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
Ealing review
CSP: Ealing
Published: July 2023
Year of death: 2016
Extracted: 39 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 missed opportunities by agencies to identify domestic abuse risk factors, particularly concerning mental health issues, family separation, and financial stress. It highlights weaknesses in inter-agency communication, the 'Think Family' approach, and the need for targeted training and consistent application of safeguarding thresholds, especially for home-schooled children.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 7.2.1(a) | LNWUHT to review the strategies and protocols to ensure that they incorporate the whole family approach and update as appropriate. Train staff in A&E and HVs on the updated strategies and protocols. | London North West University Healthcare NHS Trust |
| 7.2.1(b) | LNWUHT to audit a sample of screening tools for domestic violence and mental health to ensure that they incorporate whole family assessment. Ensure the tools are used consistently and effectively. | London North West University Healthcare NHS Trust |
| 7.2.1(c) | Levels 2 and 3 safeguarding training to remind staff of the information-sharing procedures and the importance of analysis in a whole family approach. | London North West University Healthcare NHS Trust |
| 7.2.1(d) | LNWUHT to ensure staff supervision monitors use of assessment tools, new birth protocols and policies. | London North West University Healthcare NHS Trust |
| 7.2.2 | All clinical staff in A&E to have an awareness of multi-agency training provided by the Local Safeguarding Children’s Board, which is advertised as a multi-disciplinary training, ‘Working Together to Safeguard Children’. | London North West University Healthcare NHS Trust |
| 7.3.1(a) | Link the medical notes of family members so that practitioners have pertinent information to hand when assessing a patient. | GP Surgery |
| 7.3.1(b) | Reception staff to confirm addresses and/or phone numbers whenever clients attend to avoid missed correspondence. Review with patients the surgeries’ modes of communication to identify any barriers such as literacy problems that would limit their engagement with the surgery. | GP Surgery |
| 7.3.2(a) | Apply alerts to files where there are significant events related to one of the toxic trio: mental health, substance misuse or domestic abuse, in the patient’s life or the lives of family members so that issues can be adequately explored in consultations and a care plan can be devised where required to provide on-going support. | GP Surgery |
| 7.3.2(b) | Explore the detail of hallucinations – the content, frequency, impact on the patient – to help assess the urgency of action. | GP Surgery |
| 7.3.3(a) | Specifically ask and note the identity and relationship of any adult that accompanies a child into a GP consultation. This is important so that decisions are made with those who have parental responsibility. | GP Surgery |
| 7.3.3(b) | Ask and note the identity and relationship of any adult accompanying an adult patient. | GP Surgery |
| 7.3.4 | GPs to have targeted training on domestic abuse so that they can identify patterns of presentations and create opportunities to enquire about abuse. | GP Surgery |
| 7.3.5 | Develop techniques for asking about experiences of violence, particularly for those who have come from outside the UK. | GP Surgery |
| 7.3.6 | GPs to use the safeguarding template on SystmOne. | GP Surgery |
| 7.3.7 | GP surgery to review this report together to allow a collaborative approach to learning and developing from this incident | GP Surgery |
| 7.3.8 | GP surgery to undertake a pro-active approach to routinely ask children about their emotional well-being where there are mental health problems in the family, recurrent attendances for the same complaint or similar complaints from multiple siblings. | GP Surgery |
| 7.4.1 | Recommendations from MH Review disseminated to the relevant hospital service line and an action plan created by their clinical improvement groups to address the care delivery problems noted. | West London NHS Trust |
| 7.4.2 | West London NHS Trust Clinical Directors to regularly monitor the requests for carers’ assessments to ensure that carer’s needs and safety are addressed. This is to be managed within the local teams supported through supervision. | West London NHS Trust |
| 7.4.3 | West London NHS Trust to strengthen Safeguarding Training to ensure staff are confident to apply the requirements of the new West London NHS Trust Domestic Abuse Policy. | West London NHS Trust |
| 7.4.4 | Within a year of introducing the new domestic abuse policy West London NHS Trust to assess if staff feel confident to implement the policy, especially regarding asking the questions of service users and their families, and responding to disclosures from victims and perpetrators, and identifying when to ask questions regarding domestic abuse where the service user, intimate partner or family has caring responsibilities. | West London NHS Trust |
| 7.5.1 | Social workers to question and record the evidence referrers have for ‘no safeguarding concerns for the children’ when the referral is based on concerns about the adults in the household. | Ealing Children’s Social Care |
| 7.5.2 | Develop consistency in practice through improvements in the following and dip sample case files for improvements in 6 months: | Ealing Children’s Social Care |
| 7.5.2(a) | Application of MASH thresholds | Ealing Children’s Social Care |
| 7.5.2(b) | Development of lead roles on key areas by particular team members | Ealing Children’s Social Care |
| 7.5.2(c) | Workshops on this and other cases where mental health is a feature to build team understanding about thresholds and consistent practice | Ealing Children’s Social Care |
| 7.5.2(d) | Development of a format for visits to ensure all key areas are explore | Ealing Children’s Social Care |
| 7.5.2(e) | Liaise with the elective Home Education/School Attendance services around how the interface with children’s social care may need to improve. | Ealing Children’s Social Care |
| 7.7.2(a) | include gathering and regularly updating information on the schools that children in the family attend or whether they are home schooled. This would speed up information-sharing when there are risks identified and would remind agencies working with home-schooled children that there is not another agency with regular oversight of the children. | West London NHS Trust | Ealing Children’s Social Care | Primary Care Services |
| 7.7.2(b) | gain early consent to share information with other agencies in response to identified concerns. | West London NHS Trust | Ealing Children’s Social Care | Primary Care Services |
| 7.7.2 Recommendation | Information gathering and sharing. That West London NHS Trust, ECSC and primary care services review their intake, information sharing and referral processes and procedures to: | West London NHS Trust | Ealing Children’s Social Care | Primary Care Services |
| 7.7.3 Recommendation | West London NHS Trust staff to follow-up referrals of service users and their families for safeguarding children and safety planning to record if the referral has resulted in the service user and/or their family being supported. | West London NHS Trust |
| 7.7.4 Recommendation | Joint training with West London NHS Trust, ECSC and local DA service to understand each other’s roles, referrals, assessments of risk, thresholds and assessment processes and what information could/should be shared. Develop new protocols around joint working and referrals, particularly in response to non-engagement. | West London NHS Trust | Ealing Children’s Social Care | Local Domestic Abuse Service |
| 7.7.5(a) | to engage the faith-based communities in this agenda and | Ealing VAWG Strategic Group |
| 7.7.5(b) | to link DV service providers to immigrant and other community groups and | Ealing VAWG Strategic Group |
| 7.7.5(c) | to provide information on the legal differences between religious marriages and religious marriages with civil registration. | Ealing VAWG Strategic Group |
| 7.7.5 Recommendation | Ealing VAWG Strategic Group to incorporate findings from this report in its plans for delivering the Ealing VAWG strategy, in particular, | Ealing VAWG Strategic Group |
| 7.7.6 Recommendation | Ealing VAWG Strategic Group ask agencies to audit their practices for a Think Family approach, specifically regarding practices around domestic abuse, mental health and sharing information. Practice should reflect the Think Family approach shown in their policies. | Ealing VAWG Strategic Group |
| 7.7.7 Recommendation | That the Ealing CCG raise with member GP practices as a practice point: where parents have mental health problems, suffer from domestic abuse or substance misuse, that GPs consider whether there is a role for health visitors in supporting the family and refer them if there is a role. | Ealing CCG | GP Practices |
| 7.7.8 Recommendation | That the Ealing Safer Partnership regularly send final copies of DHRs to the Ealing Safeguarding Children Board and the Safeguarding Adults Board. | Ealing Safer Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||