Lewisham review

Safer Lewisham Partnership to update the family on the progress of the Overview Report recommendations.

The Refuge Lewisham Athena service to carry out an audit of cases in 2017 in which the allocated IDVA has left or changed to identify whether the handover process was followed as per policy, including producing data on whether the client continued to engage following handover. To report the findings to the DHR Task and Finish Group.

The two GPs involved in this Review to work with the Greenwich Clinical Commissioning Group to extend and deepen their understanding of and responses to domestic abuse among their patients (potential victims and perpetrators) including the development of policies, care pathways and training to ensure they can recognise and assess the risk of domestic abuse and make appropriate referrals. Greenwich Clinical Commissioning Group to share this learning all other Greenwich General Practices. To report the outcomes to the DHR Task and Finish Group and Safer Greenwich Partnership.

Greenwich and Lewisham domestic abuse specialist agencies to report to the DHR Task and Finish Group on how their procedures, assessments and training cover the need to establish with a client which other agencies they are working with, and how they satisfy themselves that this discussion is had with clients.

London Borough of Lewisham Crime Enforcement and Regulation service to carry out a dip-sample audit of cases where domestic abuse has been identified, to establish how this has been recorded and responded to, and what the outcome of those cases were. To report on this audit to the DHR Task and Finish Group and identify any actions required to enhance the response of the service to domestic abuse cases.

Royal Borough of Greenwich Adult Social Care to carry out a dip sample audit of open cases to establish whether a carer’s assessment has been offered; and if it has been declined, that appropriate support has been offered to the carer(s) and that their role in the family is understood and addressed where possible. To report the outcomes to the DHR Task and Finish Group and Safer Greenwich Partnership.

CGL Greenwich will routinely request historical minutes / reports from agencies involved where there is domestic abuse history or current risk.

We will ensure that CGL are well represented within Greenwich safeguarding boards’ domestic abuse training.

CGL staff to identify, explore and record DV risks and safety plans – training/workshop on use of adult safeguarding maps and safeguarding module.

Establish a system that raises an alarm with regards to issues on domestic abuse that brings a team of multi-agency professionals together to look at support and prevention.

To ensure MARAC meeting minutes are circulated to all members of the CGL: Lewisham staff team.

Liaise with the National Safeguarding Lead to request a review of the domestic violence policy. Currently it sits within the Safeguarding for Adults Policy and the CGL New Direction Review Panel member will ask if a specific domestic violence policy can be developed that acts as a standalone policy.

Review and refresh with the New Direction team the missed appointments checklist and re-engagement protocols.

CGL management will undertake a review of open domestic abuse service users with clear and SMART actions where appropriate. This will be carried out by the Senior Safeguarding Lead and be completed by 30 May 2017. This review will include risk and recovery planning, joint working and engagement.

Address recording procedures with staff, so all staff are aware of providing surnames where provided or reasons why if surnames are not recorded.

Look at processes around referral and information officers completing risk assessments for high risk callers, and making referrals to MARAC where appropriate.

Lewisham & Greenwich NHS Trust will consider the impact of any partner agency reviews / recommendations on its own process.

Review of all actions with an outstanding status from 2015.

Record all instances where agencies are chased for updates on actions.

MARAC Steering Group to discuss platform options for how MARAC information is shared.

MARAC Steering Group to arrange a seminar on MARAC Flags, and how cases are recorded.

If faced with a similar situation in the future, where a number of agencies are involved, and there are repeated contacts with SCAIT and high levels of concerns re domestic violence, but where the service user declines Adult Social Care involvement, consideration should be given to carrying out a joint visit, and/or a multi-agency meeting so that agencies are clear about each other’s role and remit, and which agency is leading on the case

It is noted from this case that the victim was seen as someone being evicted for issues of domestic abuse and ASB as a perpetrator. Current practice within SHIP is to ensure that any customer advising that they are a victim abuse are given an initial housing options assessment, a CAADA completed and a referral made to MARAC. This practice will be extended out to anyone reporting domestic abuse as a victim or a perpetrator.

An element of this case not seen as satisfactory is the way other agencies send correspondence to Housing Options and then feel that their duty to refer to housing is complete. In this case, an email “For Information Only” was received from Lewisham Adult Social Care. Moving forwards, the Housing Needs Department are looking to develop and implement an Online / Offline Referral Form for this kind of notification so that referrers are expected to give more details of a case and that this will be logged on the housing system directly ensuring that a central log is held of such correspondence other than it simply being emailed to one person.

New legislation coming into force within the next 12 months will place a duty on all public bodies to make a referral to the Housing Department when they are aware that an individual is threatened with homelessness. Housing Needs will over the next 6 months provide information and guidance to relevant bodies so that they may fulfil this duty.

Greenwich and Lewisham Senior Leadership Teams dip sample custody records concerning breaches of bail linked to domestic abuse incidents to ensure the Investigating Officer is notified and a review of the risk assessment takes place.

The ‘Bail Management Toolkit – Frontline – Pre-Charge, Investigative & Post Charge Police Bail’ is updated to include the following: When an arrest is made for breach of bail, it is the responsibility of the arresting officer to notify the Investigating Officer and their supervisor for the original offence in order for a review of the risk assessment with respect to victims and witnesses, to take place.

Lewisham Senior Leadership Team dip sample non-crime domestic abuse incidents to ensure the risk is appropriately assessed and escalation of risk is being correctly identified in repeat cases.

Lewisham and Greenwich Senior Leadership Teams to dip sample domestic incident reports: to ensure all domestic abuse investigations have comprehensive investigative strategies and identify cases of coercive control; and to identify and pursue opportunities for evidence based prosecutions and DVPN/DVPO applications.

Lewisham and Greenwich to conduct a training needs analysis re DVPN/DVPO applications and identification of coercive control. If a training need is identified Senior Leadership Teams to deliver appropriate training.

NPS should clarify the expectations and eligibility of the FADA programme; it is still technically available but not supported by personnel trained to deliver the intervention.

The Lewisham probation office should clarify the expectations of offender managers undertaking police and other organisational checks to use office e-mail box for audit trail.

The Lewisham probation office should clarify its processes around monitoring and enforcement of curfews.

Better tracking of high risk of harm risk assessments should be developed by the offender manager and her senior offender manager.

There are gaps in the recording in the probation database of MARAC meetings I suggest practice be reviewed.

Refuge’s Casework Management policy and Effective Casework training should be reviewed to ensure that all staff understand the requirement to record all contact with helpline cases on to their electronic case record.

Refuge’s independent audit of services should specifically include a review of the process being used to record contact and attempted contact with helpline cases to ensure that the Casework Management policy is being followed.

A record must be made on the client’s electronic casework record of completed MARAC actions that are the responsibility of Refuge and a reason recorded for any that could not be achieved including any attempts made to follow up with the client or relevant agency. Although it may be appropriate to maintain a record of the MARAC actions for other agencies this should not be on the client’s support plan and it is the responsibility of the MARAC co-ordinator to follow these up with the relevant agencies.

Refuge’s Casework Management policy and/or training should be reviewed to ensure that it is explicit that the same requirements to ensure pre-arranged contact takes place applies to both helpline cases and referrals which have been admitted to the service.

Refuge’s Casework Management policy and/or training should be reviewed to consider whether the current case recording practice sufficiently captures the relevant information from interactions with clients.

To review policies and procedures regarding domestic violence within safeguarding procedures.

Remind/highlight to all RBG Adults Services workforce of the ‘Warnings Section’ function, to flag risks/including domestic violence whether from residents or visitors to the property/person recorded on that case record, including for closed cases.

Further raising awareness methods to highlight the purpose, process and positive outcomes of the MARAC framework; through communication tools and face to face methods in Adults Services.

Further training for staff around mental capacity and duress.

When MARAC Minutes are received by the Safeguarding Adults Team, to ensure all recorded actions for specific relevant Adult Services cases are put onto the relevant case record (adding to the existing recordings and communications used), unless there is a professional judgement that this would not be appropriate.

SLaM adult liaison services across all sites to carry out an audit to assure themselves that they are correctly managing patients who go missing emergency departments.

Together practitioners will work with the NPS Offender Managers to ensure that a collaborative Referral Form is produced at the point of referral. This will ensure that the Together practitioner has a written record of the information they need to make an informed decision about the type and duration of contact they might have with the service user.

Victim Contact Officer staff to undertake robust research of repeat victim flagged cases where domestic violence or sexual violence is outlined/flagged and to seek advice from a team leader.

Victim Contact Officers to attend a DASH refresher workshop.

Quarterly dip sampling of Domestic Abuse/Sexual Violence–repeat cases.

Domestic Abuse awareness workshops to be provided quarterly to South Victim Care Officers by the Bromley Independent Domestic / Sexual Violence Advocate Team.

Where local lock fitting service is borough applicable and crime related (victim repeat flagged) all requests for to be filtered to the target hardening project for evaluation.

Victim Contact Officers refer all sexual violence cases in the South Area to Rape Crisis South London RASASC, with the consent of the victim.

Safer Lewisham Partnership member agencies to review the CGL engagement policy to incorporate the good practice within their existing policies, procedures, engagement strategies and training. To report the developments to the DHR Task and Finish Group.

CGL New Direction and CGL Aspire to carry out a dip sample audit of cases to establish whether the engagement procedure has been used (when required) and that this is evidenced in the ways in which clients are encouraged and supported to engage with the service. To report the outcomes to the DHR Task and Finish Group and Safer Greenwich Partnership, and internally within national CGL.

SLaM and CGL New Direction to ensure that the learning from this DHR is incorporated into the ongoing dual diagnosis work. To report back on this to the DHR Task and Finish Group.

Mental health agencies (statutory and voluntary sector), drug and alcohol services and specialist domestic abuse agencies in Lewisham and Greenwich to review, and amend if necessary, their policies, procedures, training and practice to take account of the toolkits for working with clients who present with mental ill-health, substance use, and experiences of domestic and/or sexual abuse/violence. To report the developments to the DHR Task and Finish Group.

Greenwich Multi-Agency Risk Assessment Conference to adopt the procedure, developed in Lewisham, of cross-borough checks on perpetrators who live out of the borough. To report on progress to the DHR Task and Finish Group and Safer Greenwich Partnership.

The London Multi-Agency Risk Assessment Conference Coordinators Forum to highlight to all London boroughs the good practice of Lewisham’s procedure in relation to cross-borough checks for perpetrators living outside of the borough. To report progress to the DHR Task and Finish Group.

Lewisham MARAC Steering Group to carry out an audit of all the referrals for one month to assess how many are ‘complex’ in the same way as this Review has shown, and could benefit from a more in-depth approach. To report the outcome to the DHR Task and Finish Group, and for a multi-agency discussion to follow this on the next best steps for managing these cases.

Safer Lewisham Partnership to carry out a multi-agency review of the Lewisham MARAC to answer the following questions:
 Does the MARAC exist simply as a forum for sharing information about high risk victims and perpetrators?
 Do agencies view a MARAC referral as the end / beginning / part of an ongoing process of managing high risk victims? How much information do agencies share at MARAC meetings, for example the extent of the history of domestic abuse or just the most recent incident/contact?
 Do agencies fully take on that the MARAC does not hold cases, but is a forum to facilitate agencies working better together in taking action they should already be taking?
 Are actions made at the MARAC purposeful and effective in managing risk?
 How are agencies held to account for the ways, and extent to which, they engage with the MARAC process and carry out risk management actions before and after meetings?
 How can MARAC better support effective multi-agency working outside of MARAC meetings, for example through the identification of a lead professional who coordinates agency actions, through the use of additional multi-agency meetings to discuss complex cases, or through a structure that allows for the ongoing management of some cases?
For the review to produce an action plan for the MARAC Steering Group, with progress reported to the Safer Lewisham Partnership and shared with the pan-London MARAC Forum.

All agencies within the Lewisham violence against women and girls partnership response to amend their assessment, practice, policies and training to incorporate the learning from this case in relation to ‘contextual risk’. To report on developments to the DHR Task and Finish Group.