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.

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

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

63 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - adjustment disorder
  • Victim - anxiety
  • Victim - depression
  • Victim - panic attacks
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (between victims)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - neurodiverse condition diagnosis
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • 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 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 housing 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 family as a domestic abuse perpetrator
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • 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 - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services 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

31 recommendations pulled from the report · 5 matched to organisations in the index

Recommendation 4.5.1

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.2

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.3

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.4

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.5

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.6

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.7

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.8

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.9

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.10

Addressed to Safer Hillingdon Partnership (SHP)

SHP to ensure that the new MASH arrangement addresses the information sharing needs of schools and education services about cases of domestic abuse.

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

Recommendation 4.5.11

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.5.12

Addressed to Safer Hillingdon Partnership (SHP)

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.

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

Recommendation 4.6.1a

Addressed to London Borough of Hillingdon Children’s Social Care

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.

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

Recommendation 4.6.1b

Addressed to London Borough of Hillingdon Children’s Social Care

Hillingdon Children’s Social Care to ensure that domestic violence dynamics are actively addressed during supervision.

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

Recommendation 4.6.1c

Addressed to London Borough of Hillingdon Children’s Social Care

Hillingdon Children’s Social Care to introduce standards for record keeping.

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

Recommendation 4.6.2a

Addressed to Metropolitan Police

Metropolitan Police to audit the effectiveness of mechanisms in place to prioritise and actively pursue outstanding offenders of domestic abuse.

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

Recommendation 4.6.2b

Addressed to Metropolitan Police

Metropolitan Police to audit the effectiveness of arrangements for increasing the number of prosecutions using evidence based prosecutions.

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

Recommendation 4.6.2c

Addressed to Metropolitan Police

Metropolitan Police to dip sample compliance with the Victim’s Charter to ensure that victims of domestic abuse are regularly updated on progress.

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

Recommendation 4.6.3a

Addressed to Metropolitan Police | Thames Valley Police

Metropolitan and Thames Valley Police to audit compliance with investigative expectations and supervision of allegations of domestic abuse.

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

Recommendation 4.6.3b

Addressed to Metropolitan Police | Thames Valley Police

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.

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

Recommendation 4.6.4a

Addressed to Hillingdon Hospital NHS Foundation Trust

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.

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

Recommendation 4.6.5a

Addressed to Hillingdon CCG

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.

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

Recommendation 4.6.5b

Addressed to Hillingdon CCG

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.

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

Recommendation 4.6.5c

Addressed to Hillingdon CCG

Hillingdon CCG to share the findings and learning from this DHR with Hillingdon GP practices, Out of Hours Service and Hillingdon Urgent Care Centre.

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

Recommendation 4.6.5d

Addressed to Hillingdon CCG

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.

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

Recommendation 4.6.5e

Addressed to Hillingdon CCG

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.

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

Recommendation 4.6.5f

Addressed to Hillingdon CCG

Hillingdon CCG to consider commissioning IRIS or a similar domestic violence programme designed specifically for primary health care teams.

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

Recommendation 4.6.6a

Addressed to London Borough of Hillingdon Housing

Hillingdon Housing to review the local housing procedure and develop guidance on specific considerations when accommodating perpetrators of domestic abuse.

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

Recommendation 4.6.7a

Addressed to Hillingdon IDVA

HIDVA to focus support on high risk cases and review repeat victims and audit to ensure the risk levels are being reduced.

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

Recommendation 4.6.7b

Addressed to Hillingdon IDVA

HIDVA to actively manage their case load and communicate the status of cases to other agencies. This should be subject to regular audit.

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

Recommendation 4.6.7c

Addressed to Hillingdon IDVA

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.

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