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: 35 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 identified a lack of coordinated multi-agency oversight, inconsistent risk assessments, and inadequate information sharing regarding escalating domestic abuse. Gaps in adult safeguarding training and communication between health, social care, and criminal justice agencies hindered effective intervention for the victim and management of the perpetrator's known risks.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 15.10.1 | To 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 the training. | All Agencies |
| 15.10.2 | To develop appropriate information sharing protocols that can override the barriers caused by separate IT systems, and the laws regarding data protection. | All Agencies |
| 15.10.3 | All agencies should familiarise themselves with the “7 golden rules of information sharing” as published by HM Government. | All Agencies |
| 15.10.4 | Consideration should be given to the status of an unborn child who is delivered within a homicide situation. As the victim’s baby was not born there was no birth certificate, and as she was not recorded as a stillbirth there was no certificate to state that either. However the judicial system recognised that there was a child death involved in the perpetrator’s actions and he was charged with child destruction as well as the victim’s murder. | All Agencies |
| 15.10.5 | Where a victim of domestic abuse is likely to come across their perpetrator and/or their known associates within a statutory setting, a request to change an appointment time should never be dismissed as “not allowed” or impossible to do. All government agencies have a duty to respond appropriately if domestic abuse concerns are raised. | All Agencies |
| 15.1.1 | General Practice should be included in the MARAC process, and elect their own representative who can cascade relevant information to all the practices. | Primary Care Health |
| 15.1.2 | All practices should have a named person for adult safeguarding, and clear polices for escalation of concerns. | Primary Care Health |
| 15.1.3 | Adult safeguarding needs to be given the same priority as children’s safeguarding, with all staff undertaking this training as mandatory. The training needs to extend through the practices to front line and administrative staff. | Primary Care Health |
| 15.1.4 | Individual practices should be encouraged to develop policies that make all staff aware of the issues of domestic abuse | Primary Care Health |
| 15.1.5 | The West Essex Clinical Commissioning Group (CCG) in its 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. | West Essex Clinical Commissioning Group |
| 15.1.6 | The WECCG should also develop specific training for GPs regarding domestic abuse, and this training should be repeated on a regular basis. | West Essex Clinical Commissioning Group |
| 15.2.1 | The PAH adult safeguarding policy should be ratified and implemented immediately. | Princess Alexandra Hospital |
| 15.2.2 | PAH in partnership with Safer Places, should develop a robust business case for the expansion of The Daisy Project into A&E, and implement as soon as funding can be secured to make it sustainable. | Princess Alexandra Hospital | Safer Places |
| 15.2.3 | There should be a named adult safeguarding person available at all times, particularly if and when the Daisy Project is extended to A&E. | Princess Alexandra Hospital |
| 15.2.4 | Adult safeguarding training should continue to be delivered to all personnel as part of the induction process. | Princess Alexandra Hospital |
| 15.2.5 | Where there are concerns raised, every effort should be made for the patient to have continuity of care and be seen by the same midwife. | Princess Alexandra Hospital |
| 15.2.6 | Where a referral to CSC or any other agency is made there should be a more formal process for reporting back to the referring agency, thus ensuring appropriate follow up procedures are implemented. | Princess Alexandra Hospital |
| 15.3.1 | Timely information regarding a patient’s urgent referral and non-attendance should be communicated back to the referring GP and a pro-active approach to follow up taken. | North Essex Partnership NHS Foundation Trust |
| 15.3.2 | NEPFT must refer to any information pertinent to MARAC or to a MAPPA co-ordinator involvement, when undertaking patient assessments. | North Essex Partnership NHS Foundation Trust |
| 15.3.3 | All front line staff should be trained in adult safeguarding, with a specific component covering domestic abuse and/or DASH. | North Essex Partnership NHS Foundation Trust |
| 15.3.4 | Carers and family members should be included in the assessment process, and have their own separate assessment; especially if like the perpetrator’s family, they have highlighted that they are living in fear. | North Essex Partnership NHS Foundation Trust |
| 15.3.5 | Where there is proven evidence or research regarding the likely outcome of an abusive relationship, the trust should develop a clear escalation policy which alerts other statutory services or providers using an information sharing protocol | North Essex Partnership NHS Foundation Trust |
| 15.3.6 | Children and/or an unborn child identified within an abusive relationship should be flagged as routine, and this process should initiate a referral to CSC. | North Essex Partnership NHS Foundation Trust |
| 15.5.1 | All investigations should include a check with the MAPPA Coordinator as routine. | Essex County Council-Children’s Social Care |
| 15.5.2 | Where there is a “toxic trio” of drug abuse, alcohol abuse and mental ill health identified within a referral or subsequent investigation, the information should be flagged on all of the separate IT systems. | Essex County Council-Children’s Social Care |
| 15.5.3 | All aspects of domestic abuse behaviour should be factored into an evaluation of referral or risk regarding someone who has been identified as a cause for concern. It is too narrow and potentially dangerous to only look for evidence of physical violence, when other behaviours and their associated risks are well researched and documented. There also needs to be more acknowledgements of any risks to an unborn child. | Essex County Council-Children’s Social Care |
| 15.6.1 | The Housing Dept. should continue with face to face interviews with clients presenting themselves as “at risk” whenever possible. However it is noted that there is a telephone response service for all out of hours contact and this does not allow a more personalised approach to anyone presenting as homeless. This is not about the creation of a more efficient service, but would present a more compassionate and responsive service to vulnerable or abused clients. | Harlow Council Housing Department |
| 15.7.1 | Internal processes with Essex Probation should be able to flag an alert when an offender with a history of violence and domestic abuse discloses that they have started or are in a new relationship. | Essex Probation |
| 15.7.2 | When an offender (who has been convicted of domestic abuse or violence) is released from the sentence early and on license, there must be appropriate conditions placed on the terms of the release. These should be related to the original offence and must include the requirement to stay away from previous victims as a minimum. | Essex Probation |
| 15.8.1 | Essex Police should amend their approach to risk classification once there is a record of previous incidents of domestic abuse on file. This might include, but not be restricted to, issues of alcohol and or drug abuse. | Essex Police |
| 15.8.2 | Where possible information recorded on the DV/1 form should indicate any children or an unborn child who may be at risk together with the victim. | Essex Police |
| 15.8.3 | Agencies have requested information about previous incidents of domestic abuse to be included on the DV/1 form, however it is unclear whether this would comply with the law regarding the disclosure of spent convictions. More reference should be made to “the 7 golden rules for information sharing” which have been published by HM Government. | Essex Police |
| 15.9.1 | The CPS should put a “victims right to review” policy in situ. This would operate when a decision has been taken not to authorise a criminal prosecution in a domestic abuse case. | Crown Prosecution Service |
| 15.9.2 | “Violence against women” panels must be set up to review domestic abuse cases which have proceeded into the criminal justice system but have failed to secure a conviction. These panels should make referrals into an Area Casework Committee when they feel a review is required. This committee can then issue appropriate guidance to the lawyers who handle domestic abuse cases. | Crown Prosecution Service |
| 15.9.3 | A victims and witness committee should be set up to operate under the Essex Criminal Justice Board. This needs to be set up as a multi-disciplinary group and can review any shortcomings and recommendations made by the other panels or committees. | Crown Prosecution Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||