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
Haringey review
CSP: Haringey
Published: July 2023
Year of death: 2016
Extracted: 23 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 systemic failures in managing a high-risk perpetrator, including over-reliance on self-reporting, insufficient professional curiosity, and inadequate inter-agency communication. It highlights challenges in risk assessment and management at the intersection of mental health and criminal justice systems.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | GPs to be reminded to be vigilant when prescribing medications that started from hospital, especially when the patient has a forensic history | Islington CCG |
| 10 | The Trust routinely audits that the record is up to date and accurate. | Camden and Islington NHS Foundation Trust |
| 11 | The Trust, in conjunction with forensic services from which they accept patients develops a protocol for the referral and transfer of patients between services. | Camden and Islington NHS Foundation Trust |
| 12 | The protocol contains standards for the quality of clinical information, risk and care plans, and the time frame that is considered acceptable. | Camden and Islington NHS Foundation Trust |
| 13 | The Trusts audits the impact of implementation of this protocol on the service. | Camden and Islington NHS Foundation Trust |
| 14 | The Trust review the Clinical Professional and Practice Supervision Policy. | Camden and Islington NHS Foundation Trust |
| 15 | The revised policy contains a requirement that patients cared for under CPA or subject to the Mental Health Act and care coordinated by the supervisee should be discussed in supervision at least once per year. | Camden and Islington NHS Foundation Trust |
| 16 | The impact of assessment and the recording of clinical presentation on risk management be included in all risk assessment and management training. | Camden and Islington NHS Foundation Trust |
| 17 | Compliance with this recommendation be audited as part of routine monitoring and audit arrangements. | Camden and Islington NHS Foundation Trust |
| 18 | Haringey CSP to receive six monthly updates on the implementation of this action plan until such time as full implementation has been achieved. | Haringey Safer Communities Partnership |
| 19 | Haringey CSP to share the above mentioned updates with the victim’s family | Haringey Safer Communities Partnership |
| 2 | GPs to be reminded that if they are part of the system for monitoring whether a patient is in a relationship, they should record when they asked and what the response was | Islington CCG |
| 20 | Domestic abuse training for local professionals to be reviewed to ensure it includes a focus on identifying and responding to perpetrators. | LB Haringey | LB Islington VAWG Commissioners |
| 21 | Ministry of Justice to implement a requirement for evidence to be provided additional to self-reporting that persons subject to a condition not to be in a relationship are compliant with said condition. Evidence must include regular unannounced visits. | Ministry of Justice |
| 22 | Ministry of Justice to undertake an urgent review of all similar cases to ensure that risk is being adequately managed. | Ministry of Justice |
| 23 | Home Office to work with the Ministry of Justice to develop guidance for local agencies on the management of domestic abuse perpetrators who are released into the community subsequent to a detention under the Mental Health Act. | Home Office | Ministry of Justice |
| 3 | GPs to be reminded that if they are part of the system for monitoring whether a patient is in a relationship that any requests for erectile dysfunction medication should be shared with the appropriate authorities even if there is an ostensibly valid reason. | Islington CCG |
| 4 | The Trust identify all patients subject to Section 37/41 who are currently being managed by community services and who have not had a comprehensive review of their mental health history in the previous five years. | Camden and Islington NHS Foundation Trust |
| 5 | The consultant psychiatrist in conjunction with the care coordinator undertakes a comprehensive review of the past record and current actual social circumstances of each such patient and provides a summary in the clinical record. | Camden and Islington NHS Foundation Trust |
| 6 | Following a suitable interval an audit takes place to demonstrate that all such patients have been reviewed in this way. | Camden and Islington NHS Foundation Trust |
| 7 | The Trust develops and maintains a central record of patients eligible to receive aftercare under Section 117. | Camden and Islington NHS Foundation Trust |
| 8 | The electronic clinical record system is modified so that this information is included in the record of care plans. | Camden and Islington NHS Foundation Trust |
| 9 | Care planning for this group of patients is managed using the CPA process. | Camden and Islington NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||