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
Croydon review
CSP: Croydon
Published: June 2023
Year of death: 2013
Extracted: 41 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 a lack of coordinated multi-agency response to domestic violence, poor information sharing, and missed opportunities by health and social care services to identify and respond to the victim's escalating needs and disclosures. Inadequate risk assessment and follow-up, coupled with high caseloads and a disconnect between strategy and operational practice, contributed to the systemic failures.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Conduct a rigorous borough wide review of the response to domestic violence. This review must address the gap between the strategy and delivery of the strategic aims in operational practice of partner agencies. | Croydon Community Safety Partnership |
| 10 | Ensure that probation officers have quick access to the Police national computer to inform their reports and risk assessments. | Metropolitan Police | London Probation Trust |
| 11 | Complete an audit on Did Not Attend (DNAs) who were discharged from CAMHS to check that risk assessments have been or are now completed before decision to discharge as outlined in the policy and provide a new offer of support (where appropriate). | SLaM |
| 12 | Provide those referring to SLaM Child ADHD Services information to help them signpost families to other support networks at the time of the referral as it is recognised that there are at times delays from date of referral to date of first appointment, and the family may require more speedy support. | SLaM |
| 13 | Review its prioritisation of and response to the issue of domestic violence. This should include recognition of the possibility of domestic violence within each referral and policies which address routine and/or selective enquiry about the existence of domestic violence. | Croydon Safeguarding Children’s Board |
| 14 | Review corporate policy for responding to families who fail to engage with services (and make amendments) in light of the findings of this review. | Croydon Safeguarding Children’s Board |
| 15 | Audit safeguarding children’s training (and take up across the multi-agency partnership) to ensure that domestic violence is appropriately addressed. | Croydon Safeguarding Children’s Board |
| 16 | Highlight and explain the think family approach, so that practitioners, professionals and clinicians understand the concept and their roles and responsibilities regarding safeguarding children. | Croydon Safeguarding Children’s Board |
| 17 | Review the process of the early offer of help to examine its effectiveness with particular reference to CAF implementation within health services and how domestic violence is included in this assessment. | Croydon Safeguarding Children’s Board |
| 18 | Review and update the local Safeguarding Children’s Board Domestic Violence Policy and ensure it is widely circulated to all relevant professionals. | Croydon Safeguarding Children’s Board |
| 19 | Rewrite the Multi-Agency Borough referral pathway agreement which should include action taken by agencies and the outcomes of referral. | Croydon Council Family Justice Centre |
| 2 | In conjunction with other strategic boards, produce a domestic violence protocol, policy and care pathway, across the partnership and for each organisation. This should include domestic violence enquiry and provision for safeguarding children and vulnerable young people. | Croydon Community Safety Partnership |
| 20 | The Joint Strategic Needs Assessment on domestic violence should reference the findings of the two Croydon Domestic Homicide Reviews. | Croydon Council Public Health |
| 21 | Look to pilot and/or commission a borough wide system to improve the response of primary care to patients who are experiencing domestic violence, such as Project IRIS. | NHS England (Croydon Clinical Commissioning Group) | Croydon Council Public Health |
| 22 | Ensure engagement in Croydon’s coordinated community response to domestic violence through regular and appropriately senior representation at the Croydon Domestic Violence and Sexual Violence Strategy Board. | Croydon Clinical Commissioning Group |
| 23 | Develop a system where independent approaches to Children’s Social Care from individuals and families requesting help and support which then do not meet the threshold for statutory intervention are reviewed and shared with universal family support services. | Croydon Children’s Services |
| 24 | As NHS England have provided funding within GP budgets to deliver safeguarding training (adults and children), a local review of this training should be instituted to ensure domestic violence is included in this training and to an appropriate level. | NHS England |
| 25 | Ensure, when appointed, that the Lead GP for safeguarding has domestic violence included in their job description. | NHS England |
| 26 | Develop a depression screening and care pathway for GP’s, and review the tools that are used to include psychological/social aspects on the dynamic of mental health and domestic violence. | NHS England |
| 27 | Safeguarding adult training to be implemented to raise awareness of the issues identified. | NHS England |
| 28 | Include learning points in the Croydon CCG Newsletter. | NHS England |
| 29 | Include these learning points in case reflection session with GP Practices once organised. | NHS England |
| 3 | Disseminate learning from the two Croydon Domestic Homicide Reviews widely across the partnership. This should be in the form of a written briefing to all staff and dissemination sessions and incorporating findings into any domestic violence training that is commissioned and delivered locally. | Croydon Community Safety Partnership |
| 30 | Data relating to family members and dependents should be gathered at the time of registration and/or the initial health check. | NHS England |
| 31 | Consideration should be given to flagging cases where there is high-risk or potentially high-risk. | NHS England |
| 32 | Consideration needs to be given as to how information can be shared with other practices if parents have re-registered at separate practices. | NHS England |
| 33 | Meet with staff to provide a briefing on the initial review findings to enable opportunities to learn from them and develop their confidence and competence re managing such cases. | NHS England |
| 34 | Support staff through case reflection as needed. | NHS England |
| 35 | Create, disseminate and then regularly review an organisational domestic violence policy and care pathway. This should include: a. Specific reference to the use of the A&E prompts for the emergency department. b. Inclusion of routine enquiry within the service specification of any new commissioning processes, particularly for health visiting and school nurses. c. An organisational stance on providing “private time” at the antenatal booking appointment, and then throughout all antenatal care appointments to enable midwives to ask about sensitive issues such as domestic violence. | Croydon Health Services NHS Trust |
| 36 | Work with the Community Safety Partnership to ensure a workforce training programme on domestic violence is delivered (this may be part of the training led by the CSP or separately commissioned). | Croydon Health Services NHS Trust |
| 37 | Develop and distribute a universal resource on help and support available for all new parents, to support routine enquiry for domestic violence during ante natal and post natal care. | Croydon Health Services NHS Trust |
| 38 | Conduct a systematic review of the processes within A&E so that staff are aware of their role and responsibilities in relation to responding to domestic violence and any safeguarding concerns. This should include a mandatory training programme for all A&E staff and provision of information on local domestic violence support services and how to refer to them. | Croydon Health Services NHS Trust |
| 39 | Embed the use of the A&E safeguarding prompts in practice, and seek to include the key questions in the prompts in the new electronic record keeping system (Cerner) to be used by services within CUH from 30 September 2013 onwards. | Croydon Health Services NHS Trust |
| 4 | Commission a borough multi-agency domestic violence training programme. This should be done with support of other strategic boards and take up of training should be audited and monitored per agency by the Croydon Domestic Violence Strategy Group. It is recommended that the training covers awareness and dynamics of domestic violence, specific skills training on enquiry and completion of MARAC risk assessment, safeguarding responsibilities and referrals pathways. | Croydon Community Safety Partnership |
| 40 | Review and improve systems of sharing safeguarding concerns between the emergency department and other departments with CUH (including the ward staff). | Croydon Health Services NHS Trust |
| 41 | Reconfirm domestic violence enquiry practices within maternity services and ensure that staff are appropriately trained to ask about domestic violence and respond to a concern or a disclosure from a pregnant woman. This should include approaches for enquiry of pregnant teenagers and also for women who have suffered a miscarriage. | Croydon Health Services NHS Trust |
| 5 | Develop an early intervention approach to domestic violence through local schools (that ties in with the existing programme on gangs and sexual exploitation) and is age appropriate. | Croydon Community Safety Partnership |
| 6 | Review the policy of restricting intelligence checks to five years. | Metropolitan Police |
| 7 | Use this case as a briefing aid and learning tool for Croydon Police to support an enhanced response to potential victims of domestic violence. | Metropolitan Police |
| 8 | Ensure specific and open questions are asked to the Police as part of intelligence checks so that more accurate information is obtained to inform risk assessments. | London Probation Trust |
| 9 | When subject to an order, when there are a sustained number of absences in relation to children of the offender (e.g. child care) a risk assessment should be completed, supported by a line manager. | London Probation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||