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

East Staffordshire review

CSP: East Staffordshire Published: December 2022 Extracted: 8 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
Agencies failed to recognise and understand coercive control and economic abuse, particularly the heightened risk during separation. This led to missed opportunities to safeguard the victim, with professional focus often on the perpetrator's mental health rather than the victim's safety.

Home Office classifications

28 tags

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

  • Victim - housing issues
  • Victim - serious or life limiting illness
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - serious or life limiting illness
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

8 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation i.

Addressed to East Staffordshire Community Safety Partnership

East Staffordshire Community Safety Partnership should write to the Executive Director of Operations at Citizens Advice (enclosing a copy of the final report) to ask them to review whether their advisors receive appropriate training on domestic abuse (including information on coercive control and economic abuse).

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

Recommendation ii.

Addressed to Midlands Partnership NHS Foundation Trust

Midlands Partnership NHS Foundation Trust should evidence that clinical staff are adhering to the Carer Engagement Standards as well as the "Our Service User and Carer Charter".

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

Recommendation iii.

Addressed to Staffordshire Police

Reassurance should be sought by Staffordshire Police that 'prevention interviews' following missing persons episodes consider safeguarding measures and referrals to appropriate services.

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

Recommendation iv.

Addressed to East Staffordshire Community Safety Partnership

It should be standard practice that as soon as the threshold for a domestic homicide review is met, a letter should be sent on behalf of the independent chair to request access to the perpetrator's medical records.

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

Recommendation v.

Addressed to East Staffordshire Clinical Commissioning Group

The adult safeguarding training delivered by the Clinical Commissioning Group to primary care staff on domestic abuse should include coercion and control. This should be evidenced by research findings such as 'Counting Dead Women' 20 and 'Partner Femicide’.21

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

Recommendation vi.

Addressed to GP Practice

The GP Practice should seek additional support and training on domestic abuse, and it should include the signs of coercive control. This will ensure that the staff are aware of their duties to explore and document discussion following disclosures such as marital breakdown.

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

Recommendation vii.

Addressed to Domestic Abuse and Commissioning Development Board

The Domestic Abuse and Commissioning Development Board (DACDB) should seek assurance that training and development in relation to domestic abuse for GPs is meeting its objectives. The specific areas of development include coercion and control, escalation of risk linked to recent studies around the preceding steps to domestic homicide.

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

Recommendation viii.

Addressed to Domestic Abuse Commissioning and Development Board

The Domestic Abuse Commissioning and Development Board should assure the East Staffordshire CSP that awareness of domestic abuse (especially coercion & control and economic abuse) is being enhanced across a wide landscape of agencies particularly the Voluntary, Community and Social Enterprise (VCSE) community. This should further safeguard their service users and the public, in line with the findings of this review.

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