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

Lewisham review

CSP: Lewisham Published: April 2023 Year of death: 2011 Extracted: 10 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 significant failures in inter-agency information sharing and risk assessment regarding domestic violence. Concerns were raised about the support for young people leaving care, the management of mental health and substance misuse issues, and the consistent application of policies.

Home Office classifications

17 tags

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

  • Victim - housing issues
  • Victim - mental ill health
  • Perpetrator - case heard in court
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - psychosis
  • Perpetrator - supervised by mental health services
  • Perpetrator - immigration involvement
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes

Extracted recommendations

10 recommendations pulled from the report · 3 matched to organisations in the index

Recommendation 1)

Addressed to All agencies

That all agencies report progress on their internal action plans to the relevant task and finish group of Lewisham CSP.

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

Recommendation 2)

Addressed to Lewisham Community Safety Partnership

That the partnership conducts a review of its effectiveness to establish its strengths and weaknesses. This review, which should be completed by a task and finish sub-group of the Lewisham CSP, to include an examination of:
 The risk assessment processes across all agencies coming into contact with victims and perpetrators of DV, sexual violence or potentially unhealthy relationships
 The effectiveness of information sharing
 The existence and application of agency polices and procedure in relation to DV
 The effectiveness of support to young people leaving care.

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

Recommendation 3)

Addressed to Lewisham Community Safety Partnership

That a new training strategy be designed, following the review:
 to allow frontline practitioners to understand the dynamics of DV and good practice, and,
 to support an increase in questioning about DV and potential risk
 to support an increase in questioning around healthy relationships.

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

Recommendation 4)

Addressed to Lewisham Children’s Social Services

That the Leaving Care Service examine its processes (including risk assessment) when young people move towards independent living, to include consideration of the method of making plans according to specific need and the maintenance of appropriate records, including paper and computer based.

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

Recommendation 5)

Addressed to Lewisham Children’s Social Services

That all senior managers in CSC ensure that the police are requested to investigate any crime where any looked after young person is the victim or perpetrator.

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

Recommendation 6)

Addressed to Local Safeguarding Children’s Board

That the local approach to child sexual exploitation be considered by the Local Safeguarding Children’s Board.

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

Recommendation 7)

Addressed to Lewisham Children’s Social Services | Lewisham Adult Social Care

That a policy of transferring care, when necessary and following risk assessment, from CSC to ASC be implemented.

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

Recommendation 8)

Addressed to Lewisham Community Safety Partnership

That the issue of dual or triple diagnosis (DV/mental health/substance misuse) be the subject of a local project to establish understanding and future processes.

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

Recommendation 9)

Addressed to London Probation Trust | South London and Maudsley NHS Foundation Trust

That LPT and Slam agree a process to ensure all relevant staff within both organisations are provided with guidance on how a community order with a mental health treatment requirement is assessed and administered and any case where clients are being cared for by both organisations.

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

Recommendation 10)

Addressed to South London and Maudsley NHS Foundation Trust

That SLaM teams in Lewisham are made aware of referral routes and criteria for the appropriate organisation where cannabis or other type of substance misuse is discovered.

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