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: 31 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 systemic failures in multi-agency partnership, information sharing, and risk identification for domestic abuse. Agencies lacked awareness of coercive control, struggled to support the victim with complex needs, and did not effectively hold the perpetrator accountable.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 4.5.1 | Safer Hillingdon Partnership (SHP) to conduct a rigorous borough wide review of Hillingdon’s strategic overview and operational response to domestic violence. This review must address: a) the effectiveness of the SHP, specifically the effectiveness of the governance and strategic leadership that the partnership provides for domestic abuse; b) the effectiveness of the Domestic Violence Forum and related sub-groups, c) the strategic direction and priorities for Hillingdon; d) the gap between the strategy and delivery of the strategic aims by all agencies. | Safer Hillingdon Partnership (SHP) |
| 4.5.10 | SHP to ensure that the new MASH arrangement addresses the information sharing needs of schools and education services about cases of domestic abuse. | Safer Hillingdon Partnership (SHP) |
| 4.5.11 | SHP to ensure that all partner agencies agree a policy on the reallocation of domestic violence cases when a conflict of interest exists or there is a failure to develop a workable relationship with the client. | Safer Hillingdon Partnership (SHP) |
| 4.5.12 | SHP to review the multiagency training strategy including: (a) Front-line and professional staff awareness of the dynamics of domestic abuse, especially coercive control and non-engagement. This must include consideration, in partnership with Hillingdon CCG, of commissioning IRIS or a similar domestic violence programme designed specifically for primary health care teams including General Practice, the Out of Hours service and the Urgent Care Centre. (b) Front line and professional staff’s skills in safe enquiry and disclosure, and the specific challenges of working with victims of coercive control and poor engagement. (c) Ensuring front-line and professional staff are aware of the heightened risks associated with domestic abuse, mental ill health, and drug and alcohol misuse. (d) Audit safeguarding children’s training (and take up across the multi-agency partnership) to ensure that domestic violence is appropriately addressed. (e) Audit adult safeguarding training (and up take across the multi-agency partnership) to ensure that domestic violence is appropriately addressed. | Safer Hillingdon Partnership (SHP) |
| 4.5.2 | SHP to ensure that all partner agencies conduct an internal review of their domestic violence/abuse policies and procedures in relation to how they identify, risk assess, refer and respond appropriately to victims, particularly those who don’t engage and/or are subject to coercive control, and make changes as appropriate. This must include reviewing referral pathways to multi-agency forums (MARAC, MAPPA and Safeguarding) and ensuring that they are clearly identified and utilised. | Safer Hillingdon Partnership (SHP) |
| 4.5.3 | SHP to review the partnership approach to perpetrators of domestic abuse and produce recommendations for change based on the learning from the two recent DHRs. | Safer Hillingdon Partnership (SHP) |
| 4.5.4 | SHP to undertake a needs assessment and review of existing domestic abuse specialist support services (including the management of IDVA), and develop a comprehensive commissioning strategy that meets the needs of both victims and perpetrators and includes a focus on prevention and early intervention. | Safer Hillingdon Partnership (SHP) |
| 4.5.5 | SHP to review the use of the CAADA DASH risk identification checklist in Hillingdon agencies including: the purpose of DASH completion, the adoption of DASH consistently across agencies and in front line practice, the use of DASH as an on-going risk identification tool, and the arrangements for sharing of risk information outcomes between agencies involved with the same client. A multi-agency task and finish group should be established in order to develop a multiagency protocol regarding the risk assessment of victims of domestic violence. | Safer Hillingdon Partnership (SHP) |
| 4.5.6 | SHP to establish a task a finish group in order to develop a multiagency protocol on information management including creating a common information record and sharing information on victims and perpetrators of domestic violence. | Safer Hillingdon Partnership (SHP) |
| 4.5.7 | SHP to review the effectiveness of the information available to the public about the appropriate action to take if they have concerns about the risk of domestic violence against a person, to enable the police and other agencies to intervene positively. | Safer Hillingdon Partnership (SHP) |
| 4.5.8 | SHP to seek assurance from partner agencies that they are compliant with the NICE guidelines on domestic violence and abuse; multi agency working, by local agencies. | Safer Hillingdon Partnership (SHP) |
| 4.5.9 | SHP to review provision for perpetrators of domestic abuse released from prison and develop a plan to include the provision of suitable housing, access to primary health care, access to mental health services and prescribed medication. | Safer Hillingdon Partnership (SHP) |
| 4.6.1a | Hillingdon Children’s Social Care to ensure that they assess and take appropriate steps to address the abusive behaviour of perpetrators who come within the remit of their service. | London Borough of Hillingdon Children’s Social Care |
| 4.6.1b | Hillingdon Children’s Social Care to ensure that domestic violence dynamics are actively addressed during supervision. | London Borough of Hillingdon Children’s Social Care |
| 4.6.1c | Hillingdon Children’s Social Care to introduce standards for record keeping. | London Borough of Hillingdon Children’s Social Care |
| 4.6.2a | Metropolitan Police to audit the effectiveness of mechanisms in place to prioritise and actively pursue outstanding offenders of domestic abuse. | Metropolitan Police |
| 4.6.2b | Metropolitan Police to audit the effectiveness of arrangements for increasing the number of prosecutions using evidence based prosecutions. | Metropolitan Police |
| 4.6.2c | Metropolitan Police to dip sample compliance with the Victim’s Charter to ensure that victims of domestic abuse are regularly updated on progress. | Metropolitan Police |
| 4.6.3a | Metropolitan and Thames Valley Police to audit compliance with investigative expectations and supervision of allegations of domestic abuse. | Metropolitan Police | Thames Valley Police |
| 4.6.3b | Metropolitan and Thames Valley Police to review the arrangements for ensuring that all relevant information is gathered before conducting arrest attempts in relation to domestic violence in another forces area. This should be subject to dip sampling to ensure compliance. | Metropolitan Police | Thames Valley Police |
| 4.6.4a | Hillingdon Hospital to improve the arrangements for sharing safeguarding concerns between Accident and Emergency, liaison psychiatry, and all other departments within the hospital, including outpatients. Success measures should be identified and audited. | Hillingdon Hospital NHS Foundation Trust |
| 4.6.5a | Hillingdon CCG to provide assurance to SHP that CNWL’s action plan arising from the Internal Investigation Report has been implemented. The action plan will be monitored by the CCG using the Goodall Safeguarding meeting. An update on the action plan should be provided within six months of the DHR being approved by the Partnership. Further updates to be determined by the Partnership. | Hillingdon CCG |
| 4.6.5b | Hillingdon CCG to oversee the implementation of NICE guidelines on Antisocial Personality Disorders: prevention and management, and to evaluate the effectiveness of local provision for people with personality disorders. | Hillingdon CCG |
| 4.6.5c | Hillingdon CCG to share the findings and learning from this DHR with Hillingdon GP practices, Out of Hours Service and Hillingdon Urgent Care Centre. | Hillingdon CCG |
| 4.6.5d | Hillingdon CCG to work with Hillingdon health service providers to ensure that all information systems enable the flagging of high risk victims of domestic abuse. | Hillingdon CCG |
| 4.6.5e | Hillingdon CCG to ensure that all Hillingdon GP practices, the Out of Hours Service and the Hillingdon Urgent Care Centre develop policies that ensure staff are aware of the issue of domestic violence, how to identify and assess people at risk, how to identify and assess perpetrators of domestic violence, what services are available locally and the referral pathway. | Hillingdon CCG |
| 4.6.5f | Hillingdon CCG to consider commissioning IRIS or a similar domestic violence programme designed specifically for primary health care teams. | Hillingdon CCG |
| 4.6.6a | Hillingdon Housing to review the local housing procedure and develop guidance on specific considerations when accommodating perpetrators of domestic abuse. | London Borough of Hillingdon Housing |
| 4.6.7a | HIDVA to focus support on high risk cases and review repeat victims and audit to ensure the risk levels are being reduced. | Hillingdon IDVA |
| 4.6.7b | HIDVA to actively manage their case load and communicate the status of cases to other agencies. This should be subject to regular audit. | Hillingdon IDVA |
| 4.6.7c | HIDVA to ensure proactive and timely support for victims when known perpetrators are due to be released from prison. This should be overseen in supervision. | Hillingdon IDVA |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||