	SWL&StG review the Merton HTT pathway to ensure that support is offered to patients awaiting a Mental Health Act assessment.	South West London and St George’s Mental Health NHS Trust
6.1	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.	Merton Community Safety Partnership
6.2	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.	Merton Community Safety Partnership
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗