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

Bexley review

CSP: Bexley Published: April 2023 Year of death: 2016 Extracted: 15 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
Key concerns include the perpetrator's extensive use of coercive control, economic, financial, and sexual abuse, compounded by the victim's immigration status and the perpetrator's manipulation of their children. Agency responses were hampered by missed opportunities for risk identification, inconsistent information sharing, and gaps in addressing specific forms of abuse like economic abuse and abuse of process.

Home Office classifications

49 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - mental ill health
  • Victim - self harm
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Victim - immigration involvement
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - known to workplace (employer) as a domestic abuse perpetrator
  • Perpetrator - died by suicide
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - faith based abuse
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family received draft report
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - employer recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

15 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1

Addressed to UK Government

The UK Government to review the cross-government definition of domestic violence and abuse and any associated guidance to incorporate economic and financial abuse

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to UK Government

The UK Government should review the cross-government definition of domestic violence and abuse and any associated guidance to incorporate abuse of process

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Guy’s and St Thomas NHS Foundation Trust

GSTT to ensure that there is a clear policy and procedure in place to manage communication between REACH, members of staff who access the service and their managers. This should strike a balance between confidentiality and consent with the ability of REACH to seek information from or liaise with managers in high risk cases

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Guy’s and St Thomas NHS Foundation Trust

GSTT to conduct a review of decision making in relation to referral to MARAC within REACH, with particular reference to time frames, the use of professional judgement and how cases are managed when a victim disengages from the service

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Guy’s and St Thomas NHS Foundation Trust

GSTT to review pathways to MARACs in London. In doing this, GSTT should prioritize pathways with those areas with the greatest number of patients. As a minimum this should include Lambeth, Southwark and Lewisham.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to London Ambulance Service

LAS to review how it can sign up to, and participate in, MARACs and disseminate guidance to MARACs in London

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Lewisham MARAC

The Lewisham MARAC should further develop its online profile, to ensure that information and guidance on the MARAC process is as accessible as possible

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Bexley MARAC

The Bexley MARAC should ensure that information and guidance on the MARAC process is made accessible, including online and through the provision of local training

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Lewisham MARAC

The Lewisham MARAC should conduct an audit of ‘no action’ cases to identify whether this is an isolated case or whether there is any wider learning that could inform practice at the MARAC

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Bexley MARAC

The Bexley MARAC should conduct an audit of ‘no action’ cases to identify current practice and consider any wider learning that could inform practice at the MARAC

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to Lewisham and Greenwich NHS Trust

LGT to review policy and procedure in relation to the use of MARAC flags so these are used consistently

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to Lewisham and Greenwich NHS Trust | Refuge | relevant commissioners

LGT to work with Refuge and the relevant commissioners to ensure there is sufficient H-IDVA capacity, and a robust care pathway, within University Hospital Lewisham

Verified wording from the published review · Original review (PDF) ↗

Recommendation 13

Addressed to Bexley CCG

The Bexley CCG to monitor the implementation of its local action plan to improve the response to domestic violence and abuse with GPs and undertake an evaluation to ensure that the local action plan is effective and leads to improved victim outcomes.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 14

Addressed to Bexley Community Safety Partnership

The Bexley CSP to develop a profile of perpetrators locally and review practice, pathways and training in response to this group

Verified wording from the published review · Original review (PDF) ↗