Recommendation 1
It is recommended that Tower Hamlets Senior Leadership Team (SLT) carry out a dip sample of reports to ensure that ACN reports are being created where required.
Verified wording from the published review · Original review (PDF) ↗
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
Tower Hamlets review
CSP: Tower Hamlets
Published: April 2023
Year of death: 2015
Extracted: 8 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
The review identified missed opportunities by police, adult social care, and health agencies to share information, assess risks, and intervene effectively in a household with a history of domestic conflict, substance misuse, and mental health issues, impacting the victim and their vulnerable mother.
Home Office classifications
32 tags
Source-supplied classifications used by the Home Office to catalogue this review.
- Victim - was a carer
- Victim - alcohol misuse
- Victim - substance misuse
- Victim - mental ill health
- Victim - anxiety
- Victim - depression
- Victim - psychosis
- Victim - had been a victim of an abuser before
- Victim - immigration involvement
- Perpetrator - case heard in court
- Perpetrator - issued life sentence
- Perpetrator - was a carer
- Perpetrator - alcohol misuse
- Perpetrator - substance misuse
- Perpetrator - anxiety
- Perpetrator - depression
- 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 others as a domestic abuse perpetrator
- Perpetrator - known to family as a domestic abuse perpetrator
- Perpetrator - immigration involvement
- Aggravating factors - psychological or emotional abuse
- Aggravating factors - physical abuse
- Aggravating factors - economic abuse
- DHR process - police recommendations
- DHR process - social services recommendations
- DHR process - technology systems recommendation themes
- DHR process - identification of risk recommendation themes
- DHR process - training recommendation themes
- DHR process - multi agency working recommendation themes
- DHR process - other recommendation themes
Extracted recommendations
Recommendation 2
All officers involved in the investigation of the domestic abused incidents on 19/07/2014 [DAI 11] and 23/07/2014 [DAI 12] should be de-briefed by the SLT in order to assess the officers’ knowledge of the Vulnerable Adult Framework (VAF).
Verified wording from the published review · Original review (PDF) ↗
Recommendation 3
In complex cases, or where concerns are raised, practitioners convene professionals’ meetings to share information
Verified wording from the published review · Original review (PDF) ↗
Recommendation 4
Where, as a result of concern around safeguarding or risk behaviour, referrals are made to other agencies, practitioners do not close casework and they monitor responses so that their support planning can respond to advice and provision of the other agency. Where responses are delayed or insufficient to manage risk, practitioners remain involved to secure a response or escalate according to the risks or concerns that trigger the original request
Verified wording from the published review · Original review (PDF) ↗
Recommendation 5
No patient should be considered for discharge from THCfMH within 24 hours of admission without the agreement of a senior member of staff. Senior members of staff include the following: the borough lead nurse and deputy borough lead nurse, the responsible clinician or duty consultant and the modern matron or ward manager
Verified wording from the published review · Original review (PDF) ↗
Recommendation 6
That the senior management team of Tower Hamlets Specialist Addictions Services should review the migration strategy between EDM and Nebula and analyse the risks and benefits of further migration of all EDM patient data
Verified wording from the published review · Original review (PDF) ↗
Recommendation 7
LBTH Adult Safeguarding Board To commission a task and finish group to review the specific learning from this review about effective communication between safeguarding agencies, adopting a ‘think family’ approach to develop a narrative case study to be shared at relevant Tower Hamlets Partnership learning events
Verified wording from the published review · Original review (PDF) ↗
Recommendation 8
LBTH Adult Safeguarding Board To commission a project working group to explore the greater use of CCTV in the context of adult safeguarding within a suspected domestic abuse environment and present findings and recommendations for consideration
Verified wording from the published review · Original review (PDF) ↗