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

Coventry review

CSP: Coventry Published: December 2022 Year of death: 2017 Extracted: 21 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 report identifies systemic failures in recognising familial domestic abuse, often obscured by mental illness and substance misuse. It highlights inadequate risk assessments for older victims and carers, and a lack of coordinated multi-agency support for vulnerable individuals' housing and care.

Home Office classifications

44 tags

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

  • Victim - was a carer
  • Victim - carer for perpetrator
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - panic attacks
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • 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 mental health services
  • Perpetrator - supervised by probation services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • 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 - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training 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

21 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1

Addressed to Coventry Police and Crime Board

The agencies of Coventry Police and Crime Board should provide evidence-based assurance that their services are capable of
 identifying the breadth and range of domestic abuse, including tactics of coercive control and economic abuse
 identifying and responding to indicators of risk including recognising the history of domestic abuse and the potential to use weapons
 holding perpetrators of domestic abuse to account
 differentiating between domestic abuse and mental ill-health behaviours, intentions and effects

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

Recommendation 2

Addressed to Coventry Police and Crime Board

The agencies of Coventry Police and Crime Board should consider how they can increase take-up of substance misuse services for individuals with multiple needs

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

Recommendation 3

Addressed to Coventry Police and Crime Board

Coventry Police and Crime Board should consider whether the barriers experienced by older women experiencing domestic abuse in accessing services, and the barriers experienced by agencies in providing services to older women, are sufficiently understood and being addressed.

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

Recommendation 4

Addressed to Home Office

The Home Office should consider commissioning a review of the domestic abuse risk assessment, in its latest form, to ensure that it is capable of effectively assessing the risk indicators of domestic abuse for older victims.

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

Recommendation 5

Addressed to Coventry agencies

Coventry agencies to ensure that frontline staff have an understanding of, and are able to recognise, familial domestic abuse. This should include consideration of abuse to, and by, relatives who have a caring role.

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

Recommendation 6

Addressed to Coventry Police and Crime Board

Coventry Police and Crime Board should raise public awareness of familial domestic abuse including widely advertising sources of help and support; targeting families and friends

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

Recommendation 7

Addressed to Coventry Police and Crime Board

Coventry Police and Crime Board to assess whether there is sufficient multi-agency support and co-ordination for the resettlement of homeless individuals with multiple and complex needs.

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

Recommendation 7.1.2

Addressed to Coventry and Rugby Clinical Commissioning Group

Circulate the lessons from this case to all GPs in Coventry and Rugby CCG with a summary of the case history and discuss at the Face-to-Face GP training.

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

Recommendation 7.1.3

Addressed to Coventry and Rugby Clinical Commissioning Group

The CCG will review how the national strategy for supporting carers is being implemented locally by local GP primary care providers. This piece of work will review the activities of the finance, contracting, communications and clinical groups to ensure a joined up approach is being delivered to improve support to carers.

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

Recommendation 7.2.1

Addressed to Coventry and Warwickshire Partnership NHS Trust

Frontline staff to have an increased understanding of, and be able to recognise, familial domestic abuse and how it may present in the client groups served by CWPT. This should include consideration of abuse to, and by, relatives who have a caring role.

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

Recommendation 7.2.2

Addressed to Coventry and Warwickshire Partnership NHS Trust

Team managers who provide supervision to staff to have the knowledge and skills necessary to identify domestic abuse, particularly in the context of familial abuse, even if the caseworker has not recognised the abuse and is not presenting the case in the context of domestic abuse

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

Recommendation 7.2.3

Addressed to Coventry and Warwickshire Partnership NHS Trust

Staff to recognise the importance of considering known risk factors, including information provided by relatives/carers, when assessing risk

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

Recommendation 7.3.1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company

Comprehensive and ongoing review of all practitioner referrals to interventions

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

Recommendation 7.3.2

Addressed to Staffordshire and West Midlands Community Rehabilitation Company

Dip sampling of Responsible Office’s case management/assessment records to ensure correct recording of factors linked to risk of harm

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

Recommendation 7.3.3

Addressed to Staffordshire and West Midlands Community Rehabilitation Company

Quality assurance of the Responsible Officer’s enforcement action and decision making

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

Recommendation 7.4.1

Addressed to West Midlands Police

A feasibility study into the use of a referral portal app to be added to the mobile device thus enabling officers to make referrals directly from the scene. At present, front line officers have to return to a police station to do this which can be time consuming; completing a referral directly from the scene, affords vulnerable individuals greater service and is a better use time, relevant when policing faces increasing demands

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

Recommendation 7.5.2

Addressed to Whitefriars Housing Group

To increase housing practitioner’s awareness of indicators that a person may be a perpetrator of domestic abuse

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

Recommendation 8

Addressed to Coventry Safeguarding Adult Board

Coventry Safeguarding Adult Board seeks assurance from its agencies that they are delivering their responsibilities to carers under the Care Act 2014.

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

Recommendation 9

Addressed to Coventry Safeguarding Adult Board

Coventry Safeguarding Adult Board should ensure that the multi-agency dual diagnosis policy (which is out of date) is refreshed between CGL, Coventry and Warwickshire Partnership NHS Trust and other mental health providers and overseen by commissioners of those services.

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