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

Lambeth review

CSP: Lambeth Published: November 2023 Year of death: 2013 Extracted: 21 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 systemic failures by agencies to adequately assess and respond to domestic abuse risks, particularly for a victim with precarious immigration status and financial dependence. Key concerns include inadequate inter-agency information sharing, insufficient risk assessment, and a lack of tailored support for victims with no recourse to public funds.

Home Office classifications

31 tags

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

  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • 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
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Perpetrator - immigration involvement
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - economic abuse
  • DHR process - health services recommendations
  • DHR process - probation 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 - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

21 recommendations pulled from the report · 16 matched to organisations in the index

Recommendation 4.1

Addressed to Home Office

The Home Office to develop national policy and guidance to assist agencies in working with victims of domestic abuse who are in the country illegally and are not covered by existing guidance.

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

Recommendation 4.2

Addressed to Safer Lambeth

Safer Lambeth are recommended not to publish this review because in the case of both incidents the young child of each relationship was present and witnessed the respective attacks. Both children are still young and the case received national publicity both at the time of the murder and attempted murder and the eventual sentencing. It is not thought it would be possible to anonymise the review sufficiently to prevent identification whilst still retaining any meaningful information.

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

Recommendation 4.3

Addressed to Lambeth Local Safeguarding Children’s Board

Refer this review to the Lambeth Local Safeguarding Children’s Board to consider the concerns about child welfare and protection arising from this review and the C&YPS and G&St T services in particular.

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

Recommendation 4.4

Addressed to Community Safety Partnership

The Community Safety Partnership to review the training available to its member organisations about current policy and guidance in respect of domestic abuse and people subject to immigration controls.

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

Recommendation 4.5

Addressed to London Probation Trust | Lambeth Children and Young People’s Service | Guy’s & St Thomas’ Hospital

Any agency in this review check and correct factually incorrect information identified in this report held in relation to the victim (in particular but not exclusively LPT, C&YPS. G&St T).

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

Recommendation 4.6.1

Addressed to Lambeth Children and Young People’s Service

Review cultural/systemic issues around the functioning of its “No Recourse to Public Funds” team and address the findings.

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

Recommendation 4.6.2

Addressed to Lambeth Children and Young People’s Service

Audit the knowledge and understanding of domestic abuse and its implications for practice across the whole service and act on the findings.

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

Recommendation 4.7.1

Addressed to London Probation Trust

As part of her on going professional development as she trains to be a probation officer OM1 should be given guidance in how and why to select and present material for inclusion in case records.

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

Recommendation 4.7.2

Addressed to London Probation Trust

Staff of London Probation Trust should be reminded about where to find advice about dealing with immigration and other foreign national offender issues. Consideration should be given to providing refresher training to middle managers on key immigration case management issues and policy and procedure changes.

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

Recommendation 4.7.3

Addressed to London Probation Trust

London Probation Trust’s assistant chief officer for Lambeth should satisfy himself that the information supplied by social services to probation contains sufficient information.

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

Recommendation 4.7.4

Addressed to London Probation Trust | National Offender Management Service

The findings of this report should be shared with the Lead on Foreign National Offenders, Diversity Team, London Probation Trust and National Advisor to the National Offender Management Service on Equality Rights and Decency (Foreign National Offenders). He should consider how to advise UKBA about the weaknesses in their practice identified in this report and how to ensure it is not repeated in relation to future cases.

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

Recommendation 4.8.3

Addressed to Guy’s & St Thomas’ Hospital

An update for Health Visitors to include: information and signposting about resources for families with no recourse to public funds.

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

Recommendation 4.8.5

Addressed to Guy’s & St Thomas’ Hospital

Re-emphasis on Health Visiting standards to include:
 Use of assessment framework.
 Risk assessment
 Escalation process to managers and safeguarding
team when cases are not progressing
 Evaluate the scope and effectiveness of the lead
Health Visitor role in relation to domestic abuse.
 Review scope of CNN roles and areas of delegation.
 Evaluate effectiveness of child protection supervision
to determine the extent that actions proposed are being
carried out in a timely manner

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

Recommendation 4.9.1

Addressed to Lambeth Council Children & Young People’s Service

The use of DV risk matrix to be reiterated to managers and social workers and DV training to be mandatory for all social workers /managers and included in inductions.

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

Recommendation 4.9.2

Addressed to Lambeth Council Children & Young People’s Service

The need for managers to ensure all checks need to be completed and police intelligence needs to be confirmed / explored prior to a decision to close a case and recording the rationale if not completed.

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

Recommendation 4.9.3

Addressed to Lambeth Council Children & Young People’s Service

The NRTPF‘s team to ensure all assessments are holistic, take account of all information known or recorded ,and do not have a narrow focus ,but ensure they review safeguarding concerns over and above the financial issues.

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

Recommendation 4.9.4

Addressed to Lambeth Council Children & Young People’s Service

The need for assessments to be reviewed in light of new information/changing circumstances and historical information to ensure any risks is re-assessed.

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

Recommendation 4.9.5

Addressed to Lambeth Council Children & Young People’s Service

All DV cases should be discussed with the DV specialist or have a consultation with Child Protection Chairs.

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