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
Hammersmith and Fulham review
CSP: Hammersmith and Fulham
Published: July 2023
Year of death: 2020
Extracted: 32 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 concerns regarding insufficient focus on family violence within domestic abuse training and risk assessment tools, fragmented mental health care, and rigid service engagement policies for vulnerable individuals. It also highlighted a lack of holistic risk assessments and understanding of specific community needs.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Hammersmith & Fulham CSP to develop a collective module on family violence for use across the multi-agency partners. | Hammersmith & Fulham CSP |
| 10 | The CSP will formally write to the Borough Commander and request anonymised data set for H&F from 2017-22 that largely matches the publicly available data set at data.police.uk but with a unique ID based on an individual’s name and D.O.B. and which flags cases where an individual has not provided a name or D.O.B. – we, as officers, would seek a meeting with the lead Superintendent, and relevant analyst(s) to explore the parameters of data available and the abilities to obtain such data to help influence understanding in the future. | Hammersmith & Fulham CSP |
| 11 | West London NHS Trust and Victim Support to review their DNA policy to include a more flexible approach, to consider checking contact details are accurate at each successful contact and / or to attempt more assertive outreach on the third attempt. | West London NHS Trust | Victim Support |
| 2 | Hammersmith & Fulham CSP to formally write to the Royal Colleges to suggest that domestic abuse training be afforded a separate intercollegiate document that would detail how domestic abuse training should be delivered and to whom within heath care settings and that such training should become a mandatory requirement for all health staff (as recommended by NICE in 2014). | Hammersmith & Fulham CSP |
| 3 | Working with the Local Safeguarding Boards, Hammersmith & Fulham CSP to develop a systematic tracking of staff training across the relevant multi-agency workforce. | Hammersmith & Fulham CSP |
| 4 | Hammersmith & Fulham CSP to produce a briefing paper of guidance on how to better assess risk in family violence cases. For example, professionals might need to apply different considerations when using professional judgement or ask supplementary questions for family violence cases. | Hammersmith & Fulham CSP |
| 5 | Hammersmith & Fulham CSP to share the above document with the Home Office, recommending DASH be reviewed to establish what changes might be needed to make it more suitable for identifying risk in family violence cases. | Hammersmith & Fulham CSP |
| 6 | The Home Office to produce a briefing paper of guidance on how to better assess risk in family violence cases. | Home Office |
| 7 | Hammersmith & Fulham CSP to remind all relevant services that risk assessments should not only assess risk to self, partners, and children, but also to other members of a household. | Hammersmith & Fulham CSP |
| 8 | As part of its work, the Panel received an informative presentation on the Eritrean and Ethiopian community, their journey to the UK and the concept of domestic abuse within the Eritrean community. It is recommended that Hammersmith & Fulham Business Intelligence Team undertake a strategic needs assessment of the Eritrean and Ethiopian community living in the Borough of Hammersmith & Fulham and widely circulate this when complete. | Hammersmith & Fulham Business Intelligence Team |
| 9 | West London NHS Trust and local CCGs to encourage social prescribing for patients in receipt of mental health services. | West London NHS Trust | local CCGs |
| IC1 | All handovers between Liaison Psychiatry Service and Imperial College Healthcare NHS Trust should be clearly documented in patient record, detailing whether this was able to take place face to face, or via telephone, and who spoke with whom. This is currently the agreement although formal Standard Operating Procedure to be drawn up. This will be drawn up and then agreed at the next Mental Health Governance group (December 2020) | Imperial College Healthcare NHS Trust |
| IC2 | All new psycho-social assessments, or those carried out in the Emergency Department, whether by psychiatry or triage, especially where a person has a history of domestic abuse (whether as victim / survivor or alleged perpetrator) should include an overview of where the person is staying, who is there with them and any relevant information about their current residence. | Imperial College Healthcare NHS Trust |
| LBH&F1 | DV training to be updated to include familial DV. To be delivered by all housing management staff by April 2021 | London Borough of Hammersmith & Fulham Housing Management |
| M1 | To develop a specific domestic abuse policy and training for staff | Mind |
| VS1 | Review of internal DA training to include training module on family violence and child to parent violence. This will be undertaken by Victim Support’s Training and Development team with the assistance and oversight of the IDVA Community of Practice. Date for inclusion January 2021. | Victim Support |
| VS2 | Victim Support’s Training and Development team to track changes to learning packages in the same way that policy and procedure is tracked and reviewed. This is to ensure full understanding of when staff would need to have refresher training. Date for action December 2020. | Victim Support |
| VS3 | Audit of case reviews in DA cases both for those allocated to IDVAs and Independent Victim Advocates. Due April 2021. | Victim Support |
| WLT1 | Staff should follow the Trust Clinical Risk Assessment and Management Policy in that risk plans must be updated when moving between services and relevant factors clearly identified | West London NHS Trust |
| WLT10 | There should be in place the following, understood by all healthcare professionals of the service: o Operational policy for transitions team including referral process o Operational policy for recovery services including assessment of referrals in o Roles and responsibilities re duty function o Clear understanding of zoning. If any professionals have concern in relation to the safety of the service, for whatever reason, there should be appropriate escalation protocols in place. | West London NHS Trust |
| WLT11 | The service should adhere to a DNA policy that is understood by all members of staff that outlines clearly, expectations in relation to follow up of patients who Do Not Attend (DNA) appointments (to include nursing, medical, psychological and/or social work appointments | West London NHS Trust |
| WLT12 | Children’s and Young People’s Service (CYPS)Children’s and Young People’s Service to ensure front line managers and staff participate in Safe and Together on-line training in 2020 and 2021. | Children’s and Young People’s Service |
| WLT13 | Managers in CYPS to ensure that staff explore wider family relationships in assessments of domestic abuse, including maternal and paternal family members. | Children’s and Young People’s Service |
| WLT14 | CYPS to explore opportunities with Adult Social Care for joint training for social workers on parental mental health. | Children’s and Young People’s Service |
| WLT2 | Clear processes must in place to obtain forensic risk assessments and guidelines as to referral to assessment timelines made available. This should include taking a full history of new patients to identify any past traumas and potential triggers. | West London NHS Trust |
| WLT3 | The Trust should review its commitment improving awareness of, and engagement with, relatives and carers involved in the care of a service user. | West London NHS Trust |
| WLT4 | The service raises awareness of the importance of safeguarding adults and actioning recommendations made by external agencies such as MARAC. | West London NHS Trust |
| WLT5 | The appropriate MDT (Multi-Disciplinary Team) function should be engaged in considering and progressing housing requirements of service users. | West London NHS Trust |
| WLT6 | The service ensures patients requiring care coordination are appropriately allocated as soon as is practicably possible. Capacity issues should be escalated to relevant commissioners. | West London NHS Trust |
| WLT7 | The service complies with the Trust CPA policy including making sure staff understand the threshold for managing patients with mental disorder under the Care Programme Approach. This will also serve to enhance care planning. | West London NHS Trust |
| WLT8 | Recovery teams to offer family intervention and individual CBT to all patients with schizophrenia in line with the NICE guideline on psychosis and schizophrenia. If the service is not funded to be able to provide this, this is to be brought to the attention of the commissioners. | West London NHS Trust |
| WLT9 | Medical vacancies within the service should be filled and appropriate mechanisms in place with the Medical HR department of the Trust to ensure that recruitment strategies are in place to reduce vacancies. The Training Programme Director should also be sighted on trainee gaps. | West London NHS Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||