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

Harlow review

CSP: Harlow Published: June 2023 Year of death: 2012 Extracted: 28 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 systemic failures in Children's Social Care to link past domestic abuse incidents and involve children in assessments. It also highlights disparities in adult safeguarding training, poor inter-agency information sharing, and missed opportunities to assess risk and provide support to the victim and perpetrator within health services.

Extracted recommendations

28 recommendations pulled from the report

#	Recommendation	Addressed to
11.10.1	Should raise the value and importance of adult safeguarding training and awareness to that of children’s safeguarding, and to ensure that domestic abuse features appropriately within that training.	All Agencies
11.10.2	Must develop appropriate information sharing protocols that can override the barriers caused by separate IT systems, and the laws regarding data protection.	All Agencies
11.10.3	All agencies should familiarise themselves with the ”7 golden rules of information sharing” as published by HM Government.	All Agencies
11.10.4	Clinical Commissioning Groups (CCGs) in their safeguarding role, should develop a simple to use toolkit which will enable clinicians and practice staff to ask four or five pertinent questions regarding domestic abuse, and be confident about the pathway for referral if there are concerns.	All Agencies
11.10.5	Within a domestic abuse situation it is of concern that referrals and/or the escalation of any identified issues , only make reference to physical or violent abuse, whereas it is well referenced that controlling and coercive behaviour as well as emotional abuse, are often part of the pattern of perpetrator behaviours. Agencies need to factor in ALL aspects of potential risk and acknowledge that domestic abuse covers a wider spectrum of perpetrator behaviours.	All Agencies
11.1.1	In line with policy, procedure and good practice, practitioners need to ensure that children’s voices are heard. They need to be seen and interviewed in order for practitioners to gain a better understanding of what’s going on within the whole family and within that child’s world.	Essex County Council (ECC), Children’s Social Care
11.1.2	There needs to be a better link between the IRT (Initial Response Team) and their CSC colleagues after the initial referral and recommendations. This is particularly important in a situation where children have been involved in a domestic abuse situation.	Essex County Council (ECC), Children’s Social Care
11.1.3	There must be a system whereby children, step children, half brothers and sisters, can be linked to each other’s records within CSC. There also needs to be a family chronology linked to the records of individual children if CSC is to be able to work out the relationships within “reconstituted families”.	Essex County Council (ECC), Children’s Social Care
11.1.4	DASH training should be undertaken by all practitioners but particularly those practitioners involved in the IRT, who should complete this training immediately.	Essex County Council (ECC), Children’s Social Care
11.1.5	There should be a more timely use of a Family Group Conference (FGC) especially where there has been a domestic abuse incident. This will alert practitioners to the whole picture in relation to the entire family, and would provide better safeguards and monitoring arrangements in order to secure the welfare of the children.	Essex County Council (ECC), Children’s Social Care
11.2.1	The adult safeguarding policy should be signed off and implemented with immediate effect, as this has been waiting for ratification for some time.	Princess Alexandra Hospital (PAH)
11.2.2	All members of the safeguarding team should have specialist training in domestic abuse and all staff should have a basic level of adult safeguarding training which includes domestic abuse as a specific topic within the training.	Princess Alexandra Hospital (PAH)
11.4.1	SET procedures for adult safeguarding should be as accessible as the children’s SET procedures and be uploaded onto desktop for immediate access by all GPs.	Lister Medical Centre
11.4.1	SET procedures for adult safeguarding should be as accessible as the children’s SET procedures and be uploaded onto desktop for immediate access by all GPs.	The Elsenham Practice
11.4.2	Systems must be updated in order to be able to make links between parents and siblings, step children, and half brothers and sisters. A note on parental responsibility should also be added to each child’s records where there is a reconstituted family.	Lister Medical Centre
11.4.3	A training programme, which covers domestic abuse as a separate item to adult safeguarding, should be delivered to all staff including front line administrative staff.	Lister Medical Centre
11.4.3	A training programme, which covers domestic abuse as a separate item to adult safeguarding, should be delivered to all staff including front line administrative staff.	The Elsenham Practice
11.4.4	GPs should have a simple toolkit of “routine” questions for each person to flag up indicators of domestic abuse.	Lister Medical Centre
11.4.4	GPs should have a simple toolkit of “routine” questions for each person to flag up indicators of domestic abuse.	The Elsenham Practice
11.4.5	Primary care should be included in the MARAC process.	Lister Medical Centre
11.4.5	Primary care should be included in the MARAC process.	The Elsenham Practice
11.4.6	Domestic abuse incidents (via police alerts-DV/1) should be discussed at practice meetings in order to share information, highlight good practice, and to develop better response options, as well as raising a greater awareness of domestic abuse.	Lister Medical Centre
11.4.6	Domestic abuse incidents (via police alerts-DV/1) should be discussed at practice meetings in order to share information, highlight good practice, and to develop better response options, as well as raising a greater awareness of domestic abuse.	The Elsenham Practice
11.6.1	WECCG should consider the appointment of a domestic abuse lead, which could operate within the whole adult safeguarding agenda. The post could lead on the roll out of specialist training and act as an information and “expert” resource to primary care.	West Essex CCG
11.7.1	When cases are on-going, i.e. over one year, and patients are accessing services via a number of providers, there should be a multi-agency review to ensure that all of the supporting agencies are working towards the same goals for the patient, and coordinating that care for the best outcomes.	NEPFT
11.7.2	There is no evidence of risk assessments being reviewed or shared with other agencies, including primary care. The policy around risk assessments and who they are shared with should be reviewed to ensure that there are regular reviews particularly when there is a change of medication and/or the emergence of new symptoms.	NEPFT
11.7.3	There was no carers assessment completed with regard to the victim, even though the perpetrator reported that she was his main carer and she agreed that she was “looking after him”. NEPFT states that it has a policy with regard to this and it is mandatory for any carer to have an assessment. NEPFT therefore need to review how this policy is being implemented and adhered to, if situations such as the perpetrator's were allowed to slip through the process.	NEPFT
11.7.4	Compliance with prescribed medication must be based on clinical evidence rather than verbal reassurances, particularly where appointment attendance and other aspects of case management have been uncooperative or resistant.	NEPFT
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗