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

Hillingdon review

CSP: Hillingdon Published: April 2023 Year of death: 2015 Extracted: 21 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identified concerns regarding agencies' inconsistent perception of the victim's vulnerability, over-reliance on bail conditions in risk assessments, and insufficient attention to the victim's stated fears. It also highlighted issues with inter-agency communication, perpetrator accountability, and MARAC governance.

Home Office classifications

50 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - housing issues
  • Victim - pregnancy
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Victim - immigration involvement
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - post traumatic stress disorder (ptsd)
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - school recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

21 recommendations pulled from the report · 7 matched to organisations in the index

Recommendation 1

Addressed to Safer Hillingdon Partnership

The recommendations below should be acted on through the development of a partnership owned action plan. This is in addition to the actions identified in individual IMRs: initial reports on progress by agencies on their IMR action plans should be made to the Safer Hillingdon Partnership within six months of the Review being approved by the Partnership.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Crown Prosecution Service | Her Majesty’s Court and Tribunals Service | Metropolitan Police | Safer Hillingdon Partnership

A briefing to be prepared jointly by the Crown Prosecution Service, Her Majesty’s Court and Tribunals Service (HMCTS) and the Metropolitan Police outlining the current processes in place for partnership working and sharing of performance and case information (including any meetings), and for this to be distributed appropriately through each agency. The Crown Prosecution Service, HMCTS and the Metropolitan Police to meet to identify the development required to improve these processes; and to take action on these. Updates to be provided to the Safer Hillingdon Partnership.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Metropolitan Police Service | Crown Prosecution Service | IDVA service

Metropolitan Police Service, Crown Prosecution Service and the IDVA service to jointly establish a multi-agency procedure in relation to Restraining Orders, with reference to the learning in this case.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Southall Black Sisters | IDVA service | Safer Hillingdon Partnership

Southall Black Sisters and the IDVA service to ensure – through procedure, training and ongoing supervision – that all support staff establish contact with the Officer in the Case for clients who are engaged in the criminal justice system, and remain in contact with them until cases are completed. The Safer Hillingdon Partnership to also disseminate this learning to other agencies in Hillingdon that support domestic abuse victims.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Safer Hillingdon Partnership

The Safer Hillingdon Partnership to ensure that all domestic abuse specialist services operating in Hillingdon are notified of new domestic homicides at the earliest point possible.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Safer Hillingdon Partnership

The Safer Hillingdon Partnership to raise awareness – through for example fact sheets, awareness sessions and/or training, and drawing on appropriate expertise in relation to BAME female victims of domestic abuse – of the intersections of race and gender and how they impact on women’s experiences of domestic abuse. With reference to the learning from this case; and to include directions to staff on where further advice can be sought. For information to also be added to standard Domestic Abuse Awareness training.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to MARAC Steering Group

In the redevelopment of the local MARAC process, the MARAC Steering Group to develop a process through which education services (schools) and General Practices can be appropriately involved (though not necessarily always attend) in the MARAC process.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Safer Hillingdon Partnership | MARAC Steering Group | Local Safeguarding Children Board | Adult Safeguarding Boards

The Safer Hillingdon Partnership to ensure, through regular reports from the MARAC Steering Group, that the MARAC redevelopment outlined in this review continues to make progress. In particular that a review of the MARAC Steering Group terms of reference, chairing and membership has taken place with reference to the points made in this review, and that the Local Safeguarding Children and Adult Safeguarding Boards are appropriately involved.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Children’s Social Care | Safer Hillingdon Partnership

Children’s Social Care to review the free materials available from http://endingviolence.com and, also with reference to the learning in this case: ensure that fathers are always spoken with in domestic violence/abuse cases (where safe to do so, and in those cases where it is not, to document it) ensure that perpetrators are held accountable for domestic violence/abuse, and that non-abusive parents are therefore fully supported and not expected to stop the abuse themselves For this to be regularly reviewed in supervision, and for a dip sample audit to take place six months after changes have been made, with the results reported to the Safer Hillingdon Partnership.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to school

For the school to ensure that domestic violence/abuse policies, procedures and training for staff include the need to see parents alone when there has been a disclosure or suspicion of domestic violence/abuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to CNWL

CNWL to review their domestic abuse policy in light of the learning from this case, and in particular to ensure that it contains adequate information and guidance on warning signs/triggers in relation to domestic violence/abuse perpetrators.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to Hillingdon Hospital

Hillingdon Hospital to ensure that Hospital database systems link family members together so that they can be identified when an individual attends.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 13

Addressed to Safer Hillingdon Partnership

Safer Hillingdon Partnership to carry out a review to establish service users’ and partner agencies’ views on the IDVA service being located in a statutory service. The experiences of other boroughs to be sought, and the findings to be acted on accordingly in relation to service delivery.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 14

Addressed to Safer Hillingdon Partnership

The Safer Hillingdon Partnership (or a delegated short term working group) to review the use of the DASH risk identification checklist in Hillingdon agencies, covering (other issues may also be identified): the purpose of DASH completion the use of DASH as an ongoing risk identification tool (rather than as a one off threshold tool) the sharing of risk identification outcomes between agencies involved with the same client

Verified wording from the published review · Original review (PDF) ↗

Recommendation 15

Addressed to Metropolitan Police Service

Metropolitan Police Service to review the ongoing contact by Officers in the Case with victims as investigations and trials progress, in light of the learning from this case.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 16

Addressed to Specialist Domestic Violence Court (SDVC) Steering Group | IDVA service | Safer Hillingdon Partnership

The Specialist Domestic Violence Court (SDVC) Steering Group to review, with the IDVA service and other relevant services, the support provided at the SDVC to victims of domestic abuse/violence, with particular reference to victims in cases that are transferred from the Magistrate’s Court to the Crown Court. To report to the Safer Hillingdon Partnership on the Review and any actions taken as a result.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17

Addressed to Safer Hillingdon Partnership

Safer Hillingdon Partnership to carry out a review of existing domestic abuse specialist support services, that includes all services operating in Hillingdon (not just those based in Hillingdon), to establish how the needs of minority ethnic victims are met. To also include consultation with minority ethnic women in the borough on whether they feel their needs are met, and their opinion on how services should operate. For the learning from the review to be acted upon and progress reported back to the Safer Hillingdon Partnership.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 18

Addressed to Metropolitan Police Service | Safer Hillingdon Partnership

Metropolitan Police Service to review their processes (and conduct a dip sample audit) in relation to arrest, and withdrawal statements, with reference to the learning in this case, and to report back to the Safer Hillingdon Partnership addressing these learning points.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 19

Addressed to DHR Panel members | Safer Hillingdon Partnership

All members of the DHR Panel and Safer Hillingdon Partnership to conduct internal reviews of their domestic violence/abuse policies and procedures in relation to how they identify, risk assess, refer and respond appropriately to perpetrators (including alleged), to make changes as appropriate and report to the Safer Hillingdon Partnership.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 20

Addressed to Safer Hillingdon Partnership

The Safer Hillingdon Partnership to review the structure, governance, membership and Terms of Reference of the partnership responsible for domestic violence/abuse, to address the points made in this review, including but not limited to: The need to provide governance of the MARAC and MARAC Steering Group; including the necessity of different partner agencies chairing the MARAC and the MARAC Steering Group. The MARAC Steering Group to report into an appropriate partnership group. The need for the partnership to be inclusive of the voluntary sector. Ensuring that all organisations in Hillingdon understand the purpose and role of the partnership responsible for domestic abuse/violence; their role within it and their ability to present issues and potential to effect change.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 21

Addressed to Safer Hillingdon Partnership | MARAC Steering Group

The Safer Hillingdon Partnership and MARAC Steering Group to establish a procedure for all agencies and the MARAC to respond appropriately to situations in which a known perpetrator poses a risk to someone not known to agencies, including those out of area.

Verified wording from the published review · Original review (PDF) ↗