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
Barnet review
CSP: Barnet
Published: April 2023
Year of death: 2017
Extracted: 41 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 inter-agency information sharing, risk assessment, and coordinated management of the perpetrator's mental ill-health and substance misuse. Gaps in the prison release process and insufficient family support contributed to the tragic outcome.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | It is recommended that the Ministry of Justice review the current Prison release process and include the implementation of a Prison Release Risk Assessment which would be completed prior to every prisoner's release from the Courthouse (including video link court proceedings) thus ensuring notification and referral to appropriate agencies is in place to establish continuity of care, welfare, and the safeguarding of others prior to release. | Ministry of Justice |
| 10 | Newly appointed mental health practitioners should be given protected time to read through their new caseload case notes to ensure they are fully informed of their service users history and able to assess their needs using their experience. | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 11 | BEH should develop a MARAC protocol to ensure there is a clear understanding of process, attendance, and recording requirements on the patient record. Management, and the MARAC representative and their deputy should see advice for Mental Health MARAC representatives at: http://www.safelives.org.uk/practice_blog/role-mental-health-representative-marac (IMR Recommendation). This recommendation was acted upon by the Mental Health Trust Safeguarding Committee in January 2019 | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 12 | BEH clinical supervision should ensure that it includes the active exploration of assessment of needs, formulation of care plans, risk assessment, and risk management using data from caseload records and information from all available sources. (IMR Recommendation). | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 13 | BEH should engage with the Court and Prison mental health schemes with which it has regular contact to ensure that pathways of care and contact details are clear to all staff involved. (IMR Recommendation). Action complete August 2018 | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 14 | BEH should review the use and operation of the Risk and CPA facilities on RiO and develop systems that provide easy and direct access to information necessary for risk assessment and management. (IMR Recommendation). Board Level Inquiry action plan confirms this action was closed in June 2018. Simplified Risk assessments are in place on RiO. | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 15 | Following a Mental Health Act Assessment at least one of the medical assessors should make written entry of their findings that is transferred to the RiO record as soon as practicable whether or not the patient has been detained. If the patient is not detained, the reasons for the decision should be included. (IMR Recommendation) | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 16 | The Local Authority AMHP should ensure they always inform the GP that an assessment has taken place and particularly if a decision has been made not to detain the patient under the Mental Health Act. | Barnet Adult Social Care |
| 17 | Review the structure, governance, and working of the MARAC and its Steering Group including updating the Terms of Reference to ensure that: (a) the MARAC chair role is sustainable to maintain continuity to ensure that previous meeting actions are fully achieved and where outstanding agencies are challenged. (b) Agencies must submit updates on actions to the MARAC Co-ordinator by the given deadline, and the chair and MARAC coordinator should review minutes and actions before the start of subsequent MARAC meetings to ensure actions are reported completed and the plan remains fit for purpose to minimise the risk to the victim/s. The Domestic Abuse MARAC coordinator to assist in bringing these items to the attention of the chair. (c) revisions to MARAC should include a process for carrying forward a case for future MARAC review where a perpetrator is in custody to ensure that a safety plan is drawn up ready to be put in place to protect the victim/s prior to the offender's release. Where applicable this should include requesting a Restraining Order from the Court and any other relevant order i.e. Drug Treatment Order, Mental Health Treatment Order, or suitable Order available under legislation at the time. | Hestia | Barnet MARAC |
| 18 | Where a MARAC case includes consideration of specific cultural, ethnicity or religious interests, the MARAC coordinator should ensure that the relevant MARAC member organisation is invited for that case discussion either in person or through secure telephone conference facilities. The MARAC should keep under review the agency membership to ensure that it is up to date and that the required information and confidentiality agreements have been agreed and signed by the agencies called upon. | Hestia | Barnet MARAC |
| 19 | When gathering pre-MARAC information to assess risk to a victim of domestic abuse all agencies and the MARAC chair must ensure that others in the household, including adults as well as children, are identified and if found to be vulnerable and at potential risk include them in the safety plan. The MARAC Operating Protocol and MARAC Research Form should be amended to include this process. | Hestia | Barnet MARAC |
| 2 | There should be an agreed process between the Ministry of Justice and Mental Health Services as to how Psychiatric/Psychological reports are commissioned by the Courts with Terms of Reference and timings agreed within which the report will be produced. | Ministry of Justice | Her Majesty's Courts & Tribunal Service |
| 20 | The MARAC Steering Group to undertake a regular dip sample review of MARAC cases involving domestic abuse, substance misuse and mental ill-health, to ensure that information from all agencies has been shared, safety plans are appropriate, and all relevant services have offered actions to mitigate the heightened risk posed by the three combined issues. | Barnet MARAC Steering Group |
| 21 | There needs to be a clear distinction between Community MARAC and Domestic Abuse MARAC. (IMR Recommendation) | Community Safety Team |
| 22 | That the Barnet Safer Communities Board ensure they receive confirmation from the agencies involved in this Review that the learning in this DHR has been disseminated to all staff within their service once the DHR has received approval by the Home Office and the date that dissemination completed. Also, that the issues raised and learning from the Review has been built into their future training on domestic abuse. Confirmation should be required that relevant lessons for the Domestic Abuse MARAC are being include Domestic Abuse MARAC training. | Barnet Safer Communities Board |
| 23 | SX BOCU Level: - (IMR Recommendation) It is recommended that SX BOCU SLT dip sample domestic abuse reports to: - • Ensure five year intelligence checks are being completed as per toolkit. • Ensure compliance with current MARAC referral threshold and that rationale is being recorded within report. | Metropolitan Police |
| 24 | SX BOCU Level: - (IMR Recommendation) It is recommended that SX BOCU SLT reinforce the requirement for all staff: - • to understand the Vulnerability and protection of adults at risk policy • to understand the Vulnerable Adult Framework • to complete ACN MERLIN reports where they have identified vulnerability whether they are a victim, witness, suspect or member of the public they have encountered using VAF. | Metropolitan Police |
| 25 | That the Metropolitan Police review the use of the name MARAC for the Multi-Agency Anti - Social Behaviour group to avoid the confusion which arose in this DRH between the MARAC which is understood nationally for managing high risk victims of domestic abuse, and the MARAC in London for dealing with vulnerable anti-social behaviour victims. | Metropolitan Police |
| 26 | Probation officers should use their best efforts to consult with local IDVA services to inform pre-sentence reports in domestic abuse case in order to understand current risk factors, concerns, and wishes of the victim(s). Where IDVA provision exists within the Court the probation officer to liaise with them to quickly identify risks and concerns for the victim. Whilst recognising Court time constraints may impact on the practicality of this It is recommended that this is adopted as best practice. | National Probation Service |
| 27 | The NPS have introduced Performance Improvement Tools (PIT tools), The NPS to seek assurance from all line managers of Court staff that this has been integrated into the supervision process of Court based Offender Managers to ensure that assessments are of sufficient quality and there is a consistency of standards and compliance with procedures. (IMR Recommendation) | National Probation Service |
| 28 | The National Probation Service as part of its Effective Practice review should undertake a review of all training in the use of risk assessment tools to Court staff and in particular the use of the RoSH/CAS tool to ensure sufficient and consistent practice by all Probation Court Staff. (IMR Recommendation) | National Probation Service |
| 29 | That NPS Court Probation processes are reviewed and best practice implemented regarding those offenders who are released directly from the Court, including those appearing by video link, to ensure that Licence requirements are appropriate to manage the risk of harm that the offender may present. (IMR Recommendation) | National Probation Service |
| 3 | It is recommended that the Magistrates Bench and Justices Clerks are provided with information and/or training clarifying the difference between a mental health assessment and a psychiatric report, thus assisting them with determining which type of mental health report will provide the most appropriate and timely assessment to inform sentencing when considering a case in which mental ill-health is a component. | Ministry of Justice | Her Majesty's Courts & Tribunal Service |
| 30 | That Sentencers are briefed to ask for a report if it is not provided, even if the Probation Court Officers are unable to propose an appropriate sentence. (IMR Recommendation) | National Probation Service |
| 31 | Commence monthly Frequent Attender Meetings to consider the management of complex, vulnerable ED attendees, how they are monitored, reviewed, referred, and supported with multi-agency attendance. (IMR Recommendation) | Royal Free London NHS Foundation Trust |
| 32 | Review of how information is shared within the Emergency Department with contracted Mental Health support staff so that a consistent method is adapted to ensure that within the Trusts medical files all assessments are available. (IMR Recommendation) | Royal Free London NHS Foundation Trust |
| 33 | To review the training provided to trust staff to raise awareness of abuse in all age groups and how to ask about domestic abuse. (IMR Recommendation) | Royal Free London NHS Foundation Trust |
| 34 | It is recommend that the existing searching of the case management system process is enhanced to ensure that upon receiving a referral, a thorough search of the case management system is conducted on the address for the referral subject to check whether there are related cases to ensure all known risk information is available to enable appropriate allocation of cases. (IMR Recommendation) | Victim Support |
| 35 | Ensure that all Victim Support staff are aware of the timeframes stipulated in the DA Operating Procedure and provide training in areas where this practice has not been adopted. Managers to continue to address this with their teams, through team meetings and one to one supervision. (IMR Recommendation) | Victim Support |
| 36 | Ensure that present day Victim Support procedure and practice is adhered to through continued use of dip-sampling and case review and feedback to staff. This is already being actioned through the introduction of an improved case review and auditing process throughout the organisation on a national level. The Victim Assessment and Referral Centre staff should be included in this explicitly. (IMR Recommendation) | Victim Support |
| 37 | When changes are made to policy and procedure to bring them up to date, this needs to be accompanied by a “briefing note” circulated throughout the organisation and feature on team meeting agendas within a month of launching revised policy/procedure to identify any further training need. (IMR Recommendation) | Victim Support |
| 38 | All non-attendance or poor engagement in elements of care plan (e.g. group, counselling, ETE or other recovery-based activity) to be reported to lead worker and canvassed in key work and care plan reviews and MDT. (IMR Recommendation) | Westminster Drug Project |
| 39 | Workers to seek consent to liaise with service user’s family and offer invite to Family & Carers group. Outcome of both consent and family’s response to invitation to be clearly recorded in case notes. (IMR Recommendation) | Westminster Drug Project |
| 4 | In order to facilitate an improved response to the risks associated with domestic abuse and mental ill-health for victims and perpetrators, it is recommended that the DOH provide funding so that IDVA's can be placed in NHS mental health provider settings. | Department of Health & Social Care |
| 40 | Ensure staff are updating risk assessments and the respective risk management plans by checking in supervision and through local and central audit processes. (IMR Recommendation) | Westminster Drug Project |
| 41 | Workers to seek consent from service users to liaise with their GP and/or other relevant services i.e. Mental Health Services, with whom they also have involvement. | Westminster Drug Project |
| 5 | The Home Office should forward copies of all DHRs involving a mental health component to the Secretary of State for Health & Social Care and the lead minister for mental health, for their consideration and to inform policy and decision making concerning community mental health and primary care service delivery. | Home Office |
| 6 | All provider agencies working in the community involved with service users and their families should take a ‘Think Family’ approach and (in line with data sharing requirements), when assessing risk practitioners and their managers should ensure that assessments are fully informed by information from the family or carer living with the service user, in addition to research into psychosis, schizophrenia, coexisting substance misuse and domestic abuse. Any change in circumstances should trigger a review of the case. | All Community Provider Agencies |
| 7 | The Mental Health Trust should review its process for disseminating MERLIN notifications from the Police to ensure that they are inserted and easily visible on patient case notes (via a flag if possible), the case holder is informed directly, and that risk is reviewed following their receipt. Where 5 MERLINs are received in a 12 month period the care coordinator should be responsible for reviewing the risks with partner agencies and amending the risk management plan accordingly. Family members or carers should be consulted as appropriate. If there is an act of violence reported in the MERLINs management of the case should be escalated promptly. Professionals should be mindful of viewing the whole historical picture to identify escalation. | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 8 | All staff involved in assessments, CPA care planning, and risk assessments should receive dedicated domestic abuse training which includes adult family violence and abuse, risk assessment, and MARAC referral process. The training should include lessons and case studies from adult family violence DHRs. Refresher training should be built into annual professional development plans at 3 yearly intervals. | Barnet, Enfield & Haringey Mental Health NHS Trust |
| 9 | Mental Health Trust management supervision sessions with practitioners should routinely include evaluation of domestic abuse training when it has been undertaken, check the practitioner's levels of understanding against training outcomes, and assess evidence within review of cases to ensure that domestic abuse is recognised and learning is being acted upon. | Barnet, Enfield & Haringey Mental Health NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||