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: 2018
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 identifies systemic failures in multi-agency risk assessment, information sharing, and professional curiosity regarding domestic abuse and coercive control. It highlights economic abuse and increased risks during separation as critical factors.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| A | To enable a learning event for GPs on parenting capacity to give further skills in both assessing this and how to refer to early intervention services. | Bromley CCG |
| AA | That the online application for Housing Register cases is reviewed and question added to ask the applicant if they are experiencing any kind of abuse. That a question is added to ask if the applicant feels safe in their home environment. That a section is added for other information to be taken into account. | London Borough of Croydon Housing Services |
| AB | Housing Staff to complete DVAS training via the FJC. | London Borough of Croydon Housing Services |
| AC | That the South BCU Senior Leadership Team debrief the staff involved in the initial response, primary and secondary investigation of the incident dated 01 January 2017. | Metropolitan Police Service |
| AD | That the South BCU Senior Leadership Team dip sample the initial response, primary and secondary investigation of a sample of similar incidents/allegations within the BCU to establish what, if any further work is required to assist staff. | Metropolitan Police Service |
| AE | Significant conversations with parents to be recorded on the schools online ‘Class log book’. This will be passed up to each teacher to ensure that any concerns raised in previous years can be considered. | Primary School |
| AF | The Croydon Home Treatment Team to implement a clear system of task assignment and oversight arising from Clinical Review meetings to ensure that there are no delays in the completion of tasks | South London and Maudsley NHS Foundation Trust |
| AG | The Croydon Home Treatment team to revise the current system of updating care plans and risk assessment documentation to reflect risk levels and change in care needs so that these are completed at the time of identified risk changes | South London and Maudsley NHS Foundation Trust |
| AH | HTT Service Lead in collaboration with borough safeguarding lead to appraise current system of identifying events that meet the threshold for safeguarding referrals and a more robust system of discussing concerns within the team. To be outlined in operational policy | South London and Maudsley NHS Foundation Trust |
| AI | The Croydon Home Treatment Team to provide training/support in the completion of MASH referrals to ensure that concerns are appropriately documented. This will be reinforced with a request for a training session at a Croydon Borough Safeguarding meeting, to be led by a member of staff from CSC. | South London and Maudsley NHS Foundation Trust |
| AJ | The Trust to review current training provision relating to all domestic violence and abuse, including content in other safeguarding mandatory training, delivered trust-wide. This should include routine enquiry and consideration of safety planning and MARAC referrals | South London and Maudsley NHS Foundation Trust |
| AK | The Trust to build on its’ current progress in raising awareness around DVA approaches to gathering additional information and pathways to follow once DV identified. | South London and Maudsley NHS Foundation Trust |
| AL | All front line staff to have Domestic Abuse risk assessment training to ensure confidence of usage and quality of completion. | Victim Support |
| AM | Heads of Service have agreed to explore an alternative way to flag Domestic Abuse cases to ensure that automatic SMS text message is not sent out rather than the current practice of changing Domestic Abuse and Sexual Violence cases to ‘high’ risk upon receipt of referral. VS need to adopt accurate recording of risk levels, including notification of when a risk assessment has been refused and why. The Head of Service for domestic abuse services in London to work with the wider London Management Team to ensure this recommendation is considered. | Victim Support |
| B | To encourage use of the social prescriber within a Primary Care Network to facilitate onward referrals to aid patients who are suffering from social deprivation factors. Social prescribing allows GPs to refer patients to non-clinical services, with the aim of helping then to take greater control of their own health. Social prescribing came into place after these events this is an ‘actioned’ learning point. | Bromley CCG |
| C | GPs to ask direct question about domestic abuse if a woman has depression in the perinatal period. | Bromley GP Practice |
| D | Practice to maintain IRIS accreditation | Bromley GP Practice |
| E | To identify current Health Visiting practice around enquiry of domestic abuse and how this is documented in records. | Bromley Healthcare |
| F | To update level 3 safeguarding children training and provide additional research/evidence from DHR’s/SCR’s which highlight the importance of asking about domestic abuse and the ‘hidden’ signs. | Bromley Healthcare |
| G | IAPT to ensure that GP’s are sent a list of alternative services that the patient can be signposted to that relates to the issues identified in the referral if the patient no longer wishes to engage or take up the service. | Bromley Healthcare |
| H | Supervisors within IAPT to have access to the EMIS (electronic clinical records used by other BHC services). To ensure that all information can be accessed and reviewed when reviewing a referral and before discharge. | Bromley Healthcare |
| I | Recordkeeping to capture follow-up discussions practitioners in primary care are having with other statutory partners and this could be incorporated in audit programme at GP practices | Croydon CCG |
| J | Apply good recordkeeping standards by making records at the time the events happen, or as soon as possible afterwards | Croydon CCG |
| K | GPs to exercise professional curiosity to ensure that reasons for injuries sustained by young children do correspond with the actual injury | Croydon CCG |
| L | All GP practices to ensure the DASV lead attend and fully engage at the safeguarding leads forums facilitated by the safeguarding team in the CCG | Croydon CCG |
| M | All staff in primary care to receive on-going basic training on domestic abuse as part of the safeguarding training | Croydon CCG |
| N | Adopt the IRIS model to improve the GPs’ response to domestic violence and abuse (DVA) | Croydon CCG |
| O | Develop, implement and embed a Family Health Needs Assessment (FHNA) model or tool that is used in CUS into all services provided by CHS, regardless of how brief the involvement, so as to assist with earlier identification and information sharing of issues and concerns. | Croydon Health Services NHS Trust |
| One | The Home Office to review the processes in place for County Courts and Matrimonial Hearings to ensure that information is provided to both parties on the availability of domestic abuse services. If appropriate provide guidance through the appropriate legal office. | Home Office |
| P | Undertake a recordkeeping audit 12 months after implementation of the FHNA to review and monitor success. | Croydon Health Services NHS Trust |
| Q | Review all safeguarding training to ensure that a Think Family approach is embedded into service delivery. | Croydon Health Services NHS Trust |
| R | Review safeguarding training to encourage professionals to develop deeper critical thinking and to display professional curiosity, to assist with earlier identification of issues and concerns. | Croydon Health Services NHS Trust |
| S | Implementation of a group supervision model across all adult services within CHS. | Croydon Health Services NHS Trust |
| T | Continued work within the Trust to raise awareness with regards to domestic abuse. The Safeguarding service will address this by providing weekly core skills training for trust employees, Domestic Abuse awareness days, the first of which was held in September 2019. | Kings College Hospital NHS Foundation Trust |
| Three | The Safer Croydon Partnership to ensure that there is a commitment at a senior level within Croydon Housing Services to the DHR process. This should also include a training needs analysis for members of staff completing IMRs. | Safer Croydon Community Safety Partnership | Croydon Housing Services |
| Two | NHS England to review guidance for NHS professionals working in Mental Health Services to consider cases where an abusive partner could attempt to exert control through the manipulation and threat of using the Mental Health Act framework. Consideration should be given to the provision of mandatory training on Domestic Abuse for NHS Staff that is separate to the current Safeguarding Adult and Safeguarding Children training. | NHS England |
| U | The Safeguarding service has had discussions with the Emergency Department (ED) consultant who is the lead for Adult Safeguarding as to how to discuss how routine questioning around domestic abuse when a patient is triaged can take place but particularly within emergency departments. (It is already in place in maternity) The consultant will be speaking with the ED lead to discuss this further and will report back to the Safeguarding service. | Kings College Hospital NHS Foundation Trust |
| V | Social workers and team managers in assessment service to access DASH Risk Assessment training through the Croydon Safeguarding Children Partnership. | London Borough of Croydon Children Social Care |
| W | Social workers to check with Police if a 124D risk assessment was completed when receiving referrals in respect of domestic abuse/ violence | London Borough of Croydon Children Social Care |
| X | Social workers will be encouraged to speak to the domestic abuse specialist about cases where they are unsure about process or completing risk assessments. (Specialist workers to attend Team Meetings – By November 2019) | London Borough of Croydon Children Social Care |
| Y | Social workers attend the current training offered on different aspects of domestic abuse, facilitated by the domestic abuse specialist. This training will enhance social worker’s knowledge and understanding about domestic abuse and its impact on the victim and children. (Service managers and Team managers to identify and action) | London Borough of Croydon Children Social Care |
| Z | Training support and development on what makes a good and thorough C&F assessment aimed at social workers and managers. | London Borough of Croydon Children Social Care |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||