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

Chelmsford review

CSP: Chelmsford Published: May 2023 Year of death: 2012 Extracted: 27 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 identified significant failures in inter-agency information sharing and risk assessment regarding the perpetrator's violent and sexually assaultive behaviour. Agencies minimised the seriousness of incidents, missing opportunities to identify potential risks to women, including the victim.

Home Office classifications

29 tags

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

  • Victim - mental ill health
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - other educational institution 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

27 recommendations pulled from the report · 23 matched to organisations in the index

Recommendation 1

Addressed to Essex Safeguarding Children Board

Review how awareness of the new definition of Domestic Violence is being introduced into statutory and voluntary agencies and provide an update to the Chelmsford Community Safety Partnership within six months of receipt of the report

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

Recommendation 1

Addressed to Essex Domestic Abuse Board

Review current domestic abuse training in light of the new definition and ensure that it now includes reference to sexual exploitation and provide an update to the Chelmsford Community Safety Partnership on progress within six months of receipt of the report.

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

Recommendation 1

Addressed to London Safeguarding Children Board

Share the report with relevant partners and confirm to the Chelmsford Community Safety Partnership that the lessons learnt have been disseminated as appropriate within three months of receipt of the report

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

Recommendation 1

Addressed to Essex County Council Children’s Social Care

To have in place a clear contact strategy between CSC and UKBA for each young UASC to ensure that information between the two agencies is shared, as the UASC travels through the asylum process.

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

Recommendation 1

Addressed to UK Border Agency

To have in place a clear contact strategy between UKBA and CSC for each young UASC to ensure that information between the two agencies is shared, as the UASC travels through the asylum process.

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

Recommendation 1

Addressed to Havering College of Further and Higher Education

Police to be notified when a student is expelled due to assault regardless of whether or not Social Services are involved. To ensure that the incident is logged by the police in case of future incidents.

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

Recommendation 1

Addressed to UK Border Agency

The UK Border Agency should make immediate efforts to re-document failed asylum seekers in an effort to facilitate the removal. This will result in the timely removal of immigration applicants from the UK, and will evidently reduce any risk of eventual domestic violence.

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

Recommendation 1

Addressed to North East London Foundation Trust

Completion of the review of the NELFT policies and procedures on domestic violence.

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

Recommendation 1

Addressed to Essex County Council Children’s Social Care

There is a need for interagency agency working and information sharing to be improved. Where there are formal meetings, minutes and documentation should be provided in a secure way to ensure this information is received.

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

Recommendation 2

Addressed to Essex Safeguarding Children Board

Ensure that local Schools and Colleges consider the findings of this DHR and review how they currently advise/support young people about domestic abuse within relationships. This should include the role of friends and the issue of breaking a confidence when risk is known. Provide an update to the Chelmsford Community Safety Partnership after six months of receipt of the report.

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

Recommendation 2

Addressed to UK Border Agency

Other statutory agencies, whether responsible for the victims or perpetrators, should routinely and immediately contact the UK Border Agency to share information and intelligence. This will allow the UK Border Agency to focus on cases where there is a need for immediate or swift intervention in relation to immigration matters; whether to assist the victim or to deal appropriately with the perpetrator. This should also apply to information sharing to other agencies by the UK Border Agency.

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

Recommendation 2

Addressed to North East London Foundation Trust

Domestic Abuse Training to be included in the core training skills programme for all clinical staff.

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

Recommendation 2

Addressed to Essex County Council Children’s Social Care

There are gaps in communication between the UKBA and CSC. Consideration needs to be given to regular liaison and updates between the UKBA and CSC.

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

Recommendation 3

Addressed to Essex County Council Children’s Social Care

There is a need for interagency agency working and information sharing to be improved. Where there are formal meetings, minutes and documentation should be provided in a secure way to ensure this information is received.

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

Recommendation 4

Addressed to North East London Foundation Trust

Implement a system to identify/flag all LAC with an open referral on the CAMHS case load.

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

Recommendation 4

Addressed to Essex County Council Children’s Social Care

Consideration to be given to DASH training being made available to all practitioners but essentially to those involved in the initial assessment and intervention process and those working with young people.

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

Recommendation 5

Addressed to North East London Foundation Trust

To raise awareness of CAMHS staff in relation to requirements for escalation and management in the event of increased risk factors

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

Recommendation 5

Addressed to Essex County Council Children’s Social Care

Consideration needs to be given to additional training and workshops for practitioners working with this user group to assist them in their assessment of need, including where therapeutic interventions are required.

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

Recommendation 6

Addressed to North East London Foundation Trust

Health LAC team to receive notification of all LAC children placed in borough from Essex County Council within 5 working days of placement change

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

Recommendation 6

Addressed to Essex County Council Children’s Social Care

Consideration needs to be given to the formulation of policy and procedure in relation to domestic violence amongst and between young people.

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

Recommendation 7

Addressed to Essex County Council Children’s Social Care

Given the level of involvement and work undertaken with UASC in CSC, consideration needs to be given to the availability of legal support and guidance to the L&ACT working with UASC and young people.

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

Recommendation 8

Addressed to Essex County Council Children’s Social Care

UASC and young people do not often have any one to advocate for them, consideration should be given to UASC being provided with an advocate.

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

Recommendation 9

Addressed to Essex County Council Children’s Social Care

The Assessment of Need and Pathway Plan is currently devised with the young person by the Personal Advisor and reviewed every six months. More consideration could be given to this being a joint meeting with all professionals involved in the young person’s life and chaired by an independent person equal to the Statutory Childcare Reviews undertaken when a LAC.

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

Recommendation 10

Addressed to Essex County Council Children’s Social Care

Given the uncertainty around the immigration status of UASC and young people, they should not be provided with a stand-alone independent living accommodation. Consideration should be given to placement within supported Living, Supported Accommodation with Sharing Housing being considered the least favourable and last option.

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

Recommendation 11

Addressed to Essex County Council Children’s Social Care

There needs to be a balance of UASC and young people remaining in Essex and having their cultural, diversity needs met. Where possible efforts should be made to provide placements in Essex as this will ensure there is more accessibility and greater contact to the provision of service provided by Essex County Council.

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

Recommendation 12

Addressed to Essex County Council Children’s Social Care

More focus and attention should be given to the view of foster carers when considering a move onto semi-independent/independent living.

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