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: 2018 Extracted: 15 recs

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

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review identified systemic failures in multi-agency information sharing and risk assessment, particularly regarding the consistent under-grading of the perpetrator's escalating risk and stalking behaviour. The victim's needs, including the impact of domestic abuse on her, were consistently overlooked by several agencies.

Extracted recommendations

15 recommendations pulled from the report

#	Recommendation	Addressed to
1	The GP Surgery should establish a protocol for reviewing patients who have presented at A&E following a suicide attempt. This will include dealing with scanned correspondence in a timely manner and agreeing with Kent Police a process to notify them should a Firearms licence holder and/or applicant make a suicide attempt.	A Kent Clinical Commissioning Group \| Kent Police
10	The measures put in place following the Serious Further Offences Review in April 2019 should be revisited to ensure these are being robustly applied. These measures should also be shared with the Ministry of Justice managing the transition of Community Rehabilitation Companies as they transition back into the National Probation Service. (Home Office Quality Assurance Panel Recommendation).	KSS Community Rehabilitation Company
11	There needs to be more effective information sharing and challenge of partner agencies. The establishment of a MASH type functionality should close this gap. The CRC will need to prioritise finite resources to support this initiative if they are to extract the clear benefits such an information sharing structure has to offer.	KSS Community Rehabilitation Company \| Kent Police
12	A training needs analysis should be carried out to identify current gaps in training and awareness. It has already been noted that current training focuses on victims of domestic abuse rather than perpetrators. Additional specialist training facilitated by external subject matter experts will help to reinforce the need to challenge and check with other agencies any account given by a patient who is wearing a tag or admits to previous criminality involving domestic abuse. Mandatory referral to the Police Liaison Officer in these circumstances is good practice.	Kent & Medway NHS Social Care Partnership Trust \| Domestic Violence Service
13	Additional safeguarding training should be considered best practice for schools who operate separate pastoral support systems.	Education Safeguarding Service
14	Operation Encompass should be expanded to include Secondary Schools in advance of the pending Domestic Abuse Bill.	Education Safeguarding Service \| Kent Police
15	The Home Office should explore with the Department of Local Government, Housing and Communities the feasibility of establishing a permanent hardship fund for domestic abuse victims that mirrors the current arrangements for former residents of Grenfell Tower.	The Home Office
2	How DASH is used and how to manage increased risk needs to be reviewed, particularly at an operational level. Due regard to the importance of professional curiosity and judgement should be emphasised. The plan to participate in a pilot sponsored by the College of Policing for a new domestic abuse risk assessment scheduled to start before the end of 2019 will provide additional training and awareness, especially around coercion and control, to the workforce.	Kent Police
3	Specific action should be taken to address the lack of understanding in responding to Section 10 of the current DASH assessment and the importance of listening and more importantly responding effectively to ‘the voice of the child’.	Kent Police
4	A strategic review should be undertaken in respect of the role and responsibilities undertaken by the Information Management Unit, Force Control Room and Central Referral Unit in domestic abuse incidents. This should take due regard to the recommendations made by HMICFRS following their recent inspection and their view that a MASH function should be established.	Kent Police
5	The use of the risk management tool RARA as a process to manage risk needs to be reinforced with operational officers. This will require a training review and a communication plan.	Kent Police
6	The Stalking SPOC initiative launched in July 2019 should be regularly reviewed to ensure best practice and lessons learned are identified at the earliest opportunity and disseminated to practitioners to enable them to deliver the best possible service to victims.	Kent Police
7	Current policy regarding the management of a breach of bail conditions/harassment orders should be reviewed. Specific measures should be introduced that ensure any breaches are actioned in a timely manner.	Kent Police
8	The measures introduced following the Ofsted inspection in January 2019 of Front Door should be revisited to ensure there is compliance with a sharper focus on risk and urgency. An accompanying training needs analysis should be undertaken with Front Door staff. This may identify further areas of training that should be undertaken to ensure the staff are both knowledgeable and confident when dealing with the complexities that are inherent with domestic abuse incidents.	Kent Children’s Social Services
9	There needs to be more effective information sharing and challenge of partner agencies. The establishment of a MASH type and functionality and structure should close this gap. Social Services will need to prioritise finite resources to support this initiative if they are to extract the clear benefits that such an information sharing platform provides.	Kent Children’s Social Services \| Kent Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗