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
Harrow review
CSP: Harrow
Published: June 2023
Year of death: 2011
Extracted: 108 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 DHR identified missed opportunities for early intervention and support for the victim, particularly regarding domestic violence and substance misuse. Agencies struggled with information sharing, collaborative working, and consistently assessing cumulative risk, leading to inadequate responses.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | That there is an Independent Domestic Violence Advocate based within the Multi Agency Safeguarding Hub (MASH) who will provide advice and support to victims of domestic violence as appropriate. | London Borough of Harrow Children’s Social Care |
| 1 | The MPS to update the domestic violence and Hate Crime tab within the CRIS system to reflect the new DASH model rather than the older SPECSS+ risk assessment system | Metropolitan Police |
| 1 | Safeguarding training should reinforce the seriousness of domestic violence and the need for opportunistic domestic violence screenings. | North West London Hospitals |
| 1 | Harrow CCG should ensure a health practitioner is included as part of MASH’s team as this will also help to improve communication and co-ordination of care. | Harrow CCG |
| 1 | That there is mandatory training for all staff on: undertaking effective assessments and risk assessments establishing treatment goals providing effective care, including through challenging clients on their motivation and behaviours on how to use genograms and/or relationship and significant others mapping to inform practice. | Each |
| 1 | Internal case management procedures requires regular performance management of timely, high-quality responses to clients that includes prompt MARAC referrals whilst also progressing risk management and safety-planning actions in between meetings | Advance |
| 1 | The Trust will review to ensure that it has the right infrastructure to support local borough Multi Agency Risk Assessment Conference (MARAC) processes. | CNWL |
| 1 | Housing Services policy on domestic violence needs to be reviewed and on completion compulsory training for front line staff should be introduced and refresher training provided annually. Sign posting to a support service at the very least should always be provided to victims of violence and evidence of this should be added to file notes. | LB Harrow Housing |
| 1 | Include safeguarding of vulnerable adults in the programme for Child Protection Training. | Ealing Hospital |
| 1 | Develop referral pathways between health and Victim Support | Victim Support |
| 1 | Provide training for MARAC Coordinator | Hestia |
| 1 | MARAC training for London Probation Trust staff including attendance at a MARAC. | Probation |
| 10 | Ensure that supervision and risk assessment during the secondary investigation of domestic violence is conducted by trained CSU supervisors. This is required by both the MPS Standard Operating Procedures (SOP) and by CAADA guidelines | Metropolitan Police |
| 10 | That all counsellors and keyworkers provide standard reporting to their respective team leader on their individual case management weekly where there are safeguarding issues or potential safeguarding concerns related to the individual, family and children | Each |
| 10 | Improve quality of practice around holistic approach to recovery | Compass |
| 10 | (Safe Transfer of Women) STOW project in progress to transfer postnatal discharge information electronically from nhs.net to nhs.net address across London. | Ealing Hospital |
| 10 | To ensure a delegate is identified in the action plan to feedback to the victim and that is it recorded as an action in the minutes especially where both the IDVA and referring agency are involved, or where there is no IDVA involvement and a victim is not engaging. | Hestia |
| 11 | BOCU must ensure that the supervision of domestic violence investigation is intrusive and contain well detailed action plans including specific reviews of the risk. Risk assessment must be dynamic | Metropolitan Police |
| 11 | That EACH’s programme of annual clinical audits (including spot checks) of client case records, safeguarding and clinical supervisors’ notes continues to be implemented to identify gaps and address, including through use of appropriate policies and procedures where necessary | Each |
| 11 | Make recommendations to commissioners about minimum client data sets for transferring services to promote continuity of care, to include: • Basic Information • Summary of current Recovery Plan • Latest Risk Assessment | Compass |
| 11 | Person to person discussion between Trusts regarding the discharge of a client to the community where serious adult or child safeguarding concerns are identified. | Ealing Hospital |
| 11 | To ensure the MARAC list is distributed at least 8 days prior to the MARAC meeting, and to consider using CAADAs recommended pro-formas for case list, minutes and action plan agenda, to ease administrative demand | Hestia |
| 12 | BOCU should ensure that cases that have been referred to the MARAC process have been flagged appropriately with the MARAC referral flag within the CRIS system | Metropolitan Police |
| 12 | That all records of clinical supervision notes are filed and kept within the organisation at a central point established as part of governance oversight | Each |
| 12 | This should be provided for both current clients and clients discharged within the last six months (pre-transfer date) where they have had 2 or more treatment journeys (and are therefore likely to re-present) | Compass |
| 12 | Get information from other London boroughs in terms of how they are measuring outcomes. | Hestia |
| 13 | That team case management sessions are noted, signed off by team leader or senior practitioner and filed at each service in central folder | Each |
| 13 | Make recommendations to commissioners about their role in proactively ensuring the transfer of leases and premises for service delivery to reduce the risk of incoming services operating from | Compass |
| 14 | That all safeguarding issues are presented by counsellors at bi-weekly case management meetings overseen by team leaders (or senior practitioners), with notes to be signed off and reviewed by safeguarding lead. | Each |
| 14 | Make recommendations to commissioners about their role in proactively overseeing the transfer of services to reduce the risk of staff leaving if there are anxieties about TUPE being applied. | Compass |
| 15 | That relevant policies (Violence & Abuse, Safeguarding, Health & Safety, Clinical Practice) are revised to incorporate working with perpetrators of violence specifically | Each |
| 15 | Review Prescribing Guidelines so that they explicitly address pregnancy tests before each new episode of prescribing – including re-titrations. | Compass |
| 16 | That the findings from the DHR are cascaded to the SMT and to staff and within the partnerships within Brent and Harrow | Each |
| 16 | Improve Safeguarding practice (for children) so that alerts are made more proactively. | Compass |
| 2 | That the post of a Young Person’s Violence Advisor is created, based within the Early Intervention Service. | London Borough of Harrow Children’s Social Care |
| 2 | The MPS makes changes to the Standard Operating Procedures for the investigation of Domestic Violence so that initial ‘standard’ risk assessments are subjected to secondary supervision by the BOCU CSU to ensure that the appropriate level of risk has been attributed from the outset of an investigation. | Metropolitan Police |
| 2 | Joint assessment must take place between hospitals for vulnerable pregnant women with complex social needs by the safeguarding midwives. This is irrespective of the stage of transferred in or out. This also includes postnatal period. | North West London Hospitals |
| 2 | That there is mandatory training for all staff on working with perpetrators effectively and safely | Each |
| 2 | Case management procedures review to introduce consistent assessment / support plans across teams to improve engagement of survivors with complex needs; improve the quality of safety planning with women who reconcile or remain in relationships with perpetrators; promote use of Respect phoneline for perpetrators to ensure women have access to this source of help. | Advance |
| 2 | The Trust will review with the London Borough of Harrow its support for MARAC and structures for information sharing and awareness rising of the specific risks of domestic violence for adults at risk. | CNWL |
| 2 | Provide training on domestic violence for the Compass Harrow Team | Compass |
| 2 | Discuss in Leaders Meetings ward meetings and handovers. | Ealing Hospital |
| 2 | More comprehensive recording of interventions with domestic abuse clients and contacts if any with any other supporting agencies | Victim Support |
| 2 | Incorporate CAADA minutes template or alternative smart template | Hestia |
| 2 | The expectation that in all cases where the perpetrator and victim resume co-habitation that a home visit is undertaken, preferably with other key professionals involved in the case. | Probation |
| 3 | Development of a domestic violence toolkit to inform assessments within Targeted Services | London Borough of Harrow Children’s Social Care |
| 3 | The MPS creates warning markers within the CRIMINT + system for subjects that have been referred to the MARAC process (a similar marker to that which is seen regarding officer safety issues). This will alert officers to the fact that a subject had been involved in a prior MARAC referral and alert officers to the potential need to re refer a subject to the MARAC process. | Metropolitan Police |
| 3 | Inter organisational maternity safeguarding check list or a Performa is to be developed to aid effective communication and transfer of care between organisations | North West London Hospitals |
| 3 | That there is a rolling training programme on identifying and responding to safeguarding and risk, including through information sharing and joint working with other agencies and professionals | Each |
| 3 | Update and improve safeguarding procedures and practice –and a lead safeguarding professional (manager) to be identified to hold expertise to advise internally on complex cases, including where adult and child safeguarding issues coexist. | Advance |
| 3 | The Trust will review safeguarding adult policies and processes and domestic violence policies and processes, considering overlap between the two. The Trust will update policies and processes to ensure the dynamics of domestic violence are fully considered. Policies and processes to be reviewed annually | CNWL |
| 3 | Improve quality of practice in identifying and responding to domestic violence – including consideration of risk where partners in volatile relationships who are both in treatment engage/ disengage | Compass |
| 3 | Discussion in multidisciplinary meeting forums such as Monday Morning Case Review Meeting | Ealing Hospital |
| 3 | The new CMS logs who has updated the system which enables a more effective audit trail. Updates on cases need to be input in real time which has sometimes been an issue for Police based IDVA. | Victim Support |
| 3 | All MARAC referrals have information on consent | Hestia |
| 3 | Improve cross-Borough information sharing | Probation |
| 4 | Provide sessions for staff with regards to learning the lessons from the DHR. | London Borough of Harrow Children’s Social Care |
| 4 | The MPS uses the CRIMINT + system to retain a record of the minutes, actions and outcome of MARAC meetings. This will ensure that an accurate MPS record is maintained of the MARAC process | Metropolitan Police |
| 4 | NPH to carry out an antenatal quality assurance audit on frequency of domestic violence screening during pregnancy | North West London Hospitals |
| 4 | That core training on substance misuse, domestic violence and mental health is delivered to all staff | Each |
| 4 | Review our internal management case closure system to ensure this is timely and appropriate, that no necessary actions are outstanding, and that service quality and practice issues are addressed with front-line staff. | Advance |
| 4 | To work with a local domestic violence agency and the Trust Recovery College to co-produce a training package that will compliment an e-learning programme. | CNWL |
| 4 | Establish Clinical Meetings | Compass |
| 4 | Feedback from Community Team Leaders to teams to facilitate shared learning | Ealing Hospital |
| 4 | Initial Contact attempts must follow the instructions as laid out in the Domestic Violence Service Delivery Operating Procedures. | Victim Support |
| 4 | Review coordinator resource against demand to provide quality service | Hestia |
| 4 | To improve communication between probation staff and IDVAs at PSR stage | Probation |
| 5 | Children and Families provide Senior Management representation on The Domestic Violence Steering Group. | London Borough of Harrow Children’s Social Care |
| 5 | The MPS is to implement a system to ensure that the risk assessment process in cases of domestic violence is reviewed when there has been a significant change in circumstances. This should include a mandatory requirement to review the risk assessment following an individual’s subsequent arrest (if not arrested at the time of the initial report) or subsequent release from police custody whether an individual is charged or granted conditional or unconditional bail. This measure should also be adopted following an individual’s court appearance. | Metropolitan Police |
| 5 | Supervisor of midwives to reflect with the booking midwife on the need to explore safeguarding issue especially when the client discloses unusual information | North West London Hospitals |
| 5 | That there is a record of attendance at above training by staff to be kept up to date annually, evidenced through e-learning and audited through supervision | Each |
| 5 | Improve cross borough working and communication between advocacy services so that there is a system of referral between specialist domestic violence services where cross-Borough MARAC referrals are made, where court support is provided out of borough and where cases are closed because women have moved out of area and there is still perceived to be high-risk to survivors. | Advance |
| 5 | The Trust will relook at local and trust non agency policies and its links to the services’ duty of care. | CNWL |
| 5 | Embed Hidden Harm Co-ordinator within Adults Team | Compass |
| 5 | Remind all staff at group and forums meetings of the need to make contemporaneous records of plans of care and support and to whom and how, the plans have been communicated. | Ealing Hospital |
| 5 | Ensure that there is consistency and presence by the referring agency for cases | Hestia |
| 6 | The Domestic Violence Champion within Quality Assurance to undertake advanced training in domestic violence, cascade this knowledge to Targeted Services staff and to be a consistent member of the Harrow Domestic and Sexual Violence Forum. | London Borough of Harrow Children’s Social Care |
| 6 | The MPS to ensure that all officers responding to domestic violence incidents receive mandatory training in the use of the DASH 2009 risk identification, assessment and management tool in order to effectively assess risk. | Metropolitan Police |
| 6 | NPH safeguarding team to commence case-loading vulnerable women with complex social needs. | North West London Hospitals |
| 6 | That a standardised care pathway is reviewed, developed and implemented for all clients, detailing information and recording requirements from point of referral to point of exit, including through communication and liaison with external agencies to share information. | Each |
| 6 | Improve communication with referring agencies when women do not engage with our service. | Advance |
| 6 | The domestic violence training commissioned to support staff will address the use of risk assessments as a robust tool to manage risk and inform actions and outcomes, particularly where domestic violence is suspected. | CNWL |
| 6 | Improve management overview of domestic violence by creating domestic violence specific flag on Care Path to enable reports to be run for service level audit and review purposes | Compass |
| 6 | Case scenario to be presented to LW Forum / audit meeting to reiterate the importance of Contemporaneous documentation of plans of care for vulnerable adults within case notes. | Ealing Hospital |
| 6 | Where high risk cases are referred directly to the IDVA service who then refer to MARAC, the MARAC Coordinator records where the originating referral came from in order to ensure that referrals are accurately recorded. | Hestia |
| 7 | Targeted Services to be actively involved in the research project ‘Cultural Encounters in Interventions Against Violence’ including considering how best to implement recommendations. | London Borough of Harrow Children’s Social Care |
| 7 | It is recommended that the CSU Service Delivery Team conduct an internal quality assurance assessment of the MPS MARAC working practices and administration to ensure corporacy and understanding MPS wide of the referral process and record keeping. | Metropolitan Police |
| 7 | The safeguarding team should reiterate the importance of following policies and guidelines especially women who persistently DNA their antenatal appointments during monthly mandatory training. | North West London Hospitals |
| 7 | That a baseline framework is established for each individual through clinical audit and practice monitored against the pathway through clinical audit undertaken during probationary period, individual supervision and appraisals, and through annual service practice checks | Each |
| 7 | Review / update our service level agreement with Brent police to ensure consistency in referring victims as close as possible to the time of the incident being reported. This needs to be consistently applied across all our IDVA services so women do not get different responses depending on where they live or where the incident happened. | Advance |
| 7 | To work with local MARAC and agencies to address a whole system perspective. To look at partnership strategies of working with abusers. | CNWL |
| 7 | Establish on site services for domestic violence to improve referral and engagement | Compass |
| 7 | Audit of notes and record keeping of cases where Child Protection and/or Domestic Violence have been identified as a cause for concern. | Ealing Hospital |
| 7 | Outstanding actions to be included in the minutes of the subsequent MARAC meeting. | Hestia |
| 8 | Ensure that if a victim wishes to withdraw an allegation of domestic violence, that the case is reviewed by a substantive supervisor within the Community Safety Unit (CSU). | Metropolitan Police |
| 8 | Strengthen midwives’ Involvement in MARAC as this will also help to improve communication and co-ordination of care for women who are victims of domestic violence. | North West London Hospitals |
| 8 | That the standardised format is revised and issued for staff to use for session notes, incorporating prompts to identify and respond to and record safeguarding, substance use, violence and abuse and mental health issues of client | Each |
| 8 | Improve communication and referral with probation services and integrated offender management partnerships so women experiencing domestic violence and involved in offending / CJS access specialist women’s support service. | Advance |
| 8 | Increase awareness of MARAC and increase number of appropriate referrals to MARAC | Compass |
| 8 | Review the job description for the Maternity safeguarding midwife to include Safeguarding Adults as part of the role. | Ealing Hospital |
| 8 | As a safeguard, the MARAC Coordinator will check with the referrer that a safeguarding referral has also been made where children are present. | Hestia |
| 9 | Ensure that when officers attend a Domestic Incident, intelligence research is undertaken to include at least the last five years using the Integrated Information Platform, as required by the MPS Operating Procedures. Where possible officers should be encouraged to search beyond five years. | Metropolitan Police |
| 9 | Maternity senior management team should mitigate circumstances that prevent the main hospital notes to be available at every care contact with clients | North West London Hospitals |
| 9 | That all clients’ care plans and discharge plans to be signed off by team leader or senior practitioner | Each |
| 9 | Work with commissioners and other strategic and operational partners to ensure the widest possible access to our service and clarity and consistency of referral routes, especially where co-located specialist posts are placed. | Advance |
| 9 | Improve quality and timeliness of case note recording – including review of risk assessments and proactive sharing of risk and information with other agencies | Compass |
| 9 | Pathway to be documented and disseminated widely to all maternity staff. | Ealing Hospital |
| 9 | To ensure that all non-police referrals are contacted by the Hestia IDVA prior to the MARAC meeting | Hestia |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||