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: July 2023
Year of death: 2019
Extracted: 42 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 systemic issues in agency responses to domestic abuse, including inconsistent policies, procedures, and training, particularly regarding adult family violence and neurodiversity. There were also gaps in multi-agency information sharing and MARAC referral thresholds across boroughs.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| CCH-R1 | That Housing Staff to complete DVAS training via the FJC. | Croydon Council Housing |
| CHEH-R1 | Closer and revised monitoring of the referred CHEH clients (via the CHEH Operations Group, formerly SAVU). | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R10 | Training of staff and/or single points of contact for all support, whether single agency or multi-agency to ensure individuals and families are referred to the correct support services to cover all of their needs. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R2 | To adopt a whole family focused approach (including additional services such as a dedicated victim support worker. drugs and alcohol support workers family information, advice and guidance for parents and siblings, as well as a dedicated housing support worker). | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R3 | To undertake a training needs analysis for CHEO Operations Group staff to ensure a consistent level of knowledge and messaging for all clients. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R4 | To improve recording of engagement sessions. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R5 | To ensure more robust risk management at an operational level, including (a) risk assessment to be reviewed and refreshed to include details of close relationships which will be reviewed on a regular basis and (b) risk assessment will be quality controlled on acceptance and on a monthly basis. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R6 | To ensure more robust risk management at a strategic level (including introduction of a governance board – Community Harm & Exploitation Board). | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R7 | To introduce a Single Information Technology recording system or use one of the existing systems within the Council. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R8 | Commissioned services (i.e., service providers within the CHEH Operations Group) to be informed of the new approach for 2021/22 and the rationale behind it. | Southwark Council – Community Harm & Exploitation Hub |
| CHEH-R9 | Increase monitoring meetings with commissioned services to better manage risk. | Southwark Council – Community Harm & Exploitation Hub |
| CHS-R1 | Practitioners to document the full names, and relationship of any friends or relatives who accompany patients into the consultation room, after consent has been sought. The relevance of this should be included in all learning opportunities and be evidenced through audit activity. | Croydon Health Services NHS Trust |
| CHS-R2 | Raise awareness during domestic abuse training around professional curiosity. This should include the potential need for practitioners to create safe situations to speak with patients confidentially if the need arises and potential coercive control and risk is evident. | Croydon Health Services NHS Trust |
| CHS-R3 | Consideration to be given to the development of posters and/or leaflets which provide information relating to domestic abuse, the Trust’s commitment to supporting victims of abuse and explanation that in view of this, a standard domestic abuse question will be asked of all women during their maternity care. This could include a standard reference to domestic abuse in the handheld records. | Croydon Health Services NHS Trust |
| CHS-R4 | Consideration to be given to Midwives asking standard questions in a sensitive manner about experiences of domestic abuse during all antenatal appointments and not just the booking appointment (if safe to do so) and to include in the electronic patient records. | Croydon Health Services NHS Trust |
| CHS-R5 | Consider means of creating a ‘safe space’ which could be accessed during consultations if required. An example of this would be keeping the weighing and measuring equipment in a separate room. This requires further exploration with maternity and estate colleagues. | Croydon Health Services NHS Trust |
| CRC-R1 | The London CRC to ensure that all contact with service users is recorded in a timely manner and in accordance with London CRC quality practice standards. | London Community Rehabilitation Company |
| CRC-R2 | The London CRC to revise the internal transfer policy to ensure that all internal transfers within London are undertaken following discussions between transferring officers and accompanied by a record of contact within the appropriate case management system. | London Community Rehabilitation Company |
| CRC-R3 | The London CRC quality practice standards to make specific reference to sharing information and sentence plans with appropriate external partners, as to support collaborative working. | London Community Rehabilitation Company |
| CRC-R4 | The London CRC to revise Community Payback operations, to ensure an increase in the number of service users completing unpaid work requirements within the statutory 12-month period from sentence. | London Community Rehabilitation Company |
| CRC-R5 | The London CRC to mandate the completion of risk assessment and risk management training for all practitioners on a rolling 2-year basis. | London Community Rehabilitation Company |
| CRC-R6 | The London CRC to ensure the accountability structure captures information relating to service user’s engagement and recording (e.g., incomplete outcomes, case with no next appointments and acceptable absences). To ensure these service delivery measures are reviewed at an area level on a monthly basis. | London Community Rehabilitation Company |
| DHR-R1 | The Home Office to work with other government departments to develop a cross-government definition of AFV/CPV. This should include developing policy and practice guidance for AFV and refreshing the current CPV guidance (to include adult children). | Home Office |
| DHR-R10 | The Safer Croydon Partnership to work with local partners to review the findings from this DHR and evaluate the response to neurodiversity locally. | Safer Croydon Partnership |
| DHR-R11 | The Safer Croydon Partnership to ensure that, in developing its partnership response to domestic abuse and other issues, there is a robust mechanism to enable the specific consideration of the needs of minoritized communities and the implications in terms of awareness raising, training, service provision, and strategy. This should include targeted consultation with local communities and input from led by and for specialist services. | Safer Croydon Partnership |
| DHR-R2 | The MPS, as part of its current work to review referral processes with Victim Support, to review how information is transferred to Victim Support to ensure that relevant case details are included and can therefore inform the approach taken by Victim Contact Officers. | Metropolitan Police Service | Victim Support |
| DHR-R3 | The Southwark Community Safety Partnership to review the local definition and threshold for making referrals to the local MARAC based on escalation. | Southwark Community Safety Partnership |
| DHR-R4 | The Safer Croydon Partnership to review the local definition and threshold for making referrals to the local MARAC based on escalation. | Safer Croydon Partnership |
| DHR-R5 | The London VRU to review the learning from this DHR via the Violence Reduction Practitioners Network and: - Raise awareness of the issues relating to the management of cross borough moves by sharing the lessons learnt from this DHR via its knowledge hub sessions and/or the newly established Violence Reduction Practitioners Network - Encourage boroughs to ensure there is a robust mechanism to identify and manage any risk when young people move to different areas by including ‘effective handover’ as an action in the template Violence Reduction Plan | London Violence Reduction Unit |
| DHR-R6 | The London NHS Domestic Violence and Abuse Clinical Reference Group work to consider the learning from this DHR and agree actions to ensure a more consistent health response, including whether there should be a national recommendation for the development of an intercollegiate document on DVA training for all health staff. | London NHS Domestic Violence and Abuse Clinical Reference Group |
| DHR-R7 | The Southwark Community Safety Partnership to work with local partners to review the findings from this DHR and develop the response to AFV/CPV locally. This should include identifying the actions that agencies can take individually and collectively, reviewing support pathways and services, and completing a training needs assessment to identify the skills and training that professionals require to respond. | Southwark Community Safety Partnership |
| DHR-R8 | The Safer Croydon Partnership to work with local partners to review the findings from this DHR and develop the response to AFV/CPV locally. This should include identifying the actions that agencies can take individually and collectively, reviewing support pathways and services, and completing a training needs assessment to identify the skills and training that professionals require to respond. | Safer Croydon Partnership |
| DHR-R9 | The Southwark Community Safety Partnership to work with local partners to review the findings from this DHR and evaluate the response to neurodiversity locally. | Southwark Community Safety Partnership |
| GP1-R1 | Feedback to individual practice as to the findings of this review to support individual learning needs and signposting to resources from previous CCG trainings on mental health and risk assessments. | GP 1 |
| GP1-R2 | Healthcare professionals to have a lower threshold to make referral on behalf of a patient to counselling services where appropriate (instead of patient’s being asked to self-refer) and ensure they follow-up with those asked to self-refer. | GP 1 |
| GP1-R3 | Highlighting the role and use of social prescribers/navigators and Southwark Wellbeing Hub to GPs, e.g., when someone is faced with multiple issues such as unemployment and homelessness. The social prescribing service was introduced in Spring 2020. The service may be altered due to the Covid-19 pandemic. | GP 1 |
| GP1-R4 | This case to be discussed with the local Mental Health Commissioner to review local services and establish whether any support is available in adulthood to those on the autistic spectrum or whether existing services have experience in/feel they are able to adapt sufficiently to meet the needs of this group of people, e.g., counselling services, job centre, etc. | GP 1 |
| GP2-R1 | Practice to revise the template used for clinical records in relation to pregnancy and add questions as part of the clinical assessment to ask about support network. | GP 2 |
| GP2-R2 | Practice to strengthen arrangements with regards to the management of domestic abuse. | GP 2 |
| GP2-R3 | The practice should ensure safeguarding arrangements are robust and that the practice has up to date safeguarding policies relating to domestic abuse. | GP 2 |
| GP2-R4 | The [domestic abuse and sexual violence] lead at the practice should attend at least 50% of the forums coordinated by the CCG and FJC. | GP 2 |
| KCH-R1 | Clinicians, particularly front-line practitioners in the Emergency Departments are encouraged to routinely ask questions regarding domestic abuse for all services users. | King’s College Hospital NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||