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
Brent review
CSP: Brent
Published: April 2023
Year of death: 2011
Extracted: 44 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 identifies systemic failures in inter-agency information sharing, risk assessment, and understanding of domestic violence dynamics, particularly regarding the perpetrator's history and the victim's safety during separation. It also highlights significant procedural issues with the DHR process itself.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 18.1.1. | That the Home Office commission a review of the statutory guidance to include more detail about roles and responsibilities in the event of disputes between any combination of Panel Members, Chairs, report authors and the CSP. It is not uncommon for these to occur and the current guidance is ambiguous. | Home Office |
| Brent CSP | That this report be considered and work undertaken to ensure that: The recommendations below have been implemented That there are no outstanding lessons to be learned from this DHR that remain unaddressed (including paragraph 16.1) | Brent Community Safety Partnership |
| Brent Housing | Create a post within the Housing Options Team to be the lead officer for Domestic Violence | Brent Housing |
| Brent Housing | Develop and implement an interim (paper) structured social risk assessment tool for midwives to utilise at the maternity booking assessment until such time as the electronic maternity patient record is implemented. This will serve to act as aide memoir to discuss key issues such as domestic abuse, and provide a vehicle for explicit recording of domestic abuse as a routine enquiry. If routine enquiry is not feasible at the first appointment because the woman is accompanied this will be recorded and the routine enquiry made at a subsequent appointment. | Brent Housing |
| Brent Social Care | Social workers will attempt to engage fathers and or father figures in assessments. | Brent Children's Social Care |
| Brent Social Care | Framework I records will be created for fathers/father figures children subject of social work assessment. | Brent Children's Social Care |
| Brent Social Care | A system to ‘show all related people’ is investigated for the ICS in Brent | Brent Children's Social Care |
| Brent Social Care | All open cases will have an up to date chronology | Brent Children's Social Care |
| Brent Social Care | MASH systems are implemented in Brent | Brent Children's Social Care |
| Brent Social Care | IDVAs are co-located in Brent Social Care to assist social workers in their day to day assessment of domestic abuse referrals | Brent Children's Social Care |
| Brent Social Care | A Children’s IDVA is co-located in Brent Social Care to assist workers to engage children in assessments. | Brent Children's Social Care |
| Brent Social Care | Brent Social Care considers developing and implementing a system to introduce more scrutiny to the management of repeat referrals. | Brent Children's Social Care |
| Brent Social Care | Brent Social Care considers implementing a handover meeting for open cases or recently closed cases that transfer across locality services. | Brent Children's Social Care |
| Brent Social Care | Brent Social Care audits cases to ensure that partners are suitably engaged in CIN and child protection work. | Brent Children's Social Care |
| Brent Social Care | Brent Social Care robustly implements CIN planning and review systems | Brent Children's Social Care |
| Brent Social Care | All decisions to proceed to ICPC are discussed with SCD5. | Brent Children's Social Care |
| Ealing ICO Hospital | The FHA Performa should be reviewed and harmonised for all Health Visitors working in the ICO. The Performa should be much more transparent and comprehensive to include a separate social history section. | Ealing ICO Hospital Trust |
| Ealing ICO Hospital | Health visiting teams should have an appropriate guideline protocol for handover of cases during periods of leave particularly long term leave. Information should be clearly evident in case records and to other professionals. The clinical leads should discuss all cases with the health professionals within the team and allocate accordingly. This should include documented evidence on the key events sheet of a signed handover and the name of allocated Health Visitor in their absence. These cases should be individually reviewed with case records available at the point of handover | Ealing ICO Hospital Trust |
| Ealing ICO Hospital | All Health visiting staff working in CSB must attend single agency child protection training level 3. In accordance with the intercollegiate document 2010 assuming competence at level 1+2 first. | Ealing ICO Hospital Trust |
| Ealing ICO Hospital | Implement a Guideline for management of faxes received into Willesden Health visiting team. This needs to include documentation and actions on the new RIO system introduced July 2011 | Ealing ICO Hospital Trust |
| Ealing ICO Hospital | To work in line Harrow community services CSB should consider a specialist Health Visitor to caseload victims of current or historical domestic violence | Ealing ICO Hospital Trust |
| Imperial College Hea | Develop and implement an interim (paper) structured social risk assessment tool for midwives to utilise at the maternity booking assessment until such time as the electronic maternity patient record is implemented. This will serve to act as aide memoir to discuss key issues such as domestic abuse, and provide a vehicle for explicit recording of domestic abuse as a routine enquiry. If routine enquiry is not feasible at the first appointment because the woman is accompanied this will be recorded and the routine enquiry made at a subsequent appointment. Nb this is already incorporated into the design of the incipient maternity electronic patient record due for implementation in 2013. | Imperial College Health Care NHS Trust |
| London Probation | Re-launch of the London Probation Trust Safeguarding Procedures locally in Brent. | London Probation |
| London Probation | Local drive to increase home visiting in the borough | London Probation |
| London Probation | The introduction of reflective supervision for Probation Staff in Brent. | London Probation |
| Metropolitan Police | Brent BOCU must ensure that when a victim wishes to withdraw an allegation of domestic violence, the case is reviewed by a Community Safety Unit (CSU) supervisor. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that when officers attend a Domestic Incident, intelligence research is undertaken to include at least the last five years using the Integrated Information Platform, as required by the MPS Operating Procedures. Where possible officers should be encouraged to search beyond five years. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that supervision and risk assessment during the secondary investigation of domestic violence is conducted by trained CSU supervisors. This is required by both the MPS Standard Operating Procedures (SOP) and by CAADA guidelines. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must comply with the Domestic Violence SOP regarding the completion of Book 124D. The information and risk assessment must be transferred to the CRIS report. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that Book 124Ds are supervised when they are completed and also when received by the Community Safety Unit (CSU.). | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that the supervision of Domestic Violence investigation is intrusive and contain well detailed action plans, and reviews of the risk. Risk assessment must be dynamic. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that all response team officers are aware of the DASH risk assessment model, and that the information is correctly recorded on the relevant CRIS report. | Metropolitan Police |
| Metropolitan Police | Brent BOCU CSU must ensure that when a Book 124D is submitted incomplete, missing or of a poor standard, it is immediately referred back to the original supervisor. | Metropolitan Police |
| Metropolitan Police | Brent BOCU must ensure that when children come to notice in the process of a domestic violence investigation, a Merlin entry is completed (vide Every Child Matters (ECM). | Metropolitan Police |
| Metropolitan Police | The MPS must ensure that all relevant officers and staff are trained in the use of the book 124D, with the DASH risk assessment model. Also, that supervisors are trained and encouraged to intrusively supervise risk assessments. | Metropolitan Police |
| Metropolitan Police | That the MPS update the CRIS system to reflect the new DASH model rather than the older SPECCS+ system. | Metropolitan Police |
| Metropolitan Police | That the MPS may consider changes to the Standard Operating Procedures for the investigation of the Domestic Violence so that initial standard risk assessments are subjected to secondary supervision by the BOCU CSU, to ensure that the risk level is correct. | Metropolitan Police |
| NHS Brent: General P | Within GP protected learning sessions GPs, practice nurses and other clinicians working within the GP services should receive dedicated training sessions on: • Domestic violence to include a DV Risk Assessment Matrix • Information sharing Challenge and support with other practitioners outside the Health economy | NHS Brent |
| NHS Brent: General P | All documents pertaining to patients are scanned in to their records as appropriate. To check with audit after 6 months. | NHS Brent |
| NHS Brent: General P | Domestic violence and child abuse should be a differential diagnosis during consultations | NHS Brent |
| North West London Ho | All documentation has to be entered onto the IT systems held by the trust | North West London Hospital Trust |
| UKBA | The UK Border Agency should make immediate efforts to re-documents immigrants as soon as they are encountered and keep detailed records of the progress. | UK Border Agency |
| UKBA | The UK Border Agency must improve the timeliness of the processing of immigration applications, especially where vulnerable adults or children are concerned. | UK Border Agency |
| UKBA | Other statutory agencies, whether responsible for victims or suspects should routinely and immediately contact the UK Border Agency to share information and intelligence. (This is already contained within the “Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children”). | UK Border Agency | Other Statutory Agencies |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||