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
Ealing review
CSP: EalingPublished: April 2023Year of death: 2016Extracted: 8 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified a volatile relationship with mutual abuse, where the couple's fear of child removal led to non-engagement with services. Key concerns include inconsistent risk assessment, poor information sharing, lack of professional continuity, and insufficient challenge to non-engagement as a risk factor.
Home Office classifications
36 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - mental ill health
Victim - depression
Victim - suicidal thoughts
Victim - suicide attempts
Victim - had been a victim of an abuser before
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - living with victim (including adult children)
Children - present at homicide (including adult children)
Children - subject to child protection or domestic abuse prior to homicide
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - mental ill health
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - psychosis
Perpetrator - suicide attempts
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - supervised by mental health services
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - digital stalking
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family consulted about terms of reference
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - family attended dhr panel
DHR process - health services recommendations
DHR process - probation services recommendations
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - multi agency working recommendation themes
DHR process - other recommendation themes
Extracted recommendations
8 recommendations pulled from the report · 1 matched to organisations in the index
Addressed to
Ealing Children’s Service | National Probation Service
The Ealing MASH (Multi-Agency Safeguarding Hub) should improve and reinforce the protocol for sharing of critical information, such as the ECS sending CP information to the GP and the GP not being informed of the homicide. Probation should also ensure that when information is received that a perpetrator has moved back in with a victim of abuse and their family the appropriate referral is made to Vulnerable Adult and/or Children’s Social Care.
Addressed to
London North West University Healthcare NHS Trust Community 0 – 19 Service
London North West University Healthcare NHS Trust Community 0 – 19 Service should look at issues arising from this case to establish if the lack of continuity of health professionals has impacted on the quality of care
Although safeguarding training is mandatory for all health and social care staff, there remains a gap in the provision of training in relation to Domestic Abuse (including the impact on both victim and perpetrator)
That all agencies are alert to the need to balance positive observations of parenting and children’s well-being with detailed observation, direct work and research evidence to determine the impact on children of domestic violence
That all staff working with domestic violence are familiar with the cycle of violence. Workers and Managers in all agencies must challenge repeated assurances that relationships are over. Claims about relationships ending need to be backed up with solid evidence about what has changed
That when parents are minimising or denying concerns and where their non-engagement places children at increased risk of harm, all agencies evidence more challenging dialogue with parents
That when there are counter-claims or observations of abuse between partners, including controlling and abusive behaviours, a ‘culture of inquiry’ is developed to challenge stereotypical perspectives and assumptions