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
Basildon review
CSP: Basildon
Published: October 2025
Year of death: 2018
Extracted: 47 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 safeguarding a vulnerable young person, highlighting a lack of joined-up working and information sharing across multiple agencies and geographical boundaries. Despite identified risks and individual efforts, opportunities to disrupt the perpetrator's violence and support the victim were missed.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 11.1 | Agencies are responsible for completing the actions agreed through the DHR: this includes providing updates to Basildon CSP and the SET DA Team. Basildon CSP is responsible for ensuring the action plan is implemented and the SET DA team will be responsible for monitoring and updating the action plan with updates provided to the SET Strategic Development Group (SETSDG). This will include flagging where actions are not completed. | Basildon CSP | SET DA Team | SET Strategic Development Group (SETSDG) |
| 11.10.1 | That the Government introduces national standards for provision for 16 and 17-year-olds. | National Government |
| 11.10.2 | That the Home Office work with the College of Policing to ensure that all Forces have a shared understanding of protocols in place when children at risk of CSE are moved across local authority and policing areas. | Home Office | College of Policing |
| 11.11.1 | That NPS reminds all authors of Pre-Sentence Reports (PSR) of the need to consider Building Better Relationships (BBR) when making recommendations for those who have past offences related to intimate partner violence and/or present a high risk of violence to partners. | National Probation Service – SEE Division |
| 11.11.2 | That Essex CRC assures itself that all staff have read and can demonstrate a working knowledge of the policies and guidance relevant to their role, and notes that a number of workshops and briefings have already taken place around professional curiosity and an investigative approach. (Following reunification of the services in June 2021, this will be taken forward by NPS). | Essex CRC | National Probation Service – SEE Division |
| 11.12.1 | That consideration of referral to specialist services needs to form part of every assessment where there are identified concerns about substance misuse. | North East London Foundation Trust (NELFT) |
| 11.12.2 | That the Service Manager investigates the missing notes and takes the necessary action with the staff involved. | North East London Foundation Trust (NELFT) |
| 11.12.3 | That practitioners are reminded of the need to complete contemporaneous notes. | North East London Foundation Trust (NELFT) |
| 11.13.1 | That the GP surgery reflects on this case to ensure that GPs are aware of any significant risks with their patients that have been reported by other agencies. | GP Surgery |
| 11.13.2 | That NHS Greenwich CCG delivers training to all GPs within the borough on domestic abuse. This should be actioned through the implementation of the IRIS5 programme in Greenwich, which is planned for the second half of 2020/2021. | NHS Greenwich CCG |
| 11.14.1 | That SETDAB ensures that all commissioning bodies are aware of this review’s recommendation that when services move from one provider to another, the commissioner ensures that a copy of policies and SOPs, along with all staff training records, is transferred to the new provider. | SETDAB |
| 11.2.1 | That Basildon Hospital reviews its flagging alert system to consider domestic abuse. | Basildon Thurrock University Hospital |
| 11.2.2 | The review is aware that work is ongoing to identify long-term funding for an IDVA service in hospital settings. It is recommended that Basildon Hospital continues to explore how this service, which the review considers to be a crucial safeguarding role, will be funded in the future. | Basildon Thurrock University Hospital |
| 11.2.3 | That Basildon Hospital use this case to further enhance education around domestic abuse, mental health, and the importance of correct and adequate referrals. | Basildon Thurrock University Hospital |
| 11.2.4 | That Basildon Hospital reviews all its training to bring it into line with the Inter Collegiate Document for Adults to ensure that up-to-date training is provided to staff in relation to safeguarding. | Basildon Thurrock University Hospital |
| 11.2.5 | That the Named Nurse for children’s safeguarding facilitates an audit of Child Protection Information Sharing (CP-IS). This would ensure that the system is running effectively. | Basildon Thurrock University Hospital |
| 11.2.6 | That Basildon Hospital and the wider Mid and South Essex (MSE) group review its current audit programme to ensure that any learning recommendations from this DHR are implemented. | Basildon Thurrock University Hospital | Mid and South Essex (MSE) group |
| 11.3.1 | That those responsible for implementing access to CIPS within the service are made aware of this review and the implications. | East of England Ambulance Service Trust (EEAST) |
| 11.4.1 | That LAC Nursing Teams/Lead Health Professionals for ECFWS should escalate concerns to allocated SWs when health recommendations are not followed (for example, when advice is given to LAC to attend A&E and this does not happen). | Essex Child and Family Wellbeing Service (ECFWS) |
| 11.4.2 | That ECFWS has an internal process of escalation when practitioners are not able to make contact with partner agencies in relation to safeguarding/LAC concerns. | Essex Child and Family Wellbeing Service (ECFWS) |
| 11.5.1 | That the existing practice guidance is enhanced to ensure that the role of Independent Reviewing Officer (IRO) is strengthened specifically with reference to MACE and MARAC. This should include an expectation that the plans made will be shared with the IRO and that the most appropriate representative from CSC will attend multi-agency meetings. | Essex County Council – Children’s Social Care |
| 11.5.2 | The review is aware that Leaving and Aftercare Staff have access to a full training package regarding domestic abuse, but it is recommended that further training is provided to Leaving Care practitioners on the impact of domestic abuse on teenagers, and to refresh their knowledge on the range of legal powers available to disrupt the perpetrator. | Essex County Council – Children’s Social Care |
| 11.5.3 | That guidance is developed for practitioners to raise awareness of the impact of domestic abuse and having a disability, such as a hearing impairment. | Essex County Council – Children’s Social Care |
| 11.5.4 | That services commissioned by Essex County Council to provide semi-independent accommodation, include a requirement for all staff to be trained in domestic abuse, emotional wellbeing, and trauma. | Essex County Council – Children’s Social Care |
| 11.6.1 | That consideration is given to Core Groups being developed to manage those individuals (both victims and perpetrators) who are being considered at multiple safeguarding meetings, such as MARAC, MAPPA and MACE, to allow these individuals to be jointly case-managed. | Essex MAPPA |
| 11.7.1 | That Force Missing Persons Procedure should be reviewed to reflect the requirement to consider the use of specialist staff, including Missing Person Liaison Officers (MPLOs) and Children and Young People Officers (CYPOs), to conduct vulnerability interviews with frequent missing children. Additional emphasis should be placed on the need to conduct interviews not only in a timely fashion, but also by appropriately trained specialist staff, in the right circumstances, so as to maximise the opportunities to support the child, gather relevant information, and prevent further missing episodes. | Essex Police |
| 11.7.10 | That Essex Police review staff levels within the MOSOVO teams in order to ensure that these teams adopt an effective, proactive and investigative approach to the management of dangerous offenders, in line with authorised professional practice (APP). | Essex Police |
| 11.7.11 | That a review is undertaken of the existing force procedure MOSOVO (B1410), with a view to clarifying which aspects of offender management fall within the remit of MOSOVO and which should be managed elsewhere. This should include clearly defining roles and responsibilities for staff working in MOSOVO, and the inclusion of guidance on tactical options for the management of Violent Offenders. | Essex Police |
| 11.7.12 | That the Force lead reviews existing working practices to ensure that appropriate structures, procedures and processes are in place, to enable effective information sharing and working between forces regarding CSE and Child Abuse investigations. It is also recommended that a new procedure should be developed for the handover of relevant information when a child at risk of CSE, or criminal exploitation, is known to have moved to another force area. | Essex Police |
| 11.7.13 | That Essex Police and Essex CSC use the circumstances of this review to consider how best to safeguard a LAC when they are known to have moved to another geographical area outside of the Essex services boundaries. | Essex Police | Essex CSC |
| 11.7.14 | That the force reviews the existing procedures for the management of outstanding high-risk domestic abuse offenders, and other high-risk offenders, to ensure effective oversight. It is recommended that the force ensures that investigators managing such investigations have awareness of the full range of investigative tactics, including specialist support from within the Serious Crime Directorate. | Essex Police |
| 11.7.2 | That guidance is reissued to ensure that officers are aware of the requirement to complete the Police Information Report (PIR) in respect of all found high-risk missing persons and children under 18. | Essex Police |
| 11.7.3 | That Force Child Abuse Investigation Procedures are reviewed to include the requirement of a standardised CSE risk assessment recording process, which provides a full audit of the assessment. It is recommended that this is used in all cases where a CSE risk assessment is conducted, and thereafter uploaded to Athena. | Essex Police |
| 11.7.4 | That where an offender is within MAPPA, responsibility for applications for Violent Offender Orders (VOO), and similar civil protective orders, should sit with specialist staff within Management of Sexual and Violent Offenders (MOSOVO). MOSOVO staff should take the lead in liaising with Essex Police Legal Department and applying for such orders. | Essex Police |
| 11.7.5 | That a dedicated cohort of staff should be identified and provided with training in the management of violent offenders and legislation relating to protective orders: they should then lead in this area. | Essex Police |
| 11.7.6 | That the use of emails to disseminate MARAC initiated actions should cease, with the Task function in the crime recording system being utilised. The actions should be added to the system by officers upon receipt of the minutes. | Essex Police |
| 11.7.7 | That further guidance is issued to ensure that all investigative and safeguarding tasks passed between Commands, Departments and Teams are made subject to Athena Tasks. | Essex Police |
| 11.7.8 | That staff working within Crime and Public Protection, as well as MPLOs and CYPOs, should receive additional awareness training regarding the use of Domestic Violence Protection Notices (DVPN), Domestic Violence Protection Orders (DVPO), VOO, and other protective orders, to ensure awareness of the circumstances in which these orders can be obtained. | Essex Police |
| 11.7.9 | That Essex Police should review existing procedures for the completion, management and storage of Trigger Plans. | Essex Police |
| 11.8.1 | The review is advised that Essex YOS now follows a more strength-based approach so that this positive factor would now have more focus. It is recommended that a dip sample of recent cases is undertaken by Essex YOS to reassure SETDAB that the expected changes have been achieved. | Essex Youth Offending Service (YOS) |
| 11.8.2 | That dip sampling of more recent cases is undertaken by Essex YOS to reassure the SETDAB that these changes have resulted in the expected improvements to the recording of 1-1 contact. | Essex Youth Offending Service (YOS) |
| 11.9.1 | That EA BCU SLT remind officers and supervisors, concerned with this case, of the need to ensure that a MERLIN report is created in all safeguarding children cases to document a full record of information shared with partner agencies and county forces. | Metropolitan Police Service |
| 11.9.2 | That officers are reminded of their responsibilities for crime recording of domestic abuse incidents. | Metropolitan Police Service |
| 11.9.3 | That officers are reminded of the importance of thorough intelligence checks in addition to their responsibilities in relation to the assessment of VAF criteria. | Metropolitan Police Service |
| 11.9.4 | That all officers are reminded of the MPS DA Policy and VAF policies. | Metropolitan Police Service |
| 11.9.5 | That staff have a clear understanding that any CSE subject residing within MPS requires an active CSE report for assessment and monitoring of SET. | Metropolitan Police Service |
| 11.9.6 | That the process for transferring CSE subjects from area to area, as well as in and out of MPS, is clarified and delivered to all staff. Understanding must be clear for all staff that any CSE subjects residing in the MPS, requires an active CSE report for assessment and monitoring by CSC. | Metropolitan Police Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||