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: 2012
Extracted: 46 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 failures in information sharing regarding the perpetrator's mental health history, leading to inadequate risk assessment and care. There were numerous missed opportunities across multiple agencies to identify and respond to domestic violence, compounded by a lack of staff training and clear policies.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Widely disseminate learning to services mentioned in this review. This should be in the form of a written briefing to all relevant staff and dissemination session(s). | Safer Ealing Partnership |
| 10 | Ensure that the circumstances and findings of this review are incorporated into any commissioned safeguarding and domestic violence training delivered in the borough as well as into any routine audits of safeguarding adults practice. The training should have a specific focus on carer abuse and the dynamics of domestic violence that may feature and also the connection between the use of alcohol, substances, mental health and the incidence of domestic violence. | Safer Ealing Partnership | Ealing Safeguarding Adults Board |
| 11 | Review the process of carer assessments and include domestic violence screening enquiry questions into the process. | Ealing Safeguarding Adults Board |
| 12 | Produce a specific housing and domestic violence policy and procedure, to especially detail responding to repairs, noise nuisance reports and making referrals to specialist services. | Ealing Housing Providers and Registered Social Landlords |
| 13 | Ensure all staff are trained on the domestic violence policy and procedure. | Ealing Housing Providers and Registered Social Landlords |
| 14 | Ensure staff and residents have access to up to date domestic violence information, highlighting services and support available. | Ealing Housing Providers and Registered Social Landlords |
| 15 | Pilot an assessment criteria, to support and improve consistent decision making and practice when officers are considering making a referral to a specialist domestic violence support service for victims involved in a non-crime domestic. | Metropolitan Police |
| 16 | Ensure that there is a follow up for every domestic violence victim where they are seen/contacted and are provided with information on local domestic violence support services (linked to recommendation 4) and that this action is then recorded on CRIS. | Metropolitan Police |
| 17 | Ensure that officers responding to noise nuisance or housing related anti-social behaviour complaints are trained on safeguarding vulnerable adults and understand how to identify concerns and make a safeguarding adult alert. | Ealing Noise Nuisance Team |
| 18 | Conduct a domestic violence needs analysis to identify and understanding staff training requirements. | Ealing Hospital NHS Trust |
| 19 | Create a Level 2 and 3 safeguarding training package that includes domestic violence so that staff understand their roles and responsibilities. | Ealing Hospital NHS Trust |
| 1A | Work with NHS England to clarify responsibilities and requirements of commissioning GP IMRs to help resolve issues with delays and quality of GP IMRs submitted to DHRs. | Home Office | Department of Health |
| 2 | Ensure that the circumstances and findings of this review are incorporated into any commissioned domestic violence training delivered in the borough. | Safer Ealing Partnership |
| 20 | Raise awareness of the MARAC processes risk assessment tools and referral processes. | Ealing Hospital NHS Trust |
| 21 | Identify and audit DV attendances in the urgent care centre to establish if cases have been managed appropriately, including if they have been provided with information and advice and if the case has been subject to a domestic violence risk assessment. | Ealing Hospital NHS Trust |
| 22 | Explore options of commissioning independent domestic violence advocacy service provision to be located with the urgent care centre. | Ealing Hospital NHS Trust |
| 23 | Implement clinical domestic violence enquiry within the triage system for the urgent care centre. | Ealing Hospital NHS Trust |
| 24 | Scope the opportunity to devise a liaison meeting (reflecting the weekly safety net meeting held to discuss child safeguarding concerns) to share vulnerable adults concerns. | Ealing Hospital NHS Trust |
| 25 | Provide specific training to the Met Police Community Safety Team to include information on the domestic violence referral pathway. | Ealing’s commissioned specialist domestic violence services |
| 26 | Create and distribute a domestic violence card to be provided to all uniformed Police officers to give to all callers at all non-crime domestics. | Ealing’s commissioned specialist domestic violence services |
| 27 | Engage in a jointly delivered programme of community engagement activities to raise the profile and promote the domestic violence services available in the borough. | Ealing’s commissioned specialist domestic violence services |
| 28 | Commission and deliver domestic violence dynamics and domestic violence risk assessment training for all clinical staff. | RISE |
| 29 | Implement enquiry for domestic violence as part of intake assessment for all clients (both as victims and perpetrators) and ensure there is a referral pathway in place to specialist domestic violence services for both victims and perpetrators. | RISE |
| 2A | Seek to rectify the patient information systems used across all clinical settings so that attendances at health care settings can be linked and viewed in their entirety. | Department of Health |
| 3 | Produce a multi-agency domestic violence referral pathway/protocol in consultation with the Police and specialist domestic violence services and ensure partnership staff are aware of the document through training and publicity. | Safer Ealing Partnership |
| 30 | Ensure that the learning points from this review are shared across the CCG partner practices. | Ealing CCG |
| 31 | CCG Safeguarding Team to work with the GP practice in close proximity to the domestic violence refuge to support their immediate take up of the offer from the refuge service provider of domestic violence training. | Ealing CCG |
| 32 | Consider how mental health diagnosis and domestic violence issues are coded or flagged within GP records. | Ealing CCG |
| 33 | Review the use and effectiveness of the IRIS Project across London GP practices to consider potential for wider commissioning of the project. | NHS England (London Area) |
| 34 | Via the Named GP audit GP compliance with LSCB safeguarding training in Ealing. | Ealing CCG | General Practice Ealing |
| 35 | To advise Practices to use the Royal College of General Practitioners toolkit which include a domestic violence audit. | Ealing CCG | General Practice Ealing |
| 36 | Consider ways to commission domestic violence training for GP staff relevant to their roles and responsibilities (doctors, practice nurses and reception staff). | Ealing CCG | General Practice Ealing |
| 37 | Encourage all GP locations to display and have available up to date information on domestic violence and support services. | Ealing CCG | General Practice Ealing |
| 38 | When prescribing antiviral medication (such as Peginterferon) which has documented side effects of inducing psychiatric disorders, a specific verification from the patients GP concerning any mental health concerns should be obtained. | Imperial College Healthcare NHS Trust (St Mary’s Hospital) |
| 39 | Hospital Safeguarding Team to link to Ealing Safeguarding Adults Board and ensure that the Hepatology Clinic has access to information on safeguarding adult process and support services. | Imperial College Healthcare NHS Trust (St Mary’s Hospital) |
| 3A | Review and address the funding provision to domestic violence support services concerning the support offered to cases that are classed as Police non-crime domestic incidents. | Home Office |
| 3B | Review and improve access to specialist support provision for families affected by domestic homicide, (this should cover step or blended families when the biological parent is the perpetrator). | Home Office |
| 4 | Commission a borough domestic violence publicity campaign to include provision of an awareness poster and a palm size/Z card which should be distributed across the partnership to outline to victims the domestic violence support available locally. | Safer Ealing Partnership |
| 40 | Amend the notification letter sent to the GP concerning commencing antiviral treatment to specifically request that if they have any information which may have an impact on the patient to notify the Hepatology Clinic without delay. | Imperial College Healthcare NHS Trust (St Mary’s Hospital) |
| 41 | Arrange a meeting between borough safeguarding GPs and Safeguarding Vulnerable Adults Leads with the Hepatology Clinic to improve partnership working and support offered to patients who are considered vulnerable. | Ealing CCG | Imperial College Healthcare NHS Trust (St Mary’s Hospital) |
| 42 | Share information with all Ealing GP’s about the Hepatology care pathway so that they are aware and understand their role in the care plan for patients being treated by the Hepatology Clinic. | Ealing CCG | Imperial College Healthcare NHS Trust (St Mary’s Hospital) |
| 5 | Review and address the funding provision to domestic violence support services concerning the support offered to cases that are classed as Police non-crime domestic incidents. | Safer Ealing Partnership | Home Office |
| 6 | Work to secure inclusion of vulnerable adults within the evolving borough’s Multi Agency Safeguarding Hub. | Safer Ealing Partnership | Ealing Safeguarding Adults Board |
| 7 | Audit adult safeguarding links and information sharing processes between GPs, the Police and mental health services. | Safer Ealing Partnership | Ealing Safeguarding Adults Board |
| 8 | Work with services in the borough who support domestic violence victims, vulnerable adults and carers so that there is an understanding of these agendas and ensure that this is addressed in training. | Safer Ealing Partnership | Ealing Safeguarding Adults Board |
| 9 | Audit referral processes so that agencies working with domestic violence victims, vulnerable adults and carers have effective referral and safeguarding systems to respond to concerns raised by their client groups (such as Multi Agency Risk Assessment Conference, and safeguarding adult alerts). | Safer Ealing Partnership | Ealing Safeguarding Adults Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||