Kingston upon Thames review

The Trust to develop robust system for recording the details of dependent children or regular contact with children.

Impacts of parental mental illness to be embedded in safeguarding and risk training.

Impact of Domestic Violence to be embedded in safeguarding and risk training.

Mental health assessments for suicidal actions or ideation should include whether there is a risk of domestic abuse

Domestic Violence and Mental health embedded in Safeguarding Children training for all practitioners.

Where there are identified dependent children practitioners must assess, discuss and record how this information will be shared with other agencies. This includes seeking advice and consultation with the Named Professionals within the Mental Health Trust or making direct contact with the Local Authority to discuss or refer the case.

Trust to develop clear process for escalation of safeguarding children concerns.

Information sharing and confidentiality embedded in safeguarding training.

Discharge letters must conform to the trust template policy

The timeliness of recording contacts to the service should be monitored.

Emails should not be sent from individual accounts and should only be used in exceptional circumstances

There should be clear thresholds for intervention in place. These should be audited.

Use of thresholds to be consistent and in line with agreed timescales

All staff including managers should be trained in the use of threshold and risk assessment.

All staff to be made aware of changes to practice.

The duty system should ensure a systematic application of threshold

Usage of ‘roll back’ (the deletion and reinsertion of records to ensure that contacts are on the system in chronological order) to be reviewed

The maternity service will ensure that women are asked about domestic abuse on two occasions during the antenatal period and once during the postnatal period (when it is safe to do so) and that this is safely recorded in the notes

That there is a clear process to alert the midwife at all contacts to check that the question has been asked

Mandatory safeguarding training for all midwives to be updated to level 3

Safeguarding training to stress the importance of safely writing in the woman’s hospital notes if the answer to the question is ‘yes’.

Question to be added to antenatal booking questionnaire clarifying who the woman’s partner is and contact details

Late booking women are referred to safeguarding midwife for further investigation

Safeguarding issues template in hospital records on lilac paper (Lilac launched as safeguarding colour and is easily identified)

Ensure there is always adequate IDVA/DV support and advice available across SW London Division

All IDVAs should know they can ask other IDVAs or local Service Delivery Managers to provide a ‘holding service’ to their clients during periods of extended leave.

Ensure that there are the right number of high risk trained DV volunteers across the Division

Analysis to be completed to ascertain whether we have the right amount available

Contact list published and distributed amongst IDVAs and SDMs. Contact list will also be held on public drive.

Divisional IDVA meetings to be held regularly

Refresher updates on VS policy and process, and relevant legislation will be communicated more effectively to IDVAs

Record sheet included in HR files for IDVAs to sign indicating they have read relevant policies including: DV SDOI Safeguarding

Ensure accuracy of records in line with policy and process.

Training London-wide for Divisional managers and IDVAs on DHRs

Ensure that in their assessment of risk in a case Helpline practitioners should take account of any immediate risks to adults (including increased risks to women arising from domestic violence).

Where a subsequent referral is made to children’s services within 30 days of the previous referral, Helpline practitioners should seek an update on action taken and record the response on the case file.

Consider and review the application of thresholds for immediate referral out to statutory services when concerns are raised out of office hours.

Ensure that Helpline practice meets expected standards.

Review current Policy and procedure and consider the following actions: Explore whether the practice of checking back 30 days for recent referrals should be raised to 40 days, in light of research that suggests that the next domestic abuse incident is likely to happen within 40 days

Explore whether the application of thresholds for immediate referral out to statutory services (when concerns are raised out of hours) are appropriate.

Explore whether to advise adults in possible domestic abuse situations to delete emails so that email cannot be read by others

Undertake a review of the one stop shop including a focus on its capacity and resources to ensure that those who present at the service are offered ongoing support if required.

A referral of a parent to MARAC should also trigger a referral to CSC and to Safeguarding Adults where relevant.

Clarify locally who manages the risk in between referrals to MARAC, Children’s Social Care and Adult Social care. emphasise that the risk is not managed by the MARAC post-referral

Explore the local response to threats to abduct a child/remove from the jurisdiction. Ensure appropriate guidance on child abduction is circulated to LSCB member agencies. All agencies to ensure that their risk assessment tools in relation to domestic violence and safeguarding children, include reference to the threat of child abduction. Multi-agency and single agency safeguarding training to reinforce the need for practitioners working with families to take threats of abduction into account when assessing the risk to the child.

To ensure that lessons learned from this Domestic Homicide review are considered in the development of the remit, terms and conditions of the Kingston Strategic Board for Domestic Violence.