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
Lambeth review
CSP: Lambeth
Published: April 2023
Year of death: 2012
Extracted: 25 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 report identifies inconsistent risk assessment and management by mental health services, poor inter-agency communication, delays in Mental Health Act assessments, and inadequate police responses to domestic incidents, particularly regarding serial perpetrators and information sharing.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1.1 | The Trust to commission a piece of work to address interfaces between services with AMH and between AMH and non-AMH CAG services. | South London & Maudesley NHS Foundation Trust |
| 1.2 | All Trust community teams to meet with the SLAM Forensic Service to learn and develop a protocol for management when patients are discharged from prison. | South London & Maudesley NHS Foundation Trust |
| 1.3 | The Psychosis Community Service (Lambeth South) team manager and team consultant to work together to ensure mandatory training in the team is completed and up to date. This will include the following and should be audited to ensure learning is embedded: - Their responsibilities in relation to safeguarding children and adult - Risk assessment and escalation of concerns for complex patient with a history of violence, drug and alcohol use and psychosis - Clinical documentation, including ePJs, meeting minutes, correspondence between clam teams and external agencies | South London & Maudesley NHS Foundation Trust |
| 1.4 | The Psychosis CAG senior manager team to take up the following areas across the CAG in relation to AMH model work. This will include: - Mental health assessments including history, mental state examinations, formulation and resulting care plan - Drug and alcohol and the use of questionnaires available on ePJs, urinary drug screens, hepatitis B & C and HIV status. - Commissioning SLAM partners to work with the Psychosis Community Service (Lambeth South) team to facilitate team members to work together and develop a vision for the service. - Adherence to NICE Guidelines 120: Psychosis with co-existing substance misuse, March 2011. This includes the provision of the Care Programme Approach to deliver care. | South London & Maudesley NHS Foundation Trust |
| 1.5 | The Trust audits its clinical staff to establish the understanding of the extent, impact and risk of Domestic Violence and addresses the findings accordingly. | South London & Maudesley NHS Foundation Trust |
| 1.6 | The Trust reviews its physical communication systems at Community Team bases and puts in place contingency arrangements in case of failure. | South London & Maudesley NHS Foundation Trust |
| 1.7 | The Trust works with the London Probation Trust to develop a working protocol for putting in place and managing Community Order “Mental Health Requirements”. | South London & Maudesley NHS Foundation Trust | London Probation Trust |
| 2.1 | All staff to be reminded of the importance of making detailed case notes without abbreviations. | London Borough of Lambeth-Housing |
| 2.2 | Team managers to ensure monthly case audits evaluates the quality of case notes. | London Borough of Lambeth-Housing |
| 3.1 | SHP to review the priority and allocations system within the Lambeth Tenancy Support Team. | Single Homelessness Project |
| 3.2 | Review how issues/concerns or incidents concerning client risk are escalated to management level within SHP. | Single Homelessness Project |
| 4.1 | It is recommended that the MPS/Lambeth complete intelligence checks on an address at which a DV incident has taken place in addition to any individual checks undertaken on the individuals involved in the incident. | The Metropolitan Police Service |
| 4.2 | It is recommended that Lambeth BOCU officers are reminded to complete intelligence checks in relations to all Domestic Violence and recorded within the Crime Recording Information System (CRIS). This should include mandatory searches of databases including CRIS, PNC and CRIMINT ensuring that relevant information is recorded within the report. | The Metropolitan Police Service |
| 4.3 | The Metropolitan Police Service gives consideration as to how, within the existing legal frameworks, relevant Police Officers be given discretionary powers to disclose previous acts of Domestic Violence where potential victims are thought to be at risk. | The Metropolitan Police Service |
| 5.1 | A copy of this report to be sent to the Chief Constable of Essex and Her Majesty’s Inspectorate of Constabulary drawing attention to the shortcomings identified in the Essex Police responses contained in it, to ensure they are covered by the improvements already made or planned in Essex. | Essex Police Service | Her Majesty’s Inspectorate of Constabulary |
| 6.1 | It is recommended that the Assistant Chief Officer for Lambeth should be satisfied that tiering decisions across the borough are soundly based. | London Probation Trust |
| 6.2 | It is recommended that London Probation and Community Mental Health in Lambeth explore how they might work more closely together to promote the effective management and treatment of offenders with offending related mental health issues. the perpetrator would be an interesting case example for joint study. | London Probation Trust | Community Mental Health in Lambeth |
| 6.3 | It is recommended that London Probation explores whether the role of the WSO could be developed to make them more involved in decision making in the management of orders with an IDAP requirement. | London Probation Trust |
| 6.4 | It is recommended that London Probation consider how it can refresh practitioners’ understanding of the role of MARAC so that maximum use is made of this resource. | London Probation Trust |
| 6.5 | The London Probation Trust and SLaM work together to develop a working protocol for putting in place and managing Community Order “Mental Health Requirements” | London Probation Trust | South London & Maudesley NHS Foundation Trust |
| 7.1 | Refuge to record perpetrators’ names on REMIT. NB Refuge has already implemented this change, in December 2012. | Refuge |
| 8.1 | Consideration to be given to reviewing the operating protocol to improve the tracking and management of serial offenders e.g. Item 10 – Referral Criteria point 3 – Potential Escalation should this refer to number of call outs to a victim and/or an alleged perpetrator | Lambeth MARAC Steering Group |
| 9.1 | Safer Lambeth Chair to forward a copy of this DHR to the Chair and Chief Executive of South London & the Maudsley NHS Foundation Trust for the information of their Board. The Board to consider any further actions required to augment the internal review already presented to them and any necessary additions to their current action plan. | Safer Lambeth Partnership |
| 9.2 | Review the information sharing protocol to ensure it is still relevant, all necessary parties are signed up and understand its operational implications and audit how well it is disseminated across those agencies' staff. | Safer Lambeth Partnership |
| 9.3 | The Safer Lambeth Partnership monitors and reviews progress against the Action Plan | Safer Lambeth Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||