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: November 2023 Year of death: 2016 Extracted: 14 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 highlights critical failures in providing independent communication for the victim due to language barriers and unassessed mental capacity. It also identifies missed opportunities to assess the perpetrator's mental health and her role as a carer, which contributed to the homicide.

Home Office classifications

25 tags

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

  • Victim - physical disability
  • Victim - serious or life limiting illness
  • Victim - immigration involvement
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Child - immigration involvement
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - immigration involvement
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

14 recommendations pulled from the report · 12 matched to organisations in the index

Recommendation 1

Addressed to Croydon Clinical Commissioning Group | Croydon Health Services

Croydon Clinical Commissioning Group and Croydon Health Services ensure that referral protocols between primary care, and specialist services include reference to the language needs of patients.

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

Recommendation 2

Addressed to Safer Croydon Partnership

Safer Croydon Partnership work with statutory healthcare agencies and local NGOs to implement an initiative raising awareness of mental health and consider the role of carers when safeguarding adults. This will include the promotion of Non-Government Organisations supporting older adults and people with disabilities.

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

Recommendation 3

Addressed to Croydon BME Women’s Project

Croydon BME Women’s Project work in partnership with local statutory healthcare providers and Non-Government organisations to support training for staff.

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

Recommendation 4

Addressed to Croydon Clinical Commissioning Group | Croydon Health Services | South London and Maudsley NHS Foundation Trust

Croydon CCG, CHS and SLaM ensure that the learning from this case is disseminated to practitioners.

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

Recommendation CCG_IMR_1

Addressed to Croydon Clinical Commissioning Group

The practice should review the recording and consideration of the compliance with the Mental Capacity Act (2005) and Best Interest Decisions

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

Recommendation CCG_IMR_5

Addressed to Croydon Clinical Commissioning Group

The practice should review their safeguarding policy with the support from the CCG Safeguarding Team and incorporate Domestic Abuse including referral pathways.

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

Recommendation CCG_IMR_7

Addressed to Croydon Clinical Commissioning Group

The practice must attend CCG Safeguarding Training, Updates and Workshops and other learning opportunities within the borough.

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

Recommendation CHS_IMR_1

Addressed to Croydon Health Services

The Trust must ensure the application of the Mental Capacity Act is embedded in all practice appropriately including fully documenting mental capacity assessments and Best Interest Decisions.

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

Recommendation CHS_IMR_2

Addressed to Croydon Health Services

The Trust must ensure that all staff use the interpreters/language line when there is a language barrier, in line with Trust guidance.

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

Recommendation SLaM_IMR_1

Addressed to South London and Maudsley NHS Foundation Trust

The MHOA&D Clinical Academic Group should ensure that staff are aware of the process for booking an interpreter and that all non-English speaking patients to be offered the opportunity to meet clinical staff with a trained interpreter.

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