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

Kent review

CSP: Kent Published: December 2022 Year of death: 2015 Extracted: 13 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identifies systemic failures in agencies' recognition of the victim's vulnerability and 'mate crime', alongside a lack of professional curiosity and multi-agency information sharing. This led to incidents being treated in isolation, hindering effective risk assessment and safeguarding.

Home Office classifications

35 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by probation services
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

13 recommendations pulled from the report · 9 matched to organisations in the index

Recommendation 1

Addressed to Police | EKH | Thanet Council | Kent and Medway Social Services | KMPT | SECAmb | NPS | CRC | Kent YOS

Front line officers or staff who, as part of their job description, visit premises or interact with members of the public, have the opportunity to identify potential victims of ‘Mate Crime’ or Domestic Abuse. Officers and staff should be encouraged to exercise ‘professional curiosity’ and follow up on indications of an abusive relationship or safeguarding issues that relate to a person who may not be the primary focus of their work.

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

Recommendation 2

Addressed to Kent Police | East Kent Housing | Thanet District Council

Where there are complaints of Anti-Social Behaviour, it is important to establish who is the victim, who is the perpetrator and whether they are vulnerable and in need of assessment.

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

Recommendation 3

Addressed to Police | EKH | Thanet Council | Kent and Medway Social Services | KMPT

The concept of ‘Mate Crime’ or the harming of vulnerable persons in abusive relationships by offenders who set out or take the opportunity to abuse a victim, should be incorporated into agencies policies and working practice, and staff should be trained accordingly. This type of offending should be treated in a similar way to Domestic Abuse e.g. structured risk assessment, information sharing protocols, victim safeguarding plans etc.

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

Recommendation 4

Addressed to East Kent Housing | Thanet District Council

Housing providers should undertake a risk assessment when they are aware that someone has moved into a property with a potentially vulnerable tenant.

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

Recommendation 5

Addressed to East Kent Housing | Thanet District Council | Thanet CSU

To facilitate information exchange, East Kent Housing to attend formal and minuted Tasking and Coordinating Meetings held by the Thanet Community Safety Unit.

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

Recommendation 6

Addressed to Kent and Medway CCG’s/NHS England

To provide each GP practice with an up to date adult safeguarding policy that reflects national and local guidance and best practice to guide and support staff in responding to victim and perpetrators of domestic abuse and self-neglect.

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

Recommendation 7

Addressed to Kent and Medway Social Services

In exercising their responsibility in assisting young adults leaving care, Social Services should endeavour to ensure such individuals are registered with a GP, (none of the Rose Brothers were registered with a GP at the time they attacked Joyce).

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

Recommendation 8

Addressed to All agencies

Agencies should recognise that an individual’s safety and wellbeing may be, in whole or in part, compromised by self-neglect rather than abuse inflicted by a third person. Agencies should ensure that published guidance on self-neglect is both delivered in training and conformed to as outlined in the Kent and Medway Adult Safeguarding Board Policy.

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

Recommendation 9

Addressed to Kent Social Services | Medway Social Services

Social Services have a responsibility to assist young adults leaving care, which will include helping them find suitable accommodation in which to live. In addition to establishing the accommodation is suitable for the care leaver, a risk assessment should also take place intended to identify safeguarding issues in relation to the existing occupants.

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

Recommendation 10

Addressed to Social Services | NPS | YOS | Housing Providers

In considering the appropriateness of accommodation for persons leaving prison or detention centres, agencies involved should use their own risk assessment processes to determine the suitability of the premises in respect of the vulnerability of existing occupants. Information from risk assessments should be shared with other agencies.

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

Recommendation 11

Addressed to NPS | YOS

When adult offenders have been previously subject to youth offending supervision, liaison must take place with the previous allocated YOT worker/s in order to gather information to inform risk assessment and risk management.

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

Recommendation 12

Addressed to NPS | YOS

When offenders subject to statutory supervision are related, professionals with offender management responsibility must work collaboratively in order to build a holistic view of the family to inform the assessment and management of risk.

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

Recommendation 13

Addressed to Kent and Medway Adult Safeguarding Board

This review and its recommendations should be brought to the attention of the Kent and Medway Adult Safeguarding Board. In so doing the Board and its member organisations may be able to provide guidance and a degree of consistency to those charged with implementing recommendations particularly relating to the use of professional curiosity, mate crime and self neglect.

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