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

Kingston upon Thames review

CSP: Kingston upon Thames Published: April 2023 Year of death: 2011 Extracted: 26 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 systemic failures in Children's Social Care, inadequate risk assessments by mental health services, and missed opportunities for intervention across multiple agencies. Key concerns included poor information sharing, inconsistent risk assessment tools, and insufficient staffing, alongside a lack of consideration for the victim's insecure immigration status and childcare needs.

Extracted recommendations

26 recommendations pulled from the report

#	Recommendation	Addressed to
ACTION 1	The Trust to develop robust system for recording the details of dependent children or regular contact with children.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 10	All contacts in CSC will be put on the system within 24 hours.	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 11	All staff to be informed that email should not be used for giving information and advice.	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 12	Threshold document to be developed and made available to staff.	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 13	Use of thresholds to be consistent and in line with agreed timescales audit process.	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 14	All staff to receive training on thresholds and risk assessment, and new staff to undertake training as part of mandatory induction training.	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 15	Feedback changes to practice to staff	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 16	Duty stem to be reviewed	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 17	Review of the usage of ‘roll back’ and develop new guidance	KINGSTON CHILDREN’S SOCIAL CARE
ACTION 18	Ensure that the antenatal assessment tool has a ‘prompt’ to remind midwives to ask the question. Redesign the question and review of records to ensure clarity in the notes that the question about domestic violence has been asked, and if the response is negative or positive.	ST GEORGE’S MATERNITY SERVICE
ACTION 19	Question asked prompt will be on all antenatal pages of the maternity notes Flowchart in safeguarding folders demonstrating process for questioning and Introduction of a flowchart All midwives are aware of the flowchart	ST GEORGE’S MATERNITY SERVICE
ACTION 2	Impacts of parental mental illness to be embedded in safeguarding and risk training.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 20	Mandatory safeguarding training for all midwives to be updated to level 3 midwifery. Deliver 3 hour sessions to include scenario situations in managing DV.	ST GEORGE’S MATERNITY SERVICE
ACTION 21	Safeguarding training to stress the importance of safely writing in the woman’s hospital notes if the answer to the question is ‘yes’.	ST GEORGE’S MATERNITY SERVICE
ACTION 22	Add question to booking demographics on K2 system	ST GEORGE’S MATERNITY SERVICE
ACTION 23	Safeguarding midwife contacts children’s services to ascertain if family is known to them	ST GEORGE’S MATERNITY SERVICE
ACTION 24	Template in use and in hospital notes with clear summary of safeguarding concerns	ST GEORGE’S MATERNITY SERVICE
ACTION 25	DV Manager will keep record of all annual leave requested and booked for 10FTE IDVAs from across Division. Senior Service Delivery managers to sanction all annual leave	VICTIM SUPPORT
ACTION 26	Inform all IDVAs that they must ensure their current clients have access to our service even when they are away from work for extended periods. No client must be asked to wait for support because an indivi	VICTIM SUPPORT
ACTION 3	Impact of Domestic Violence to be embedded in safeguarding and risk training.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 4	Domestic Abuse to be included as a specific risk indicator in the trust risk assessment tool.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 5	Domestic Violence and Mental health embedded in Safeguarding Children training for all practitioners.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 6	The Trust to develop robust system for recording the details of dependent children or regular contact with children.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 7	Trust to develop clear process for escalation of safeguarding children concerns.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 8	Information sharing and confidentiality embedded in safeguarding training.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
ACTION 9	Discharge information to include: Confirmation of the patient’s details and the context and reason for presentation A summary of the risk assessment. Any safeguarding concerns for children or adults.	SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH TRUST
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗