Case of Penina Overview and Chronology.Pdf
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Public Protection Unit T: 020 7035 4848 2 Marsham Street www.gov.u/homeoffice London SW1P 4DF Chris Williams Head of Community Safety and Public Protection Community Services London Borough of Brent 26 October 2015 Dear Mr Williams, Thank you for submitting the Domestic Homicide Review report for Brent to the Home Office Quality Assurance (QA) Panel. The report was considered at the Quality Assurance Panel meeting on 23 September 2015. The QA Panel would like to thank you for conducting this review and for providing them with the final report. The Panel found this to be a thorough and robust report with a high level of analysis and which demonstrated sound knowledge of domestic abuse and sexual violence. The Panel particularly commended the chair and author for their resolve in obtaining information from an agency that initially declined, and which ultimately led to new lines of enquiry. There were some aspects of the report which the Panel felt may benefit from further consideration, or be revised, which you may wish to consider before you publish the final report: The Panel suggested the gender and ages of the children should be removed to further increase anonymity; The Panel queried whether the Nursing and Midwifery Council (who were represented on the panel) will be using the findings from this review to consider the future of the perpetrator as a nurse given that the Council do not appear to be conducting their own investigation; The action plan requires additional information. For example, there is no date of completion and outcome column. There are no actions in the plan for recommendation 11. The Panel queried whether the lack of robust action in following up the reporting of the perpetrator’s inappropriate sexual behaviour at the Children’s Centre in 2008 requires recommendation 3, for Children’s Services, to be framed in such a way to demonstrate that failure to deal with such incidents in future may result in disciplinary action being taken; The Panel noted the use of family members as interpreters and felt a recommendation around the possible risks associated with this may be useful; Please ensure the recommendations feature in the executive summary to allow it to be read in isolation; The Panel noted that a common feature with DHR reports from Brent is that they lack a front title page. The Panel asked if this could be addressed in this and future reports. There were also a number of typing or other errors which you may wish to correct: Please proof read as the reports have formatting issues. For example, paragraphs 364, 370 and 382 have different line spacing compared to other spacing. The text size changes at the bottom of page 16, recommendation 3 section 7 and recommendations 28 to 31. Paragraph 3 (page 3) in the executive summary also has small text in one sentence. Paragraph 297 (page 57) line 3 – “be” should be “he”. Paragraph 299 (page 57) – should be Nursing and Midwifery Council and not Nurses and Midwifery Council. Paragraph 143 (page 28) and paragraph 349 (page 66) – should “Islamia school” be “Islamic school”? Paragraph 469 (page 87) line 4 – “Had she have been recognised” – “have” not needed. The Panel does not need to see another version of the report, but I would be grateful if you could include our letter as an appendix to the report when it is published. I would be grateful if you could email us at [email protected] and provide us with the URL to the report when it is published. Yours sincerely Christian Papaleontiou Chair of the Home Office DHR QA Panel DOMESTIC HOMICIDE REVIEW London Borough of Brent Case of Penina Robinson 1 DOMESTIC HOMICIDE OVERVIEW REPORT – PENINA ROBINSON CONTENTS SECTION 1 – INTRODUCTION 5-7 About Brent 5 Summary of the Case 5 Post Mortem 6 Inquest 7 Court Dates 7 SECTION 2 - THE REVIEW PROCESS 8-18 Decision to Hold a Review 8 Convening the Panel 8 Scope of the Review 8 Terms of Reference 9 IMRs and Chronologies 11 Timescales 12 Parallel Investigations 13 Contributors to the Review 13 Dissemination 14 Confidentiality 14 Independence 14 Equality and Diversity Issues 15 Involvement of Family & Friends 16 Pen Portraits of Family Members 17 Acknowledgments 18 Condolences 18 SECTION 3 – CHRONOLOGY 19-30 February 2001 – November 2004 19 December 2004 – July 2009 19 August 2009 – December 2010 20 January 2011 – December 2012 23 January 2013 – October 2013 24 SECTION 4 - INDIVIDUAL AGENCY RESPONSES 31-66 North West London Hospitals’ Trust 31 Adult Community Health Services 36 General Practitioners 38 2 Children’s Community Health Services 43 Brent Adult Social Care 43 Priory Nursing Agency & Homecare 48 Metropolitan Police 49 Hertfordshire Police 53 Brent Children’s Social Care 58 Willow Children’s Centre 61 University of West London 62 Disclosure and Barring Service 64 Brent Education – School Admissions and SENAS1 65 Schools – Lyon Park Infants, Gladstone Park Primary, Manor Special 66 SECTION 5 - CONCLUSIONS 67-91 Analysis 67 Additional lessons learned 89 SECTION 6 - WAS THIS HOMICIDE PREVENTABLE? 92 SECTION 7 - RECOMMENDATIONS FROM THE REVIEW 93 SECTION 8 - GLOSSARY 99 APPENDICES 1. Terms of Reference 102 2. Chronology attached separately 3. Action Plans attached separately 4. Note on the Nursing and Midwifery Council 107 5. Email from DBS 111 6. Letter from DBS 113 7. Full Code Test 116 8. Checklist of Risk Factors 121 1 Special Educational Needs Assessment Service 3 REPORT INTO THE DEATH OF PENINA ROBINSON2 Name Age at the Relationship point of the murder Penina Robinson 64 Victim Rizwan Ahad Ibrahim3 31 Son in law / Perpetrator Elizabeth4 28 Wife of perpetrator and daughter of victim Child 15 First child of of Elizabeth and Rizwan Child 26 Second child of Elizabeth and Rizwan The family had a number of addresses in Brent including Address 1, which was searched by Hertfordshire Police in May 2013 in relation to allegations that Rizwan had sexually assaulted two former hospital patients. Address 2 is the home in Brent where Penina lived with her daughter and son-in-law and their twin children from June 2013 until her death. 2 Not her real name 3 Not his real name 4 Not her real name 5 First child 6 Second child 4 SECTION 1 - INTRODUCTION 1. This Domestic Homicide Review (DHR) report examines agency responses to Penina Robinson, a resident of London Borough of Brent, her son-in-law, Rizwan Ahad Ibrahim, and Rizwan Ahad Ibrahim’s children up to the point of Penina’s murder in October 2013. 2. The key purposes for undertaking DHRs are to: Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims; Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; Apply these lessons to service responses including changes to policies and procedures as appropriate; and Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter- agency working.7 About Brent 3. Brent is an outer London borough in north-west London with a population of approximately 312,000. It includes the areas of Kilburn, Wembley, Willesden and Harlesden. It is composed of industrial, commercial and residential land and includes Wembley Stadium within its boundaries. More than half of Brent’s residents are from black and minority ethnic communities and it is recognised as one of the most ethnically diverse local authorities in the country8. It has relatively high levels of child poverty. Brent includes three parliamentary constituencies - Brent North, Brent Central, and Hampstead and Kilburn, which also includes part of the London Borough of Camden. 4. The crime rate in Brent is considered by the Metropolitan Police to be average for London. It has one of the highest crime detection rates in London9. In 2013, when Penina was murdered, there were a total of 6524 domestic violence reports made to the Metropolitan Police in Brent. Of these, 1984 were recorded as crimes with the remaining 4540 logged as non-crime domestic incidents. This was 14% above the London average (based on the total number of domestic incidents and offences recorded by the Metropolitan Police divided by 32 (boroughs covered)). In common with many local areas, Brent has a MARAC and an IDVA service. Summary of the Case 7 Home Office, 2011, Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, p6, https://www.gov.uk/government/publications/statutory-guidance-for- the-conduct-of-domestic-homicide-reviews 8 http://www.londoncouncils.gov.uk/services/lept/boroughmap/brent/ 9 http://www.londoncouncils.gov.uk/services/lept/boroughmap/brent/ 5 5. Penina was a native of Fiji and lived there for most of her life. She was described by her daughter as a humble, caring and generous woman who was loved by everyone who met her. 6. In 2009, when she was in her early sixties, Penina and her husband moved to Britain where two of their three daughters lived. Enroute she experienced a stroke which left her with a degree of impairment, including the loss of speech in English. 7. On discharge from hospital, Penina and her husband went to live with their daughter, son-in-law and twin grandchildren in Brent. Penina remained largely independent, caring for her husband until his death in March 2012. However, in April 2013 she was admitted to hospital following a fall. Her health deteriorated over the next six months up until her death.