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: Ealing Published: April 2023 Year of death: 2016 Extracted: 8 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 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.

Extracted recommendations

8 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	Ealing Children’s Service \| National Probation Service
2	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	London North West University Healthcare NHS Trust Community 0 – 19 Service
3	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)	NWL CCGs \| Ealing Local Authority
4	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	Ealing Children’s Service
5	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	Ealing Children’s Service
6	That an unwillingness to engage with family support services is explicitly treated by all agencies as an indicator of higher risk	Ealing Children’s Service
7	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	Ealing Children’s Service
8	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	Ealing Children’s Service
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗