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: KentPublished: December 2022Year of death: 2018Extracted: 10 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review highlights a lack of holistic understanding of the victim's complex vulnerabilities (mental health, cancer, child residency fears) and the impact of coercive control on her engagement with services. Missed opportunities to explore reasons for disengagement and share information across agencies were identified.
Home Office classifications
47 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - died by suicide
Victim - alcohol misuse
Victim - substance misuse
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - panic attacks
Victim - suicide attempts
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Victim - case heard at marac before homicide
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 - subject to child protection or domestic abuse prior to homicide
Child - primary address same as victim
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to mental health services as a domestic abuse perpetrator
Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
Perpetrator - known to probation services as a domestic abuse perpetrator
Perpetrator - known to housing services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - supervised by probation services
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family received draft report
DHR process - police recommendations
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - idva or other domestic abuse support service recommendations
DHR process - housing services recommendations
DHR process - technology systems recommendation themes
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
10 recommendations pulled from the report · 4 matched to organisations in the index
Kent Police must have processes in place to ensure that intelligence received (from any source) about domestic abuse, particularly if it refers to a high-risk victim, is evaluated and disseminated expeditiously to the relevant department to ensure it is acted upon appropriately.
Kent County Council must, as part of the performance monitoring of its contract with Centra, consider how the concerns identified in this report are being addressed by Centra to ensure that the service provided to high risk victims of domestic abuse is improved.
Clinical Commissioning Groups should ensure that when it is known to a GP practice that a patient is a victim of domestic abuse, this is clearly highlighted in their notes if they transfer to another practice.
Kent and Medway CCGs should encourage GP practices that have electronic recording systems for patients’ notes with a flagging facility, to use this to flag patients (and where relevant, children and other family members) who are victims of domestic abuse.
Kent and Medway Domestic Abuse and Sexual Violence Group should consider how best to ensure that a high-risk domestic abuse victim’s GP is invited to attend or contribute to a MARAC meeting at which one their patients will be discussed.
Area A NHS Trust should ensure that initial and refresher training for staff includes emphasis on asking patients about domestic abuse, including coercive control, when completing the Concern and Vulnerability Form.
KCC ICS must ensure that safeguarding training for its staff includes the safeguarding responsibilities of the service beyond its primary role of child protection, including the need to share safeguarding concerns with other relevant organisations
Kent and Medway Domestic Abuse and Sexual Violence Group should: ask the housing association to report on the additional training provided to its staff; and consider circulating details to other housing associations in Kent and Medway.