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
Kent review
CSP: Kent
Published: April 2023
Year of death: 2011
Extracted: 5 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 significant failures in mental health service provision, including inadequate risk assessment, care planning, and Mental Health Act assessments. There was poor multi-agency communication, insufficient recognition of domestic abuse and adult safeguarding risks, and a lack of support for vulnerable carers.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| bullet_1 | There should be an identified clear communication protocol outside of the Kent Police custody environment for police to refer and be able to seek advice regarding mental health issues in the community. | Kent Police |
| bullet_2 | Consideration of the creation of a multi-agency information sharing and assessment process to identify and manage people with mental health issues that present a potential safety risk to the public. (Individuals outside of existing protocols such as MARAC, MAPPA etc). | Kent Community Safety Partnership | Medway Community Safety Partnership |
| bullet_3 | The issue of GPs providing reports as opposed to IMRs conducted by an independent GP requires consideration by the Kent and Medway Community Safety Partnership with a view to raising it with the Home Office to consider including GPs in the DHR process. | Kent and Medway Community Safety Partnership |
| bullet_4 | The MHA Assessment process could be improved. | Kent and Medway NHS and Social Care Partnership Trust (KMPT) | Kent County Council |
| bullet_5 | KMPT should review their IMR process when internal reviews have already been completed to ensure all relevant matters are included in the IMR. | Kent and Medway NHS and Social Care Partnership Trust (KMPT) |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||