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
Bexley review
CSP: Bexley
Published: April 2023
Year of death: 2015
Extracted: 21 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 identifies missed opportunities by professionals to identify coercive control and domestic abuse, particularly when the victim's health was deteriorating. There was a lack of professional curiosity regarding the victim's care needs and the impact on her children, and the perpetrator remained largely unrecorded by agencies.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Home Office to launch a campaign to help the public understand coercive control and to direct them to local sources of support. Campaign to target cultural and social norms that support, accept or disguise coercive control, particularly acknowledging the issues of shame and so-called honour-based violence. | Home Office |
| 1 | After the pandemic has subsided, the agencies represented on this DHR Panel review their safeguarding provision to ensure that they have the capacity to meet the needs of statutory review processes such as domestic homicide reviews. | Bexley Community Safety Partnership | South East London (Bexley) Clinical Commissioning Group | Kings College Hospital NHS Foundation Trust | Dartford and Gravesend NHS Foundation Trust | Oxleas NHS Foundation Trust | Bexley Adult Social Care | Bexley Safeguarding Adults Board | Bexley Children’s Social Care | Solace Women’s Aid | Metropolitan Police Service |
| 1 | When a physical health condition is identified as having an impact on activities of daily living, a referral to occupational therapy would be recommended to assess for appropriate support for patient to manage their daily activities. | Dartford and Gravesham NHS Trust |
| 1 | King’s College Hospital outpatient departments to make routine enquiries about domestic abuse for all patients accessing the service. This will include episodes of care involving IVIG/Clinical research. This aligns with KCH Safeguarding Adults Service on going work to raise awareness around domestic abuse. | King’s College Hospital NHS Foundation Trust |
| 1 | Domestic abuse to be included in all safeguarding adults and safeguarding children face-to-face training offered to trust staff. | Oxleas NHS Foundation Trust |
| 1 | CCG to advise that GP palliative care meetings should be extended to consider anyone with a new diagnosis of a life-limiting condition in order to review their situations and ensure that appropriate support is offered to those: (a) with caring responsibilities for a child or vulnerable adult (b) who may have no support themselves (c) who may rely on young members of their households as carers. | Bexley Clinical Commissioning Group |
| 10 | That adult and child safeguarding training in Bexley include training on unconscious bias and systemic discrimination, including cultural attitudes that discourage people from seeking help from agencies, and professionals’ understanding of cultural attitudes. Staff to be alerted to information and resources available locally to understand and address these concerns. | Bexley Community Safety Partnership |
| 11 | Bexley Community Safety Partnership provide regular updates to Andrea’s family on the completion of this review’s action plan. | Bexley Community Safety Partnership |
| 2 | NHS England to ensure that health professionals giving a terminal diagnosis organise for immediate support to be available to patients to discuss the impact of their illness and the prognosis on their life, and the support likely to be needed and available. | NHS England |
| 2 | Bexley Community Safety Partnership to launch a campaign help the public understand coercive control and to direct them to local sources of support. Campaign to target cultural and social norms that support, accept or disguise coercive control, particularly acknowledging the issues of shame and so-called honour-based violence. | Bexley Community Safety Partnership |
| 2 | Records of consultations and appointments to include the identify and relationship of the person attending with the patient. | Dartford and Gravesham NHS Trust |
| 2 | King’s College Hospital to ensure that episodes of care involving IVIG/Clinical research are recorded and accessible to other professionals. | King’s College Hospital NHS Foundation Trust |
| 2 | The safeguarding team to promote the domestic abuse e-learning to all adult facing staff. | Oxleas NHS Foundation Trust |
| 3 | The Department of Education require parents who are home-educating to register this with their local authority’s Education Services. That the Department of Education provide guidance on when and with whom local authority Education Services can share this information with other agencies. | Department of Education |
| 3 | Bexley Community Safety Partnership to ensure that all safeguarding adult and child training use this case to make several points: (a) Everyone has a role to play in stopping domestic abuse (b) It is critical that opportunities to enquire and support patients/clients are not missed. (c) If in doubt, staff should discuss domestic abuse concerns with their Safeguarding Lead and then, if appropriate, refer the case to someone more specialised. (d) How a Think Family approach might have opened a number of routes to safety for this family. (e) Include information about local voluntary agencies that might provide additional support to patients. | Bexley Community Safety Partnership |
| 4 | Review policies regarding care of patients with disabling conditions to ensure that conversations about support and care needs are introduced when the symptoms impact daily living. | Dartford and Gravesham NHS Trust | King’s College Hospital NHS Foundation Trust | Oxleas NHS Foundation Trust | Bexley GPs | community care services |
| 5 | That the Domestic Abuse Health Subgroup works to ensure the following: (a) That health referrals to domestic abuse services are monitored as part of the evaluation of health professionals’ training on domestic abuse. (b) That a consistent and coordinated plan is developed for routine enquiry in health services based on best practice (c) That health training on domestic abuse includes the cultural barriers that might stop ethnic minority victims reporting and that might affect health professionals’ responses to ethnic minority victims. | Domestic Abuse Health Subgroup |
| 6 | Local health services (GP surgeries, Oxleas, KCH and DVH) to use this case in training to (a) Identify the need to think about wider safeguarding issues when working with patients, including considerations of Andrea as an adult at risk, and the children being at risk of neglect (b) Promote the understanding of coercive control, what it might look like in situations where the victim has a progressive illness (c) Develop professional curiosity about the impact of patient’s symptoms on their daily lives and how they manage their lives, relationships and children, and how to ask patients about their lives (d) Identify what further support might be necessary to keep patients and their children safe and healthy and ensure the patient is connected to that support (e) Consider how to improve the gathering of information about clients and sharing that information with other health agencies. | GP surgeries | Oxleas NHS Foundation Trust | Kings College Hospital NHS Foundation Trust | Dartford and Gravesend NHS Foundation Trust |
| 7 | That Bexley CSP ask local statutory and voluntary agencies to include in their borough-wide policy and practice, that when professionals learn that a client or patient is home-educating and gain consent of the parents, that the fact of their home-educating is shared with Bexley’s Education Services. | Bexley Community Safety Partnership |
| 8 | That the Bexley Education Services determine and communicate the mechanism for agencies to inform them of families who are home-educating and have consented to the sharing of this information. | Bexley Education Services |
| 9 | That the Bexley Community Safety Partnership and the South East Clinical Commissioning Group work together to see that secondary and primary care health professionals in Bexley are provided with information about the variety of local support organisations in Bexley and how to refer clients to them. That LBB ensures that health professionals are supplied with information to share with patients about the help that is available through these organisations. | Bexley Community Safety Partnership | South East Clinical Commissioning Group | London Borough of Bexley |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||