Home / Sources / Domestic Homicide Reviews / Kensington and Chelsea · Apr 2023
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

Kensington and Chelsea review

CSP: Kensington and Chelsea Published: April 2023 Year of death: 2015 Extracted: 13 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
The review identifies systemic failures in inter-agency information sharing and communication, particularly concerning domestic abuse risk assessment and mental health crisis response. It highlights missed opportunities to engage the victim and extended family, and a lack of consistent application of risk assessment tools.

Home Office classifications

40 tags

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

  • Victim - alcohol misuse
  • 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)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - psychosis
  • Perpetrator - suicide attempts
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • 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 received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - housing services recommendations
  • DHR process - school 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 - other recommendation themes

Extracted recommendations

13 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to Multi-agency

Frontline professionals should be reminded of the perceived threat families can feel when they are being assessed and how parents can guard responses to professionals in sharing the true family dynamic; domestic abuse or health problems.

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

Recommendation 1

Addressed to Multi-agency

The most recent policy around conducting welfare checks requires further consideration and clarity for frontline professionals in relation to the threshold for welfare checks.

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

Recommendation 1

Addressed to NHS England | West London Clinical Commission Group

Achievable means should be explored of enabling primary health practitioners to have access to historic records that could contribute to a holistic assessment of an adult or child who may be at risk.

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

Recommendation 1

Addressed to Multi-agency

All agencies and frontline professionals should consider the use of a DASH risk assessment where domestic abuse is featured even if it appears at a low threshold level.

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

Recommendation 2

Addressed to Multi-agency

Professionals should not be thwarted in obtaining wider information from extended family members who may have key perspectives to share, particularly where parental relationships are volatile. The child’s welfare must be paramount.

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

Recommendation 2

Addressed to Multi-agency

All agencies need to cascade this to their frontline staff to promote a common understanding and mutual expectation as to when and how such checks would be executed.

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

Recommendation 2

Addressed to NHS England | West London Clinical Commission Group

Information sharing should extend to considering risks wider than health such as domestic abuse.

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

Recommendation 2

Addressed to Multi-agency

It should particularly be used in the face of high risk factors such as pregnancy, separation, disclosures being made by children or by other family members that their parent/relative is in an abusive relationship.

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

Recommendation 3

Addressed to Multi-agency

Fathers should always be included in assessments unless there is a legitimate reason why this is not possible. This should be monitored via supervision and audit.

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

Recommendation 3

Addressed to Community Safety Partnership

The Community Safety Partnership needs to have a monitoring and audit role to assess the impact and wider implications that restricted welfare checks are having on public safety.

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

Recommendation 3

Addressed to NHS England | Central and North West London NHS Foundation Trust

The service redesign of crisis mental health services should include a robust information sharing system.

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

Recommendation 4

Addressed to Multi-agency

Multi-agency professionals, in RBKC including professionals in schools should receive updating training around domestic abuse and coercive control and how to respond to disclosures made by children to gain a more sophisticated understanding and ensure children are heard.

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

Recommendation 4

Addressed to Central and North West London NHS Foundation Trust

Where a patient is being seen in the same health organisation but in different parts of the service each part of the service should be able to practically information share what is held on that patient by each part of the service.

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