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
Haringey review
CSP: Haringey
Published: April 2023
Year of death: 2013
Extracted: 56 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 a poor understanding of domestic abuse dynamics, including coercive control and victim non-engagement, across agencies. This led to fragmented multi-agency responses, insufficient perpetrator accountability, and missed opportunities to safeguard the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Haringey Council to develop and implement a domestic abuse policy as a matter of urgency. This would provide information and guidance for staff working with the public. It would also include information and guidance for employees of Haringey Council as managers, colleagues and victims of domestic abuse and include information for how to escalate concerns about one’s own situation or that of others so that Haringey can be pro-active in tackling domestic abuse and supporting victims. | Haringey Council |
| 1 | That the Hertfordshire DA Partnership Board review the provision for DV victims presenting to GPs with local CCGs to ensure GPs understand their unique role in identifying domestic abuse and are trained to respond effectively. | Hertfordshire DA Partnership Board |
| 1 | HMPS develop a national policy and practice for working with perpetrators of domestic abuse when they are in custody and for addressing its role in keeping victims and their children safe. This policy would: (c) Ensure that perpetrators of domestic abuse are identified when in custody (even when offence leading to custody is not obviously domestic abuse), and that (d) The new OM model explicitly addresses the abusive relationships of offenders. Work is undertaken with DV perpetrators in custody (whether for short or longer-terms) to address their abusive behaviours and views. Where prisoners are assessed as not suitable for this work yet, work is undertaken to prepare them for such work. (e) The prison acknowledges its role in protecting victims by: (f) Creating opportunities for victims to access support (g) Signposting victims to support, and highlighting the freedom to make choices that the perpetrator’s incarceration may be offering them (h) Improving communication and information-sharing with agencies in the community that work with victims and their children (i) Incorporating as part of the new initiative of monthly Offender Pre-Release Meetings, a requirement to explicitly address offenders’ relationships, identifying abusive relationships and linking to external support for offenders and victims, and their families, so that safety measures can be put in place to protect victims and their children when the perpetrator is released (j) Offering support services for women prisoners who are victims of domestic abuse | HM Prison Service |
| 1 | Implement the IRIS scheme nationwide to educate GPs and engage them in helping victims, perpetrators and their families. | NHS England |
| 1 | That the HO conduct an audit of criminal justice processes to ensure that the system and its various agencies work together to create a coordinated response for the safety of victims of domestic abuse and to hold perpetrators accountable. | Home Office |
| 1 | It is recommended that Barnet Senior Leadership Team (SLT) develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete, regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: (a) MAPPA (see Appendix 5) (b) Information-sharing | Metropolitan Police Service |
| 1 | That Hertfordshire Constabulary develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete, regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: (a) Basic domestic abuse awareness, including coercive control (b) Sharing the lessons learned in this review (c) Domestic Abuse Policies and Toolkits (d) DASH First responders/ Specialist Staff/ Supervisors (e) RARA (f) MAPPA (g) MARAC (h) IDVA (i) IOM (j) Research – local/ cross border (k) Counter allegations (l) Information sharing (m) Safety planning and liaising with the victims | Hertfordshire Constabulary |
| 1 | That the CPS review and revise its record-keeping policy so that it can contribute meaningfully to Domestic Homicide Reviews by providing details of its decision-making in cases of domestic abuse and where protective orders are in place. | Crown Prosecution Service |
| 1 | That Homes for Haringey create a policy and procedure that comprehensively deals with their role in situations where tenants are perpetrators or victims, or where domestic abuse has occurred in their premises. It should include: (a) A response that prioritises the safety of victims and clear roles for staff (b) Training for frontline workers, especially concierges and repair staff, to identify abuse and engage victims in help-seeking (c) The sharing of information with other agencies so that the risks are known (d) An understanding of risk assessment in domestic abuse (e) Links to DV support structures in Haringey and neighbouring boroughs (f) A process for sharing information on threats to staff safety internally (g) Considerations of the alleged perpetrator’s known relationships, where staff feel threatened (h) Ensure all staff know the process for this and the expectations of Homes for Haringey about their role. (i) Ensure all staff know about the counselling helpline. | Homes for Haringey |
| 1 | Refresh and formalise the procedure for requesting information from the MPS to ensure that requests are targeting all the information relevant to the concerns that the ASB is investigating. | Haringey Anti-Social Behaviour Team |
| 1 | Strengthen systems with referring agencies, including: (a) Request that referring agency supplies several safe contact numbers, if possible, and asks the victim for safe times to call. (b) Staff training includes notifying referrer when contact cannot be established with referred victim. (c) Staff to be reminded in case review sessions to notify referrer in such situations and ensure this action is recorded on the VS case management systems. (d) As part of case management, random sampling of closed cases to be undertaken to ensure that case notes show whether referrer was notified of non-contact. | Victim Support London |
| 1 | That any victims of domestic abuse that are referred to the IDVA and MARAC that do not engage should be discussed in case reviews as a standing agenda item and other ways of getting support to the victim discussed. | Solace Women’s Aid | NIA |
| 1 | That Hertfordshire IDVA service liaise with the local NPS Victim Contact Scheme to provide support and safety planning for victims and their families when perpetrators are released. | Refuge – Hertfordshire IDVA Service |
| 1 | London MAPPA Strategic Management Board should maintain its focus on the assessment and effective management of the risks posed by domestic abuse offenders. Key areas include the following: (a) Training for MAPPA chairs to include domestic abuse awareness, particularly an understanding of coercive control (b) Use of the MAPPA Category 3 (other dangerous offenders) where appropriate so that domestic abuse perpetrators who do not qualify for MAPPA Category 162 or for Category 263 may be managed under MAPPA. (c) The relationship between MAPPA and MARAC so that this is understood and implemented locally, in accordance with the Ministry of Justice MAPPA Guidance64, as local guidance produced by the London MAPPA Executive Office and incorporated in NPS London MARAC Guidance. | London MAPPA Strategic Management Board |
| 1 | That the IOM Unit refresh and formalise the procedures and guidance for: (a) Actions to proactively manage non-compliance with IOM requirements and/or licence conditions. This would include clear guidance and standards for investigation, recording and enforcement (b) Standards of non-compliance that should trigger a partnership assessment (c) Appropriate actions where offenders commit acts of violence against women and girls, including coercive control. | Integrated Offender Management Unit |
| 1 | Create clear guidance on the robust management of absences by those on licence so that the opportunity to address offending and reduce risk to others is not missed and so that offenders are held accountable. | London Community Rehabilitation Company |
| 1 | Develop training for women-only cohorts so that issues of domestic abuse can be explored and strategies put in place during the probationary period. | National Probation Service |
| 1 | Substance misuse services should: (a) Include in their domestic abuse policy a response to non-engagement with services by those on licence. This case shows the link between non-engagement and increasing risk. (b) Engage with multi-agency approaches to addressing victim safety and perpetrator behaviour. | Substance Misuse Agencies |
| 1 | Domestic violence training to become mandatory for all clinical staff, with priority given to staff in ED, maternity and sexual health clinics. Training to include: (a) Routine enquiry (as stated in the Managing DV Policy, s. 62) (b) Identifying behaviour, symptoms and injuries that are likely to be indicators of domestic abuse and enquiring further about them (c) Creating a safe space to ask questions of the possible victim (d) Responses to disclosures, including risk assessments, MARAC and referral pathways. Access to further information and advice (e) Encouraging engagement of victims (f) The unique role of health services in supporting and protecting victims of domestic abuse. | North Middlesex University Hospital NHS Trust |
| 10 | It is recommended that MPS circulate to their CSUs and PVPs information about their policy that allows the waiver of recovery costs for vehicles that have been reported as lost or stolen in situations of domestic abuse. | Metropolitan Police Service |
| 2 | Haringey Council to encourage or require (as is appropriate to the relationship) organisations that work in partnership with the Council, such as independent schools, and Arms-length Management Organisations (ALMOs) to have domestic abuse policies and practices for its employees and those who use their services. | Haringey Council |
| 2 | As part of oversight of the local VAWG services, monitor Hertfordshire Constabulary’s referrals to local support services, in particular the new IDVA service for high-risk victims. | Hertfordshire County Council |
| 2 | That the NHS provide improved guidance to GPs on how to engage with DHRs including: (a) The legal basis for sharing information in these circumstances (b) The nature of the information needed by this process (c) The selection of an appropriate IMR writer (d) Support for staff in the surgery following a homicide of a patient of the surgery. | NHS England |
| 2 | That the Ministry of Justice work with the HO to create a system enabling the police to be alerted when civil orders are granted that provide protection in domestic abuse cases (This ties into MPS Recommendation 9 and Hertfordshire Constabulary Recommendation 3. | Ministry of Justice | Home Office |
| 2 | It is recommended that Haringey SLT develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete, regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: (c) Sharing the lessons learned in this review (d) Domestic Abuse Policies and Toolkits (e) DASH First responders/ Specialist Staff/ Supervisors (f) RARA, (risk management model: remove risk, avoid the risk, reduce the risk or accept the risk) (g) MAPPA (h) MARAC (i) IDVA – referral to and working with to engage the victim (j) IOM (k) Research – local/ cross border (l) Counter allegations (m) Information sharing (n) Safety planning | Metropolitan Police Service |
| 2 | Risk Assessments of frontline officers are monitored and a feedback is provided to ensure consistent and accurate risk assessments are provided by the staff. | Hertfordshire Constabulary |
| 2 | Improve information sharing with other agencies through referrals to Hearthstone, MARAC and engagement with MAPPA and other multi-agency meetings. Monitor these to track the impact of improved training and procedures. | Homes for Haringey |
| 2 | ASB develop a VAWG policy that identifies their role in addressing VAWG, the training that staff need, the policies and procedures that link to this (safeguarding policies, for instance) and the link to the safeguarding procedures and relevant procedures and referral procedures. The ASB team’s role in multi-agency work around VAWG, e.g. MARAC, MASE, MASH. | Haringey Anti-Social Behaviour Team |
| 2 | Staff to review CMS for victims’ details where contact with victim has not been established to identify repeat DV incidents and possible referrals to MARAC. | Victim Support London |
| 2 | That the IOM Team receive training on violence against women and girls, including general awareness, safeguarding procedures and referral and other procedures to address the safety of victims. | Integrated Offender Management Unit |
| 2 | In light of the restructure, that LCRC ensure it is part of the local coordinated community response to domestic abuse by (a) Training LCRC staff on: (i) Their part in addressing domestic abuse (ii) The local referral pathways to services for perpetrators and victims (b) Preparing and attending the multi-agency groups that address domestic abuse, that is, MARACs, MAPPAs, and IOM. (c) Creating protocols and policies to embed this involvement. (d) Monitoring participation in MA groups and referrals to specialist agencies. This information is compiled and sent to the local VAWG strategic group. | London Community Rehabilitation Company |
| 2 | That oversight of cases includes improvements in: (a) Timing and quality of risk assessments; (b) The recording of risk management plans and progress against them; (c) The recording of MA discussions (MARAC, MAPPA, IOM) and resulting action plans in client files; (d) Regular investigation of information and research to corroborate information from offenders and hold them accountable. | National Probation Service |
| 2 | That the Trust provide an IDVA service in ED. | North Middlesex University Hospital NHS Trust |
| 3 | Haringey Council require all local authority schools to: (a) Include responses to domestic abuse in their HR policies for staff and (b) Provide advice to staff about domestic abuse. | Haringey Council |
| 3 | It is recommended that Enfield SLT develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: (o) Sharing the lessons learned in this review (p) Domestic Abuse Policies and Toolkits (q) DASH First responders/ Specialist Staff/ Supervisors (r) RARA (s) MAPPA (t) MARAC (u) IDVA – referral to and working with to engage the victim (v) IOM (w) Research – local/cross border | Metropolitan Police Service |
| 3 | It is recommended that upon receipt of a court order and/or restraining order that ‘specified’ crime report be opened, the victim contacted and the following actions completed: (a) Contact the victim to gather and share information. (b) DASH (c) RARA (d) IDVA – referral to and working with to engage the victim (e) Emergency planning (f) Special schemes (g) Panic Alarms (h) Special personal alarms (i) Research (j) Crime Information System (CIS) (k) MARAC (l) MAPPA (m) IOM (n) ASBO (o) Supervision (p) Enhanced supervision (q) DVPO/injunction/restraining order. | Hertfordshire Constabulary |
| 3 | ASB team source VAWG and DA training for staff, including general awareness training, an understanding of risk assessment in domestic abuse and the MARAC process, safeguarding procedures and application of the relevant procedures and referral procedures. | Haringey Anti-Social Behaviour Team |
| 3 | At four-weekly case reviews with managers, cases where the RIC was borderline high risk, that is 12 or 13, are reviewed against previous and new incidents to inform professional judgement in the case. | Victim Support London |
| 3 | That the IOM Unit work with domestic abuse services to review their processes around prison release to identify opportunities to protect victims of VAWG. | Integrated Offender Management Unit |
| 3 | That LCRC develop a domestic abuse policy that addresses offenders as victims and perpetrators of domestic abuse, including: (a) Specific work with women on Community Payback scheme who are victims of domestic abuse (b) Ways to identify and support victims of domestic abuse, for instance, by adding relevant questions to assessment processes and by creating opportunities for women to disclose, discuss and address the abuse they have and are suffering (c) Clearly outlines the response to violent offenders’ reports of their relationships that addresses the risk to offenders’ partners, especially when there is a history of violence against women. | London Community Rehabilitation Company |
| 3 | Ensure that domestic abuse victims and their families are informed about the Victim Contact Scheme and the information it can provide when the perpetrator is sentenced to 12 months or more in prison or when the offender is detained as a mental health patient. | National Probation Service |
| 3 | The Trust’s DV guidelines to be expanded to be used by staff across the Trust. | North Middlesex University Hospital NHS Trust |
| 4 | Haringey Council use this case in DA training to emphasise common weaknesses in a response to domestic abuse and how to address them, emphasising the role of every agency in delivering a coordinated community response for every victim of abuse. | Haringey Council |
| 4 | It is recommended that Waltham Forest SLT develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete, regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: (a) Sharing lessons learned in this review (b) Domestic Abuse Policies and Toolkits (c) DASH First responders/ Specialist Staff/ Supervisors (d) MARAC (e) Information sharing (f) Safety planning. | Metropolitan Police Service |
| 4 | That LCRC explore the option of female-only projects as a way to create opportunities for victims of domestic abuse to discuss and address domestic abuse. | London Community Rehabilitation Company |
| 4 | That the Victim Contact Scheme provide details of the local domestic abuse service(s) to victims and their families, and particularly when the service informs victims and their families of perpetrators’ imminent release. | National Probation Service |
| 4 | The Trust develops DV Champions throughout the hospital, again prioritising ED, maternity and sexual health clinics. | North Middlesex University Hospital NHS Trust |
| 5 | Haringey CSP ensures that action plans associated with responses to domestic abuse, including this DHR, are completed as quickly as possible to minimise the harm resulting from domestic abuse to its staff and residents. The action plan from the original internal review should be updated and outstanding actions rolled into the action plan from this review. | Haringey CSP |
| 5 | It is recommended that Islington SLT develop and deliver a training package for primary and secondary frontline investigators and supervisors to ensure understanding and compliance with Domestic Abuse policies and procedures. Once complete, regular ‘dip’ sampling should be conducted to ensure compliance. This training should include: a) Sharing lessons learned in this review b) Domestic Abuse Policies and Toolkits c) DASH First responders/ Specialist Staff/ Supervisors d) Research – local/cross border | Metropolitan Police Service |
| 5 | The Trust’s DV policy is updated to reflect these changes. | North Middlesex University Hospital NHS Trust |
| 6 | Drawing on this report and the experience of Review Panel members, create a strategy and guidance for addressing the situation of domestic abuse victims that find it difficult to engage with services. Consider high-risk victims, victims of serial violent offenders and victims with complex needs. | Haringey Council |
| 6 | It is recommended that the MPS review how ‘high risk’ domestic abusers are profiled and flagged to ensure that investigators have the fullest available picture when assessing and managing risk. | Metropolitan Police Service |
| 7 | When commissioning substance misuse agencies, Haringey Council require that such services: (a) Gather information about clients’ relationships and families as part of their assessments, (b) They identify risk and include this information in referrals and feed this to partner agencies through the multi-agency groups, including MARAC, and that they contribute to MARAC. | Haringey Council |
| 7 | It is recommended that this review be forwarded to Simon Tee, Head of the Criminal Justice Offender Managers Services (CJOMS), for the lessons learned to be considered by the Judicial Order Working Group. | Metropolitan Police Service |
| 8 | It is recommended that this review be forwarded to Detective Superintendent Sean Oxley, for the lessons learned to be considered by the ‘Offender Management Working Group’. | Metropolitan Police Service |
| 9 | It is recommended that upon receipt of a court order and/or restraining order that ‘specified’ crime report be opened, the victim contacted and the following actions completed: (g) Contact the victim to gather and share information. (h) DASH (i) RARA (j) IDVA – referral to and working with to engage the victim (k) Emergency planning (l) Special schemes (m) Panic Alarms (n) Special personal alarms (o) Research (p) Crimint (q) MARAC (r) MAPPA (s) IOM (t) ASBO (u) Supervision (v) Enhanced supervision (w) DVPO/injunction/restraining order. | Metropolitan Police Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||