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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

13 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	Multi-agency
1	The most recent policy around conducting welfare checks requires further consideration and clarity for frontline professionals in relation to the threshold for welfare checks.	Multi-agency
1	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.	NHS England \| West London Clinical Commission Group
1	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.	Multi-agency
2	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.	Multi-agency
2	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.	Multi-agency
2	Information sharing should extend to considering risks wider than health such as domestic abuse.	NHS England \| West London Clinical Commission Group
2	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.	Multi-agency
3	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.	Multi-agency
3	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.	Community Safety Partnership
3	The service redesign of crisis mental health services should include a robust information sharing system.	NHS England \| Central and North West London NHS Foundation Trust
4	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.	Multi-agency
4	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.	Central and North West London NHS Foundation Trust
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗