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

Bexley review

CSP: Bexley Published: September 2023 Extracted: 11 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identified systemic issues in multi-agency information sharing, risk assessment, and a lack of holistic understanding of the victim's complex needs, including domestic abuse, mental health, and substance use. Concerns also arose regarding the application of bail conditions and restraining orders in court processes.

Home Office classifications

20 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - depression
  • Victim - post traumatic stress disorder (ptsd)
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

11 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation 1

Addressed to Community Safety Partnership

Community Safety Partnership to share this learning from the Review and request all organisations in Bexley to review policies, procedures, guidance and training to ensure that accurate language is adopted that reflects responsibility for domestic abuse (the nature of this will be specific to each organisation and their requirements).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Community Safety Partnership | Local Safeguarding Children’s Board (SHIELD) | Adult Safeguarding Board | Health and Wellbeing Board | Bexley Voluntary Sector Council

Community Safety Partnership and other partnership boards in Bexley to communicate to all members the learning from this case and the need for accurate recording of the facts, not of opinions, unless these have been corroborated, and to ensure that in cases of domestic abuse the victim’s voice is present.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Bexley Community Safety Partnership

All services and agencies to ensure they have an appropriate Domestic Abuse Champion in place, and that all Champions have accessed the relevant Level 3 Borough-wide training on domestic abuse, which includes coercive and controlling behaviours.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Domestic Abuse Partnership Strategic Board | MARAC Steering Group

Domestic Abuse Partnership Strategic Board and MARAC Steering Group to put in place an escalation process to address any issues in agency referrals, meeting attendance, information sharing and completing of actions in relation to MARAC.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Community Safety Partnership | MARAC Coordinator

Community Safety Partnership to receive assurances from core MARAC agencies that leads are identified and consistently attend MARAC. MARAC Coordinator to ensure that agency MARAC representatives receive appropriate inductions to their role.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to MARAC

MARAC to ensure that, when an individual is discussed and they are seen to have a high level of needs, an appropriate lead practitioner is identified who coordinates an additional professionals’ meeting.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Community Safety Partnership | Local Safeguarding Children’s Board (SHIELD) | Adult Safeguarding Board | Health and Wellbeing Board | Bexley Voluntary Sector Council

Community Safety Partnership, and other partnership boards in Bexley, to communicate to all members the expectation that organisations will support and train staff to be proactive in calling professionals’ meetings when required for service users.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Community Safety Partnership | Local Safeguarding Children’s Board (SHIELD) | Adult Safeguarding Board | Health and Wellbeing Board | Bexley Voluntary Sector Council

Community Safety Partnership and other partnership boards in Bexley to communicate to all members the learning from this case and the need for professionals to appropriately enquire into service users’ histories, social and family circumstances and how these may impact on their ongoing needs; and to consider the impact of any trauma on service users’ behaviours. For agencies to, as appropriate to their role, share this within internal communications and supervision and seek training.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Local Safeguarding Children’s Board (SHIELD) | Bexley Domestic Abuse Partnership Strategic Board

Local Safeguarding Children’s Board (SHIELD) and the Bexley Domestic Abuse Partnership Strategic Board to learn from good practice in Greenwich and elsewhere about what works in responding to children and young people who have experienced domestic abuse from a parent or a parent’s partner. To act locally to work towards addressing this gap.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Home Office

Home Office to develop and make available a leaflet about Domestic Homicide Reviews for friends and family of those deceased through suicide.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to Community Safety Partnership | Bexley Magistrate’s Court | Crown Prosecution Office

Community Safety Partnership, Bexley Magistrate’s Court and local Crown Prosecution Office representatives to review the response to domestic abuse cases that come to court, with reference to the learning identified in this Review, to ensure that bail conditions are appropriately put in place and restraining orders are consistently considered.

Verified wording from the published review · Original review (PDF) ↗