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.

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

Summary AI-generated

Verify against the full report at the source link
The review identified systemic failures in inter-agency information sharing and risk assessment, particularly concerning escalating domestic abuse and stalking. There was a consistent failure to recognise and safeguard children as direct victims, with agencies often taking the perpetrator's account at face value.

Home Office classifications

31 tags

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

  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - present at homicide (including adult children)
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • 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 probation 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 - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • 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 - other educational institution 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 - other recommendation themes

Extracted recommendations

15 recommendations pulled from the report · 7 matched to organisations in the index

Recommendation 1

Addressed to CCG and Kent Police

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.

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

Recommendation 2

Addressed to Kent Police

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.

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

Recommendation 3

Addressed to Kent Police

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’.

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

Recommendation 4

Addressed to Kent Police

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.

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

Recommendation 5

Addressed to Kent Police

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.

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

Recommendation 6

Addressed to Kent Police

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.

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

Recommendation 7

Addressed to Kent Police

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.

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

Recommendation 8

Addressed to Kent Children’s Social Services

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.

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

Recommendation 9

Addressed to Kent Social Services and Kent Police

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.

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

Recommendation 10

Addressed to KSS Community Rehabilitation Company

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).

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

Recommendation 11

Addressed to KSS Community Rehabilitation Company and Kent Police

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.

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

Recommendation 12

Addressed to KMPT and Domestic Violence Service

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.

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

Recommendation 13

Addressed to Education Safeguarding Service

Additional safeguarding training should be considered best practice for schools who operate separate pastoral support systems.

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

Recommendation 14

Addressed to Education Safeguarding Service and Kent Police

Operation Encompass should be expanded to include Secondary Schools in advance of the pending Domestic Abuse Bill.

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

Recommendation 15

Addressed to The Home Office

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.

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