Independent report

Safer Brent Partnership: offensive weapon homicide review (accessible version)

Published 23 July 2025

Report into the lives and learning through service engagement with the homicide victim FS and the alleged perpetrator OA respectively.

This review is part of a 12-month Home Office pilot.

Jo London

Independent Chair and Author

June 2025

The Safer Brent Partnership, the Offensive Weapons Homicide Review Team and the Independent Chair would like to express their deepest regret for the loss of FS’s life; as well as extending their sympathy to his daughter, his family, and to his friends for their loss.

The Partnership also recognises the considerable distress experienced by OA, his family and those who know him.

1. Brief Outline of Homicide

1.1 In August 2023, FS, a 40-year-old Somalian man, was discovered deceased in his home, following community and family concerns, and as a result of a Metropolitan Police Service (‘MPS’ or ‘Police’) welfare visit to the home.

1.2 FS had died some hours earlier that day following a sustained and horrific attack, including multiple post mortem injuries.

1.3 The next day, following intelligence from the local community, the Police identified, arrested, and charged OA, the alleged perpetrator; a criminal trial was scheduled for June 2024. OA claimed ‘self-defence’ and stated that FS was the first to begin an argument when wielding a weapon towards him (OA).

1.4 FS and OA appear to have become friends in April 2023 and were known to drink and take drugs together (and with others).

1.5 The Coroner has been informed of the death, opened, and then temporarily suspended the case, until the outcome of the criminal trial. This is the usual process in such matters.

1.6 At the June 2024 trial, the Trial Jury were unable to agree a verdict and a retrial was scheduled for early 2025. Publication of this report was delayed until after the re- trial to update on the outcome of the trial which is included for completeness.

1.7 At retrial OA was sentenced to 12-years imprisonment for ‘manslaughter by loss of control’.

2. The Purpose of an Offensive Weapons Homicide Review (OWHR)

2.1 OWHRs were introduced through the Police, Crime, Sentencing and Courts Act 2022 and require the Police, Integrated Care Boards (ICB) and Local Authorities in England to review the circumstances of certain homicides where the victim was aged 18 or over, and the events involved, or were likely to have involved the use of an offensive weapon.

2.2 These reviews are separate from any criminal investigations or criminal proceedings, and they are in addition to any inquest or other form of inquiry, if applicable.

2.3 The purpose of OWHRs is to identify any lessons which can be learnt in relation to the death, and to consider whether there is any action which should be taken as a result to aid in preventing future homicides. The review will bring together all the relevant local partners and bodies. It will review their work to consider whether any changes need to be made in policies or practices to aid in preventing future homicides involving offensive weapons. The reviews are not investigations into the death or designed to identify culpable parties or disciplinary processes.

2.4 OWHRs are currently being piloted in certain areas of London, the West Midlands and South Wales prior to a decision being made on whether they will be adopted nationally across England and Wales.

2.5 Members of the Safer Brent Partnership (which includes Metropolitan Police Service, North West London Integrated Care Board and Local Authority services), with reference to the statutory guidance, confirmed that FS’s death met the legal criteria for an OWHR to be completed.

2.6 Families, friends and other people who knew the parties linked to the homicide are invited to take part in the review, and to have the opportunity to speak voluntarily to the Independent Chair and Author. Families and friends can help in providing wider context, and a level of understanding of the lives and experiences of individuals prior to the incident which would otherwise be lost.

2.7 An OWHR will normally be completed within approximately 12 months of the death.

2.8 This OWHR report has been anonymised in accordance with statutory guidance and the date of the homicide has been removed. All relevant information (including names and associated review documentation) is secured by the London Borough of Brent on behalf of the Safer Brent Partnership.

2.9 This report will use initials instead of pseudonyms (in accordance with FS’s family’s expressed preference to avoid the use of pseudonyms) as follows:

Initials	Applied to	Information Source*
FS	Homicide Victim	Reported
OA	Alleged Perpetrator	Reported
CFS	FS’s Cousin	Interview
UFS	FS’s Cousin’s Husband/ “Uncle”	Interview
MOA	OA’s mother	Reported
FFO	Friend of FS and OA	Reported

*Where information is ‘Reported’, this has been taken from contemporaneous notes and records held by service partners to best report the words used by the individual at the time of in-person contact with services.

2.10 In September 2023, the Safer Brent Partnership, having established that FS’s death met the legal criteria for an OWHR in accordance with the statutory guidance, proceeded to commission an independent OWHR.

2.11 A process for recruiting a Home Office trained OWHR Chair was begun, and the independent chair was appointed in November 2023.

2.12 This OWHR outlines the review process, the findings and recommendations considered by the Safer Brent Partnership in considering the lessons learnt from events prior to the homicide of FS, a resident of London Borough of Brent at the time of his death.

3. Governance and Structure of the Review Process

3.1 In accordance with the legislation, the Safer Brent Partnership is the statutorily defined forum which retains overall responsibility for local oversight, carries out the review on behalf of Partners and has responsibility for the sign off of the report. It has responsibility for implementation of any recommendations arising from the OWHR. The partnership delegated operational decision making and sign off of reports to the Brent OWHR Strategic Group which includes a member of each statutorily relevant review partner.

3.2 The London Borough of Brent is the lead agency for the Partnership in delivering OWHRs. It has applied resources through the Violence and Vulnerability Coordinator - OWHR Lead role to engage with the Home Office, the Metropolitan Police, the North West London Integrated Care Board (NWL ICB) and to support this and other active OWHRs.

3.3 Findings from this work are captured and reported to the Brent OWHR Strategic Group for consideration and challenge. The group will submit the final report and recommendations to the Safer Brent Partnership for review and sign off before submission to the Home Office.

4. The Applied OWHR Process Governance Cycle

• Brent Community Safety Partnership (Governance and Oversight)
• OWHR Strategic Group (Operational governance, Initiation, Briefings and Support)
• OWHR Case Review Meetings (Gather Data, Reflection and insight)
• Family/Friends Engagement (Report Enrichment and Insight)
• Service Specific or Themed Meetings (Focus, Clarify and Challenge)
• Review and Reflection Meetings (Establish Learning and Develop Recommendations)
• OWHR Strategic Group (Consider, Challenge and Propose for Sign off)

5. Contributors to this Homicide Review

5.1 The Brent OWHR Strategic Group, comprised of senior and experienced senior representatives that met regularly, usually on a fortnightly basis, to oversee and support active OWHRs:

OWHR Strategic Group Members

• London Borough of Brent Community Safety Team
• Metropolitan Police (North West Basic Command Unit)
• Metropolitan Police (Specialist Crime Review Group (support role)
• North West London Integrated Care Board (Lead)
• North West London Integrated Care Board - Safeguarding (support role)
• Brent Probation Service (non-decision-making standing member)
• NHS England - Mental Health (where applicable)

5.2 The OWHR Case Review Group, comprised of largely frontline and specialist representatives from key service areas where it had been established that contact had been had with either FS or OA respectively:

OWHR Case Review Group Members

• London Borough of Brent Community Protection Team
• London Borough of Brent Housing Needs Team
• Metropolitan Police Service and MPS Specialist Crime Review Group
• Central and North West London NHS Foundation Trust - Safeguarding
• Brent Community Mental Health Team
• North West London Integrated Care Board - Safeguarding
• Brent Probation Service
• Via - New Beginnings – Drug and Alcohol Support Service
• Barnet Homes
• London Borough of Brent (OWHR Lead) – Support role
• Independent OWHR Chair
• Imperial College Healthcare NHS Trust – Safeguarding
• London North West University Healthcare NHS Trust – Safeguarding

5.3 Case Review Group members were of the appropriate level of expertise and were independent, having no direct line management of anyone with first hand contact with FS or OA.

5.4 Additional community insight was gained through discussions with a Somalian community representative. This offered useful insight into the location and the concerns of the local Somalian community.

5.5 The OWHR Chair and Author of this report is Jo London. Jo has received Home Office accredited training in chairing Offensive Weapons Homicide Reviews. Jo has extensive experience in homicide and serious case reviews and critical incident learning, gained throughout a senior leadership career in social housing, community safety in local government and, as a long-standing Trustee of a voluntary and community sector organisation specialising in responses to violence against women and girls.

5.6 Jo holds a MSc in Forensic Psychology and Criminal Investigation - specialising in critical incidents and homicide reviews.

5.7 Jo was appointed in November 2023 and acts in an independent role in this review; they have no connection with the Safer Brent Partnership or any of the agencies involved in this case.

5.8 Family and friends’ involvement in this review was recognised as an important aspect, especially as neither FS nor OA had lived in the borough more than a few months and therefore background information and insight is limited to a short time frame.

5.9 Letters of introduction to the OWHR and the Chair as well as follow ups were sent to family contacts for both FS and OA.

5.10 We recognise that engagement from family and friends is difficult in these circumstances and especially where an individual was a possible witness in the case.

5.11 We are grateful for the time and engagement given by CFS and UFS in providing background information for FS which enabled a greater insight to the person, their history and also in their loss. They also offer a helpful insight into Somalian culture and community.

5.12 We respect OA’s family in their decision not to engage with this review.

5.13 We have been able to establish a profile of OA from criminal justice services and from information provided as witnesses by family and friends.

6. The Scope and Terms of Reference of the Review

6.1 The Terms of Reference and OWHR Scoping Document for this review were considered and signed off by the OWHR Strategic Group in December 2023.

6.2 In accordance with section 28(2) of the Police, Crime, Sentencing and Courts Act, 2022 and OWHR statutory guidelines, the Terms of Reference included the ambition to produce and support new legislation, and to shape the content for evaluation as part of the Home Office pilot phase of introducing OWHRs. In addition, the review should:

• Identify the lessons to be learnt from the death;
• Consider whether it would be appropriate for anyone to act in respect of those lessons learnt;
• Identify factors that may have made it harder for local professionals and organisations, working with the victim, alleged perpetrator(s), other persons connected to the death, and with each other, to reduce the risk of violence to begin with;
• Identify what can be done differently at an agency and system level to prevent future homicides and reduce serious violence to begin with;
• Identify areas of good practice and successful interventions which could be incorporated into general processes and system responses.
• Sign off the draft OWHR Report for consideration and final approval by the Safer Brent Partnership.

6.3 The Scoping Document was informed by the initial information returns received from key services shortly after the confirmation of the OWHR proceeding.

6.4 Requests for information were made to key service agencies who may have had a record of contact with FS and/or OA respectively.

6.5 The information requested was standardised first stage information requested in accordance with statutory guidelines towards building:

• i) comprehensive chronologies including;
  • a. a summary of known information about each individual; and
  • b. a profile of the nature of service engagement prior to the homicide.

6.6 FS and OA appear to have separately and unrelatedly moved into the borough in March/April 2023, shortly before they came into contact with each other. It was therefore agreed that the review period would cover the 12-month period to August 2023. The Independent Chair and the Senior Investigating Officer (MPS) agreed the timeline.

6.7 Finally, where there was agency contact with or insight into FS or OA prior to these dates, agencies were asked to summarise this, and review any issues pertinent to the OWHR. Significantly this was helpful in understanding housing experiences as well as prior contact with health and criminal justice agencies.

6.8 The following specific areas of interest were considered within the scope of the review:

• Profiling the individuals – to develop insight into the lives and lived experience of FS and OA both as individuals and to understand the dynamics of their friendship/relationship. Consideration will be given to equality and diversity factors and any protected characteristics of the individuals subject to this review.
• Nature of the Homicide and Post-Mortem Events – FS’s death appears to have been an unplanned and brutal event. Consideration will be given to events leading up to the murder, the nature of the death, and of the immediate post mortem actions of OA and others.
• Chronology of Service Engagement – A chronology of service engagement by FS and OA respectively will be compiled covering the agreed timeline.
• Location – Church End Area – Both FS and OA lived and spent time in and around the Church Road area. The area is “known for behaviours related to drinking and drug misuse” (family, community representative, and frontline police and staff respectively). The Review considers service engagement and frontline experience of those supporting residents which may include Community Policing and outreach drug and alcohol services.
• Drug and Alcohol Insights – Drug and alcohol are features of this OWHR, and this review will consider insights to improve understanding into the drug and alcohol use related to this homicide; specifically looking at the use of alcohol, cocaine and risks related to large volume use of nitrous oxide.
• New or Emerging Issues – The review will consider any unexpected, new, or emerging issues that relate to the homicide or associated matters/individuals if they should surface during the Review period.

7. Equality and Diversity

7.1 Consideration has been given to the nine protected characteristics under the Equality Act 2010^{[footnote 1]}; including examining barriers to accessing services in addition to wider consideration as to whether service delivery was impacted.

7.2 Protected characteristic insights have been gathered through first hand reports from the individuals themselves to agencies or family; where this is unknown, consideration is given through known information (i.e. age and relationships).

Characteristics	FS	OA
Age	40 years	28 years
Disability	No	No
Gender Reassignment	No	No
Marriage and civil partnership	Yes	Not known
Pregnancy and Maternity	No	No
Race	Black African	Black or Black British
Religion or Belief	Muslim	Muslim
Sex	Male	Male
Sexual Orientation	Heterosexual	Heterosexual

7.3 FS, fled a war situation in his country of birth; he experienced early life trauma and family separation. This may have placed greater dependency on secure housing and may explain what appears to have been a disproportionate reaction (self-harming and suicide ideation responses) to receiving a Notice of Seeking Possession^{[footnote 2]}.

7.4 Family and community insight indicates that there is likely to have been a reluctance from both men to share their adult life experiences (including drinking, police attention and drug use) with their family due to their own or their respective families’ religious beliefs. This may have resulted in both men distancing themselves from the potential stability of supportive family members.

7.5 Priority community safety engagement in the Church End locality is targeted at young people (under 23yrs) at risk of offending and or victimisation. Both men are notably older than this cohort and are not gang affiliated, but exhibited risky behaviours in drug and alcohol use, and in OA’s case in criminal behaviour. Neither individual was known to drug, alcohol, or community safety support.

7.6 In addition to protected characteristics, both men experienced socio-economic disadvantage with one being out of work and in long term receipt of benefits (FS), and the other out of work for three years, not claiming benefits and seemingly financing his life through crime (OA). OA was also denied access to advice on work options through Probation Officer oversight and lack of engagement. However, both men were clearly capable of and enjoyed working in the past.

8. Background information

8.1 Both FS and OA became residents in their L B Brent properties five months prior to the homicide. Little is known about the dynamics of their acquaintance/friendship other than through statements taken related to the homicide.

8.2 Profiles of FS and OA are offered by way of background information (outside of the scope of the review) to give a contextual profile of each man beyond the focus on the homicide itself.

8.3 Chronologies collated from local service providers, health, and the criminal justice services, offer additional insight into the two men, and to the challenges they faced and presented to services with, as well as their approach and engagement with frontline agencies.

8.4 Where this report makes assumptions about dynamics, decisions, or relationships this has generally only been made where there are at least two strands of supportive evidence.

9. FS’s Profile

9.1 FS was aged 40 years old at the time of his death. He was a black African man who arrived in the UK having fled from war in his home country of Somalia in 2002 aged 19 years. FS arrived in the UK alone as, during events related to fleeing Somalia he became separated from his mother and sister, who continue to live together in Switzerland.

9.2 FS lived in South London with his cousin (CFS) who he grew up with in Somalia and with her brother initially and later with her husband (UFS) whom FS referred to as ‘Uncle’. CFS and UFS were considered to be parental figures to FS and were his next of kin.

9.3 FS grew to be some 6ft tall and weighed around 50kg.This height and weight are not considered unusual in his family.

9.4 FS is described by the family as “a good man, who was intelligent and wanted to do good things with his life”. He attended college and studied English, maths, administration, and computers/IT.

9.5 The family recall that FS was “very kind – too kind” and was never known to be violent. He is described as ‘fun’ and ‘always smiling’ and was someone who had lots of friends. CFS described how FS enjoyed cooking for the family and how “no one went hungry when FS cooked”.

9.6 FS had previously married (through a Somalian service in the UK) and had a daughter (aged around 13 years at the time of his death). FS had lost contact with both his ex- partner and his daughter which he and his family regretted. FS expressed a desire to see his daughter to Mental Health professionals in July 2023, but it would appear he did not have the opportunity to act to achieve this.

9.7 FS is described by the family as being at his happiest prior to 2019 when he had been settled for many years in a council flat in North West London. He also lived here with his wife and their child for a period and was in employment for a time.

9.8 FS was reportedly evicted from his council flat home in 2019 for rent arrears which he sought to avoid by borrowing £5000 from the family. It is unclear if/why the eviction had proceeded when the money was made available to pay the arrears to the court/landlord. (The family question if anyone at the landlord council had/could have engaged with FS at this stage – to ask why and how things had gone wrong after a long period of a successful tenancy. They recognise that this question sits outside of the scope of this report but consider that the eviction was a major turning point in the life of FS).

9.9 Since 2019 the family had less frequent contact with FS but they ‘remained close’ with telephone contact from time to time. The family describe an intervention where they met with FS sometime in 2021. The intention was to ensure that FS took better responsibility for his wellbeing. The family describe how they unexpectedly ‘bumped into’ FS sometime after when he appeared well dressed, happy and sober. They felt reassured that FS was doing much better. He was known to have relationships with women including a longer- term relationship with a European woman.

9.10 Family members only became aware of the extent of FS’s alcohol use in recent years. CFS recalls that when she was supporting FS to get a passport, he disclosed for the first time that he had been arrested previously for alcohol related offences and was concerned that this would affect his ability to get a passport or travel.

9.11 FS was known to the police on six occasions in the two years prior to his death – twice for being drunk and aggressive in May 2022 and February 2023 respectively; and on four occasions as the victim of violence (Grievous Bodily Harm and Assault).

9.12 The last time the family saw FS in person was in July 2022, and FS and CFS last spoke on the telephone in June 2023.

9.13 After eviction, FS lived for some time with a friend and then spent the next two years in a private landlord rented property in Barnet until March 2023. He then presented as homeless to Barnet Homes and cited concerns about his personal safety following a recent serious assault^{[footnote 3]} resulting in hospitalisation for 18 days. He was accepted as homeless and was temporarily housed in a street property in Church End, Harlesden.

9.14 FS’s home was a good quality, one bedroom ground floor flat in a street property, provided by a small local landlord in Brent, acquired for use as temporary accommodation by London Borough of Barnet. He moved in in April 2023. FS had changed the layout and use of the flat to better meet his needs and FFO describes how FS liked things to be tidy in his home and how he ‘would mop up any spillages’. FS was clearly very keen to keep his tenancy and presumably to progress to a secure tenancy property in time. This is evidenced by his seemingly disproportionate and extreme anxiety and suicidal ideation, when he thought, he was going to lose his home when served Notice to Quit because he wasn’t home at the time of the landlord’s early tenancy inspections. After the homicide, the property was described as sparsely furnished with considerable evidence of drinking detritus in the property including large quantities of empty bottles.

9.15 Barnet Homes advise that people who are from the Somali community can be referred to the Barnet Somali Community Group to access support in employment, health, and other services. There is no automatic referral mechanism but instead the decision is left to the Assessing Officer to determine if a referral is warranted. There are no notes to evidence consideration of this option, but instead it is considered likely that as the offer of accommodation being made was temporary in nature and ‘out of borough’ then such a referral may have been considered not suitable, if considered at all.

9.16 Barnet Homes gave a section 208 of the Housing Act 1996 notice^{[footnote 4]} to L B Brent for the out-of-borough placement of FS in Brent. Almost all single person lettings are let to vulnerable people under the provisions of the Homelessness Reduction Act 2017^{[footnote 5]} (The Act). The Act aims to reduce homelessness by improving the quality of the advice available, refocusing local authorities on homelessness prevention work, and increasing support for single people. It is questionable however whether the offer of accommodation would have been considered a ‘suitable’ offer (without support in place) if Barnet had been aware of FS’s drink and drug vulnerability and of the concentration of drink and drug related crime in the Church End area.

10. OA’s Profile

10.1 OA self-defined as a Black British man (family believed to be of Somalian origin) who was 28-yrs of age at the time of the homicide. He reports that he had a stable upbringing where he was raised by and lived with his mother in the London Borough of Ealing until 2017. He does not have any siblings or children. He describes a largely happy childhood and advises that he did not experience any major trauma or domestic abuse when growing up. He remains in contact with his mother and family.

10.2 OA’s mother describes him as being ‘very polite and not suffering any problem’ when he was growing up. OA states that his mother did not approve of his pro-criminal lifestyle that he had adopted over the past few years, and this had caused tension between them.

10.3 OA reports that he attended school and gained several GCSE qualifications. He later attended college where he attained City and Guilds and NVQ qualifications in motor mechanics. OA reports that he didn’t enjoy the physical demands of working in motor mechanics.

10.4 At some point it appears that OA moved to Manchester where he worked in a warehouse, sub-let properties and worked in car showrooms buying and selling cars. It is unclear if he was also buying and selling cars privately, generating extra income. OA reports how COVID-19 impacted on his business opportunities, and he turned to crime as a means of making money in place of buying and selling cars.

10.5 OA had twelve contacts with the Police in the two years prior to the homicide including four stop and searches with no drugs or knives present. In addition to theft, violence and drug charges, OA’s record shows arrest but no further action for: assault (October 2021); knife robbery (May 2022); threats with a knife (July 2022); possession of a knife reported (CCTV) (July 2022); and GBH with two knives on Church Road (August 2022). In March 2023 he was sentenced to 3 years imprisonment for Possession with intent to supply Class A drugs.

10.6 OA received a Conditional Discharge (CD) for Possession of Class A Drugs, and then received a 14-week custodial sentence for breach of the CD and Theft from a Person on the tube – which he served 7 weeks custodial time for, before being released in January 2023. In March 23 he was arrested and charged with Possession with Intent to Supply class A drugs - for which in September 2023 (after arrest for this homicide) OA received a three-year custodial sentence. There was no violence with weapons linked with either offence; both offences took place in L B Brent.

10.7 A further incident in August 2022 is noteworthy because it took place on Church Road, Harlesden. It involved OA pulling two knives from his waistband on a stranger following an argument at a bus stop. The victim received what appeared to be defence injuries to both hands. OA was arrested for this offence, but the case was discharged before trial, due to the victim withdrawing their support for the case.

10.8 OA has six arrests involving knives that resulted in No Further Action within a three-year period. On each occasion, case disposal was appropriate and subject to available evidence. He is not considered by the Police to be a habitual knife carrier due to not being charged or convicted for these offences. This appears to be backed by the four stop and searches he was subject to where no weapons were found in his possession.

10.9 In April he appears to ‘stay’ in insecure accommodation with ‘a friend’ in a house in multiple occupation (HMO)^{[footnote 6]}. OA’s accommodation was described by officers who attended the property as ‘desolate’ with a number of vulnerable people present (largely dependent on alcohol or drugs living in substandard, shared HMO conditions).

10.10 OA’s criminal behaviour appears to be motivated by money. OA does not present as a criminal operating to feed his own drug habit. There is no indication that OA was seeking employment however, and he didn’t claim benefits. He had indicated that he wanted to stop drug dealing.

10.11 OA is described by someone who knew him as “a good person… because he used to help people” (FFO).

11. FS and OA’s Relationship

11.1 The information which is known about the 24 hours prior to the homicide gives us some insight into the relationship between FS and OA and how they spent their time. This information is taken largely from witness statements (including from OA himself) and from what was known by community or family members, and through pathology and toxicology reports.

11.2 FS and OA do not appear to have known each other before they each arrived in Church End in April 2023. During the period April to August 2023, they had formed a friendship recognised by others in the neighbourhood, and where community members knew of them as new arrivals to the area. They appear to have spent significant time together.

11.3 Each man had other friends and appeared to have positive relationships with other local people. They spent time with a man and two women during the evening until the early hours preceding the homicide. FS was seen to wave at a woman passing in a car the day before and to approach people in the street; both men engaged with other local people including for short distance taxi rides. FS hugged a woman whom he had previously met, when he unexpectedly came across her.

11.4 OA describes being in an ‘on/off’ relationship with a (Somalian) woman from outside of the neighbourhood at the time. He left the party with this female that he called “my girl” for some hours before returning to FS’s home to continue to drink and take nitrous oxide. It does not appear that FS was in an intimate partner relationship at the time of his death.

11.5 Neither FS nor OA are known to be gang nominals or affiliates.

11.6 FS and OA would drink significant quantities of alcohol - “crazy drinking” (FFO) - and consumed large quantities of nitrous oxide (balloons and cannisters) when together and this would mainly be at either OA’s or FS’s homes. They were described as “drinking together like brothers” (FFO).

11.7 FS advised a Health Professional in March 2023 that ‘he smoked tobacco every day and had done so for many years’ and that he ‘drank alcohol every day before being admitted to hospital – and would drink until he collapsed or did not have any money’. OA reported to a Health Professional that he stopped smoking when he was 21 years old.

11.8 FS appears to have been active (and successful) in facilitating opportunities to bring people together to enable access to money, drinking and/or taking nitrous oxide. For instance, the day before/day of the homicide he appears to have little or no money. It is believed that events unfold as follows:

• FS was waiting to meet OA when he had a chance meeting with a woman he knew (FFO);
• when he hears that her friend is on their way with money he asks to borrow £20;
• when he is aware that the friend has a nitrous oxide cannister but doesn’t know how to use it, he offers to help;
• he connects with OA, and they go to OA’s home to use the nitrous oxide;
• when they are moved on from OA’s home, he offers for them to go back to his home;
• where they consume considerable alcohol including ‘vodka, whiskey, Bacardi, cider, and beers’ (bought mainly by OA and FFO with at least three trips out for alcohol);
• and consume between three and nine N2O cannisters (bought by OA, FFO, and her friend).

11.9 OA however appears to:

• have money for purchasing alcohol;
• initially purchasing two nitrous oxide cannisters;
• takes a number of taxi rides on the evening;
• has sufficient funds to spend three or four hours in a burger bar/shisha shop;
• owned a mobile phone which he used to contact FS by text and phone calls;
• however, during the party FFO was ‘mainly’ the one who was sent to the shops with her bank card, and at other times earlier in the evening for additional alcohol;
• and in the early hours of the morning OA ‘borrowed’ FFO’s bank card to withdraw a loan of £100 from the garage;
• and he returned with 6 additional nitrous oxide cannisters; and failed to return FFO’s bank card.

11.10 There is toxicology evidence that FS had taken cocaine and cannabis prior to his death and that OA had also taken cocaine and cannabis prior to his arrest.

11.11 The cause of the argument between FS and OA which ultimately led to FS’s death remains unclear but was reportedly related to money that OA felt he was owed by FS and which FS did not have. The argument appears to have escalated dramatically and was in contrast to their exchanges across the rest of the previous 24 hours.

12. Chronology

12.1 The timeline scope of this review was agreed at one year prior to the homicide, namely the period to August 2023.

12.2 The initial information produced by agencies related to this OWHR enabled the OWHR Case Review Group to analyse the service contact with FS and/ or OA and to surface areas of learning for this OWHR.

12.3 A second round of standardised questions were sent out with some additional questions related to the Scope of the Review and any emerging issues of interest. Full responses are held by L B Brent.

12.4 The principal service engagement initiated by both FS and OA are health related and the key elements of Health Professional contact has been captured in the chronology overview (see 12) for clarity. As a result, the chronology overview does not do justice to the work of FS’s GP Practice who worked extensively to try to gain access for FS to alcohol and mental health support. Their return totalled 77 specific consultations or actions, including a home visit and proactive contact within the notes. Contact is made with Barnet Mental Health Services (presumably for continuity of support) who advised a 3 month sobriety requirement.

12.5 It is noteworthy that when both men attended hospital for A&E or appointments it is recorded they were with either an ‘uncle’ or ‘cousin’. It is commonplace in Somalian culture for close friends and family members to be referred to by these titles and it does not necessarily confirm the actual relationship. FS’s family members have confirmed they do not recognise the appointments or familial attendance. It is possible (given the timing and closeness of their friendship) that the person in attendance could have been either FS or OA supporting each other, however having reviewed these instances, the identity of these people is not recorded.

12.6 It is also noted that each time OA is admitted into hospital with chest pains and anxiety, he returned to his mother’s home for two or three days for the first time since 2020 before returning to Church Road.

12.7 OA was imprisoned for 14 weeks for Breach of Conditional Discharge and Theft from 6 November 2022. He was released in January under post sentence supervision to an address in L B Ealing. Probation has a duty to put a Sentence Plan in place within 15 days of release. The initial meeting took place with this intention. However, support referrals were not actioned. OA failed to contact Probation throughout February 2023. On 17 March OA was arrested and charged with Possession with Intent to Supply Class A Drugs. He was bailed until September and sentenced to 3-years imprisonment. It appears that the Probation Practitioner believed that OA had been remanded rather than bailed and therefore failed to schedule future appointments. Probation was aware of OA living in Brent only in July 2023.

13. Chronology Overview

FS Chronology

August 2022

September 2022

October 2022

November 2022

Failed to attend GP appointment.

December 2022

January 2023

Northwick Park Hospital - GP referral for operation for abdominal obstruction. Post op bleeding and cardiac arrest. Discharged to GP care.

February 2023

25th: St Georges Hospital (South London)- admitted following assault by multiple assailants with weapons in friend’s home in South London. Broken shin/knee, broken nose, dislocated finger, injured eye and neck. 18 day stay.

26th: Severe acute respiratory syndrome (coronavirus).

Police: Drunk and Aggressive.

March 2023

1st: Seen in Mental Health Clinic. Discharged.

Approached Barnet Homes citing assault and ongoing fear.

18th: Failed to attend hospital outpatient appoint - Discharged to GP.

22nd: GP unable to make contact (x3) to arrange MH and medication review - possibly when FS in hospital.

30th: Referred to Barnet Mental Health - Auditory hallucinations and chronic alcoholism. GP referral - ‘has been abstinent from alcohol for 2 weeks’ -Alcohol Service requires 3 months abstinence. Declined referral.

April 2023

St Georges Hospital follow up appointment. Discharged.

Moves to accommodation in Brent.

Advised Health professional no further suicidal thoughts and no self harm. Prescribed Mirtazapine.

June 2023

Reported to MH team - had received threat from ‘people who broke his leg’.

Victim of fight in the street. Approximate Date: FS texted his mother (CFS) “You are the only person I have in this world”.

July 2023

11th: Attempted overdose visual/auditory hallucinations - voices asking to kill himself, self harm to arms. Low mood triggered by service of Tenancy Notice to Quit. Had attempted suicide twice in past - impulsive decision and was happy be stopped.

12th: GP visit to FS at home discussed his mental health, and self harm to arms with knife. Asked directly if he will kill other people - answers ‘no reason to harm other people just himself’.

Victim of Common Assault Community MH follow up appoint referral made.

August 2023

Family receive message from local Somalian community with concerns about FS’s wellbeing. They make plans to go to him.

Two days later FS is the victim of homicide.

OA Chronology

August 2022

Police: GBH on Church Road with two knives - No further action as victim withdrew from case.

September 2022

October 2022

November 2022

14 wks imprisonment - breach of CD and Theft.

December 2022

January 2023

23rd: Released from prison on licence at half custodial sentence (1/3/23) OA admits to starting to use Nitrous Oxide from this point (27/6).

February 2023

March 2023

Arrives in Brent. Specific date unknown.

17th: Charged Possession with Intent to Supply Class A Drugs (Ultimately sentenced to 3 Years Custody on 1/9/23).

April 2023

Registers with GP.

June 2023

26th: St Marys Hospital (A&E) - Chest Pains/ Short of Breath - Left before investigation complete.

27th: St Mary’s Hospital (Ambulance) - Chest Pains/Anxiety - Discharged with Neurology Plan - Admitted using 5x more N2O than usual in 3 days.

28th: Attended Northwich Park Hospital (A&E) - Chest Pain; declined investigation or psychiatric referral.

29th: St Marys Hospital (Ambulance) Chest pains/Anxiety - reviewed by Mental Health Team - discharged with advice and leaflet.

July 2023

3rd: Neurologist Review - disclosed 4-5 cannisters of N2O with 1-2 bottles of whisky/vodka between 3 people over weekend.

15th: St Marys Hospital (A&E) with Chest Pains/Anxiety - investigations completed - discharged with safety advice and pain relief.

21st: MRI due.

25th: GP - New Patient Health Check - Denied drug or alcohol concerns.

August 2023

Present at homicide

14. Chronology Insights

14.1 FS appears to have had confidence in his GP, Health Professionals and gave candid disclosures related to how his injuries occurred, his mental health, his aspirations to meet his daughter, his excessive drinking, his self-harming and suicidal ideation. He also shared information related to his housing and recent attack honestly in his housing application to Barnet Homes.

14.2 OA also offers open disclosure of his N2O use and attributes this to his presenting symptoms at hospital. He proactively and consistently refers to significantly large quantities of cannister N2O use and is clearly concerned about his own wellbeing.

14.3 Neither FS nor OA were known to Via - New Beginnings - drug and alcohol support – who have offices located in Church End. FS also failed to meet the three-month abstinence requirement of Barnet’s Alcohol Support services despite GP support.

14.4 Judicial bail decisions are difficult decisions where individuals have the presumption of bail unless they present as a serious risk of reoffending or flight. It is also the case that bail is rarely given where it is anticipated that an individual is likely to receive a lengthy prison sentence. It could be considered surprising therefore that OA received Court bail in March 2022 (for drugs possession related offences for which he was later sentenced to 3 years imprisonment); and noteworthy that had he been remanded in custody from March 2022, he would never have come into contact with FS at all.

14.5 OA’s contact with Probation Practitioner support should have resulted in referrals to commissioned providers for housing and financial support but these were not made. Also missed appointments were not acted upon as breaches of licence.

14.6 It is noted that OA’s own actions, non-attendance at Probation appointments, his failure to notify of his change of address for some two months, and his reoffending, overtook events. By delaying notification, he prevented the opportunity for easier access to probation support from Brent’s Probation Office on Church Road.

14.7 A couple of days before FS’s death – a member of the local Somalian community spoke to FS’s family (CFS and FFS) saying “you need to get to FS. You need to get him back. He is different, his life has changed. He is losing everything”. At the time of his death the family were making plans to visit FS.

14.8 FS moved to Brent to flee personal safety concerns and as a step towards secure accommodation back in L B Barnet. Due to a lack of available temporary accommodation in Barnet he was offered the property in Church End. On the face of it, the move was a positive one to good quality accommodation offered in an area he was familiar with and with an established Somalian community. However, Barnet Homes were unaware of the local concentration of drink and drugs related anti-social behaviour. There is no mechanism in place for Boroughs to notify each other of locations associated with higher risks, where they may consider placing vulnerable people who are new to the area. It is noteworthy that if FS could have been housed in Barnet, he would likely have been referred to a local Somalian Community organisation for support. This does not happen with out of borough lettings. It is also noted that FS was not at home (in Brent) when the local landlord attempted an early home welfare visit within the first couple of months of the tenancy. The landlord’s next response was service of a Notice to Quit (NTQ) to recover the property seemingly without a further attempt to contact FS. We know that FS felt suicidal at receipt of the NTQ and the prospect of losing his home.

14.9 A noticeable feature of locality partnership working are Brent Joint Action Group (BJAG) meetings, where the language in minutes is focussed on offending behaviours rather than on the risk of exposure or concentration and proximity of vulnerable people. Referrals are however, made to Community MARAC (Multi Agency Risk Assessment Conference) for vulnerable people who meet the threshold. There appears to be no joint reporting or outcome tracking from actions or referrals. This might give an enhanced focus and evidence a trauma informed approach to partnership engagement, bringing together health, Adult Social Care, and support agencies with work outside of successful enforcement activities (licensing, HMO closure etc).

14.10 On the day of FS’s death, the family were notified by community members that FS was in trouble and had possibly been killed. They travelled to FS’s home in the afternoon and were unable to obtain a reply or gain access to the property. They report that they made multiple calls to the police from outside of FS’s property and were advised on one occasion to break into the property themselves, which fortunately they declined. They were finally assisted by the police in gaining access to the property in the evening, reportedly some 10 hours after FS’s death. Pathology advice indicates that FS had been killed prior to the family being notified.

14.11 The family have not made a complaint against the police and no referral to professional standards has been made related to this case.

14.12 Whilst the chronology offers a short window into the lives of both FS and OA, with concentrated engagement with services in the last three months, there is a consistency which gives confidence to the information relied upon here.

15. Nitrous Oxide

15.1 Nitrous Oxide (N2O) features prominently in the last few months covered in this review and therefore was considered separately to the chronology.

15.2 N2O is a colourless gas. It is often referred to as ‘laughing gas’ because it can give those who inhale it as a recreational drug, a short-lived euphoric mood. N2O has street names of ‘NOS’, ‘noz’ or ‘balloons’.

15.3 Since November 2023, (post this homicide) N2O has been classified as a Class C drug under the Misuse of Drugs Act, 1971, marking a key change to how possessing this psychoactive substance is treated in law.

15.4 The OWHR Case Review Group considered the presence of excessive use of Nitrous Oxide in this case, specifically professional briefing advice^{[footnote 7]}:

• a) The mental health concerns, hallucinations, suicidal ideation, and self- harming presented by FS (under the assumption that he also took large quantities of N2O with is friend OA) are possibly consistent (but very unusually) with symptoms attributed to N2O use.
• b) The reported high-volume use repeatedly referenced by OA in health presentations to hospital are consistent with symptoms attributed to N2O use.
• c) The potential of N2O to contribute to any increased risk i) to the homicide event itself; or ii) to the excessive and explosive violence linked to the homicide including postmortem actions. Specialist and frontline experienced Health Professionals and Drug and Alcohol Practitioners advise that there is unlikely to be a link between N2O use and the risk of i) homicide or ii) excessive or explosive violent incidents. Instead, the OWHR Case Review Group consider that alcohol was to be the more likely contributor to the excessive violence leading to death.
• d) Representatives from the MPS Serious Investigation Team linked to this case, reported the presence of N2O ‘across the board’ of serious crimes they were investigating including other homicides. Health, and Drug and Alcohol colleagues do not report the same prevalence in serious crime as their MPS colleagues but recognise that they do not hold data to evidence this either way; not least given the short-term effects of N2O which may have passed by the time they come into contact with the person.

16. Church Road/Church End Locality

16.1 Church Road, as part of the wider Church End area of the London Borough of Brent, presents with a range of social and community safety related challenges for the local population, service providers and for the wider Safer Brent Partnership.

16.2 Church End is recognised as an area requiring concentrated partnership working through a BJAG where key frontline community protection staff and organisation representatives seek to share intelligence, problem solve and to plan interventions. The BJAG also makes referrals to Community MARAC which is a multi-agency risk assessment conference held to discuss vulnerable adults which meet its threshold.

16.3 Church Road is just one part of the wider Church End BJAG area which is described as a place with “young males, selling and taking drugs. Residents and businesses feel threatened and have been subjected to verbal abuse. Members of the public are in fear of reporting any incidents that have taken place in the past. A lot of street drinking particularly with the Somalian community. A number of Partners are aware”.

16.4 The area is well resourced for many local support services including a Police Station, garage, local shops, a Probation Office and Drug and Alcohol Support Services. However, this remains a community with an overconcentration of vulnerable (largely addicted) people and an overconcentration of pro-criminal activity.

16.5 OA was staying in a House of Multiple Occupation (HMO) which featured in BJAG activity and had been identified by BJAG as having “an open-door policy where ASB happens”. Since (but not related to FS’s death) through engagement with the landlord the property has been ‘closed’ and sytexed. OA was not known to frontline staff working on the HMO closure.

16.6 The BJAG approach clearly achieves some successful outcomes through concerted efforts around HMO’s and licensing but would benefit from developing an equalities impact approach. This would ensure there is appropriate understanding of the dynamics and drivers of crime and victimhood in neighbourhoods. Especially where there is a strong or dominant cultural concentration – in this case the Somalian community. Appropriate resources, language speakers, engagement and outreach work could then be tailored to the specific area – and a wider focus on a trauma informed, public health approach to serious crime and community confidence building could be put in place. This approach could work well immediately following a serious incident such as this homicide - where clearly a number of vulnerable people will have been impacted by the loss and nature of FS’s death, by proximity to the individuals or their families, or indeed from the loss of their friends or acquaintances. Failure to explore further opportunities for engagement and proactive support could continue to normalise serious crime and its impact, leaving behind deep rooted fear and poor mental health outcomes.

16.7 The local Somalian community, along with the wider community and local businesses are reportedly reluctant to report concerns about individuals or issues related to criminality or anti-social behaviour. Without effective engagement, we cannot be certain if this is down to a proud community that wishes to resolve its issues itself, or out of fear from those who might retaliate, or out of a lack of confidence in police or Community Partnership effectiveness or any other reason. Without understanding this, the appropriate response cannot be achieved.

16.8 Family, frontline staff and community representatives all mentioned the ‘normalisation’ of unwelcomed behaviours in and around the Church End area including open drinking, drug use/dealing, khat use, N2O use and of poor-quality HMOs as places which attract anonymity and criminal or anti-social behaviour. There is concern at what is considered high concentrations of vulnerability, and suggestions of the need for regeneration of the area, improved outreach, and support to the Somalian community. There is also the potential of developing an ‘ask’ of local business to ‘step up as community leaders’. There is an under reporting of concerns and crime in this area which is interpreted by a community leader as due to the community being overwhelmed by its experiences and uncertain of how to respond safely.

16.9 The local authority and partners recognise that Church End locality area would benefit from regeneration investment. The Mayor of London is funding a £1.2m regeneration project in Church End and the surrounding areas as part of a 10-year larger scale regeneration proposal. There is a strong sense within the community and amongst businesses that they were moved away from Wembley Central to facilitate regeneration, and that they have been left again with a poorer neighbourhood as a result.

16.10 There is also a call for greater proactive engagement, especially with people who are new to the area. With a focus on drug and alcohol and mental health services and through the local employment of Somalian language speaking outreach work.

17. Public Health Approach to Crime Reduction

17.1 The Safer Brent Partnership made a renewed commitment:

‘Over the next 3 years [we are] committed to ensuring that our ‘Public Health’ preventative approach is embedded across every strand of our work. We need to act earlier, smarter, and more proactively to tackle crime and disorder, as well as protecting the most vulnerable’^{[footnote 8]}.

17.2 As part of this review, we considered any evidence of this approach in practice.

17.3 Partners generally failed to recognise the term ‘public health approach’ but instead recognised the terms ‘early intervention and prevention’.

17.4 The public health approach to crime reduction is recently introduced and therefore it is too early to draw firm conclusions on the effectiveness of the partnership approach in Brent. From a range of multi-agency forums held related to this review, it is apparent, that at this stage there is little confidence in bringing forward examples of the approach in practice.

17.5 As part of this review the Borough’s Community Safety Team undertook a self- assessment against the Local Government Association’s “Top Ten Tips” for local authorities in promoting a public health model approach to crime reduction^{[footnote 9]}.

17.6 Brent’s Community Safety Partnership appears to have the key component parts which feature in successful use of this model but would appear to have some difficulty presenting strong evidence, relying on interpretation of data captured for different purposes and for demonstrating what success looks like against its interventions and outcomes.

17.7 The Cardiff Model^{[footnote 10]} for Violence Prevention approach is recognised as ‘the gold standard’ public health approach to violence prevention. The approach has a four-step systematic approach to data collection, targeted research in factors that increase or decrease risk of violence; data informed intervention design; and finally scaling up and dissemination of prevention information.

17.8 The Safer Brent Partnership approach may benefit from adopting the Cardiff Model and framework for data informed insights, interventions, design, and evidencing outcomes.

18. Trauma Informed Approaches to Engagement with Service Users

18.1 The government defines trauma informed practice as:

“…practice [that] aims to increase practitioners’ awareness of how trauma can negatively impact on individuals and communities, and their ability to feel safe or develop trusting relationships with health and care services and their staff.

It aims to improve the accessibility and quality of services by creating culturally sensitive, safe services that people trust and want to use…”^{[footnote 11]}

18.2 As part of this review, we considered whether we could evidence any trauma informed approach to supporting either FS or OA.

18.3 We were unable to surface evidence of this approach in practice (not least given the relatively short time both men lived in the borough). However, it is clear that Partnership members and frontline staff recognise the potential benefits for adoption of trauma informed practice and professional curiosity in health, housing, mental health and in drug and alcohol support.

18.4 In 2020 a covid community outreach project was deployed to proactively engage with the Somalian community (to promote vaccination) and would appear to offer a good foundation for broader health engagement related to mental health and possibly substance misuse.

19. Conclusions

19.1 FS’s death was a tragedy; an unexplained and unimaginable event that is not easily understood. FS’s death does not arise from a service specific failing identified in this review. It is clear however, that when FS lived in a secure environment he developed meaningful relationships and maintained regular positive contact with his family. He was a man who wished to re-establish contact with his daughter, to maintain family ties with those who loved and supported him as a young man, and initially through secure accommodation, wanted to rebuild positive aspects of his life. He was known as a ‘good hearted man with a big smile’.

19.2 The Case Review Group has sought to understand FS and OA’s lived experiences, and to consider the issues in their lives that might help explain the circumstances of the homicide or identify relevant learning.

19.3 The Safer Brent Partnership, through the delegated representatives have shown themselves to be a partnership which is committed to listening, to challenge and to learning from the devastating death of FS. It found it difficult, to surface examples of good or best practice in public health model or trauma informed approaches or related to community safety and/or support for vulnerable individuals and communities.

19.4 In practice, the learning in this case related to services, agencies, and their interactions directly with FS and OA is limited.

19.5 The OWHR Case Review Group has explored all available contact, and tried to build a wider holistic, non-judgemental understanding of the lives of the two men most impacted by the homicide, through their voices, and through the memories of people who were close to them. While this has highlighted some issues and areas for consideration (which have been expressed as recommendations), there were no specific issues which could be directly attributed to predicting the outcome of homicide through these circumstances or the relationship.

19.6 In hindsight we can see opportunities for alternative paths for both individuals, and this gives insight which can inform learning and changes in practice. It is recognised however that in all of our lives, individuals make choices which are sometimes not in their best interest or make decisions where they are blind to risk.

19.7 Following the conclusion of an OWHR, there is an opportunity for agencies to consider the local response to the learning and recommendations. This is relevant to agencies both individually and collectively. It is hoped that this will ensure the learning from this tragedy is shared, and appropriate action taken.

19.8 The recommendations of the report should be acted upon through the development of an action plan, with progress reported to the Safer Brent Partnership within six months of the review being approved by the Partnership.

20. Improving Systems and Practice (National, Regional and Local):

The recommendations arising from this review are taken from the range of engagement in reviewing this case. These recommendations are intended to provide an opportunity to improve Partnership services and are recorded here as an opportunity to improve outcomes for vulnerable people in Church End and more widely.

20.1 Recommendation 1: GP Engagement - For health and third sector colleagues to engage with GPs and wider practitioners to refresh awareness of the local offer for vulnerable people including the Single Point of Access (SPA), one number and email address, for referrals to secondary mental health services, support in a mental health crisis and drug and alcohol services.

20.2 Recommendation 2: Establishing N2O Data - It is recognised that greater numbers of serious weapons injuries report to Hospital Accident and Emergency Depts than report to the police. Health colleagues to explore the potential of introducing capture of N2O- use data in serious crime incident presentations to hospital – including professional enquiry into i) short term use, ii) long term use and/or iii) excessive use.

20.3 Recommendation 3: Better Informed Out of Borough Housing Offers - It is recommended that L B Brent engage with the Local Government Association (LGA) as part of its guidance review on out of area (housing) placements across London; to advocate for shared information on higher risk areas of crime and/or concentrated drug and alcohol challenges to support suitable offers of accommodation. If the timing of this recommendation is out of alignment with the LGA review, the Council could consider adopting this approach with their neighbouring London boroughs who place residents in Brent.

20.4 Recommendation 4: Service Access Info for New to Borough Arrivals - For Strategic Health and Local Authority Partners to develop a leaflet and digital information sharing, to welcome newcomers to the borough and to outline the range of services and support they can access in L B Brent. This should include how to access support (i.e. self-referral, GP referral etc). Partners should explore promotion through local and social landlords, council premises, local shops, libraries, community centres etc.

20.5 Recommendation 5: Equality Profile BJAG Activity - For the Safer Brent Partnership and Strategic Local Authority Partners to consider Equality Impact Assessment or similar to profile BJAG areas as well as associated Community MARAC activity and outcomes, in order to evidence intelligence informed strategies and measures of success.

20.6 Recommendation 6: BJAG and Community MARAC Joint Outcome Reporting - To review combined BJAG activity and associated Community MARAC outcomes. With a focus on localities which have a concentration of people with vulnerabilities. This should include a focus on long-term outcomes for people as perpetrators and victims of anti- social behaviour and crime. For example, BJAGs measure HMO closures but could also include information on the people displaced by the closure, their engagement with services and the impact on their longer-term wellbeing. Reporting of this nature could provide important insight into the Safer Brent Partnership’s work in priority areas and the long-term outcomes.

20.7 Recommendation 7: Community Confidence Building to Promote Reporting of Concerns - For the Local Authority to review engagement with local communities and businesses in BJAG areas to build local confidence that things are improving, including updates on any regeneration, police activity/campaigns, successes and to promote local business-led community leadership and reporting of concerns.

20.8 Recommendation 8: Review Partnership Data Capture towards Long Term Crime Reduction - For the Safer Brent Partnership to review its systemic data capture approach to the Public Health Model to crime reduction in light of the Cardiff Model; so that it can evidence increased insight, improve early intervention and prevention, and deliver successful use of resources towards long term outcomes that reduce crime.

20.9 Recommendation 9: Evidencing Trauma Informed Working - For the Safer Brent Partnership to consider how it will evidence trauma informed engagement with service users is taking place or eliciting changes in working practices.

20.10 Recommendation 10: Probation Service Operational Management Assurance

• 20.10.1 Probation Service
  • i) to provide the learning outcome of any internal review;
  • ii) to give assurance that adequate operational control measures are in place to ensure that Sentence Planning referrals are actioned and;
  • iii) to review internal control measures to ensure that bail/remand decisions are correctly captured and followed up appropriately.

20.11 Recommendation 11: Proactive Early Intervention Engagement after Serious Incident - For the Safer Brent Partnership to oversee the development of a proactive engagement initiative from health and support services after a serious or critical incident has occurred. To include asking vulnerable people ‘how are you’? (health and wellbeing enquiry) rather than ‘what happened here?’ (possible police evidence enquiry). In this case it could have included proactive engagement with the public in and around Church End, including HMO residents offering support with their drug, alcohol, housing and general wellbeing issues.

20.12 Recommendation 12: No Further Actioned Knife Related Allegations and Risk - It is noted that OA was previously linked on five occasions with alleged knife threat/use but these all received ‘No Further Action’ (NFA’d). The case disposal was appropriate and subject to available evidence on each occasion (including withdrawal of victim statements). However, it is likely that victims of crimes involving offensive weapons may be more reluctant to press charges and attend court hearings related to these fearful and serious events. The Home Office could consider the prevalence of offensive weapons related NFA’s in the antecedence of homicides involving offensive weapons; and consider if there is a need to review sentencing guidelines which may assist the Police/CPS (in charging), in cases at risk of being NFA’d due to victim fear based reluctance. A parallel is drawn to domestic abuse where victims may be similarly reluctant and yet charges can be progressed without the involvement of witnesses in certain circumstances.

L B Brent will produce an action plan (for Safer Brent Partnership) resulting from these recommendations, with the aim of reporting progress in all recommendations within a six month period from the date of approval of this report at the quarterly Safer Brent Partnership meeting.

Dissemination

The list of recipients to receive copies of this Report (in line with guidance and due to the recommendations of this Report) are as follows:

Organisation	Yes	No	Reason
Brent Community Safety Team
Metropolitan Police Borough Command Unit - Brent
North West London Integrated Care Board – Brent
Brent Probation
Home Office
Metropolitan Police Specialist Crime Review Group
London North West University Healthcare NHS Trust - Safeguarding
London Borough of Brent Housing Needs Team
Central and North West London NHS Foundation Trust – Safeguarding
London Borough of Brent Community Protection Team
Brent Community Mental Health Team
North West London Integrated Care Board Safeguarding
Via - New Beginnings – Drug and Alcohol Support Service
Barnet Homes
Imperial College Healthcare NHS Trust – Safeguarding
Royal Free London NHS Foundation Trust – Safeguarding

Final Confidence Check

This report has been checked to ensure that the OWHR process has been followed correctly and the report completed as set out in the statutory guidance.

☒    I can confirm that this Report section is at a standard ready for publication.

☒    Once completed this report needs to be sent to the Secretary of State for the Home Office. (Tick to confirm that this has been completed).

Statements of Independence

Chair

I make the following statement that prior to my involvement with this review:

• I have not been directly involved in the case or any management of oversight of the case.
• I have the appropriate recognised knowledge, experience, and training to undertake the review. Therefore, I have met the criteria of an Independent Chair.
• The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as ser out in the Terms of Reference. I recognise that the purpose of this is to identify learning from the case, not to attribute blame to practitioners or agencies.

I have read and understood the equality and diversity considerations and will apply accordingly.

Signature:

Name: Jo London

Date: June 2025

To be completed by the Home office:

☒     Please tick here to confirm thar the Chair was appointed from the Independent Chairs List held by the Home Office.

If the Chair is not a member of the Independent Chairs List, then please give details to confirm how the alternative Chair fully meets the Competencies set out in the OWHR guidance.

1. Equality Act 2010. Equality Act 2010 (legislation.gov.uk). ↩

2. Shelter Legal - Secure tenancy notices - Shelter England. ↩

3. Note: The Police reviewed the details of the assault and ruled out any connection to later events. ↩

4. Homelessness code of guidance for local authorities - Chapter 17: Suitability of accommodation - Guidance - GOV.UK. ↩

5. Homelessness Reduction Act 2017 - a summary.pdf. ↩

6. Note: The HMO has since been closed down following an intervention by the local authority due to unrelated ASB activity). ↩

7.  https://indd.adobe.com/view/fd036d4c-dfb9-47d5-8b8c-6ce842bffde4 (DrugWatch). ↩

8. Safer Brent - Community Safety Strategy 2024-2026, Foreword https://democracy.brent.gov.uk/documents/s139077/14a.%20Appendix%201%20-%20Safer%20Brent%20-%20Community%20Safety%20Strategy%202024-2026.pdf. ↩

9. https://www.local.gov.uk/sites/default/files/documents/10.46%20Taking%20a%20public%20health%20approach%20-%20Violent%20crime_03_0.pdf. ↩

10. https://www.cardiff.ac.uk/documents/2665796-the-cardiff-model-for-violence-prevention#Helpful-and-unhelpful-influences. ↩

11. https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice. ↩