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
Guildford review
CSP: GuildfordPublished: April 2023Year of death: 2012Extracted: 15 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified systemic failures across police forces and an NHS Trust in consistently applying domestic abuse policies, conducting risk assessments, safeguarding vulnerable adults, and sharing critical information. These shortcomings resulted in missed opportunities to intervene in the escalating violence experienced by the victim.
Home Office classifications
35 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - alcohol misuse
Victim - substance misuse
Victim - housing issues
Victim - physical disability
Victim - mental ill health
Victim - depression
Victim - self harm
Victim - suicidal thoughts
Victim - suicide attempts
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Children - removed into care
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to friends as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - attended drug and alcohol services
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - police recommendations
DHR process - health services 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
DHR process - other recommendation themes
Extracted recommendations
15 recommendations pulled from the report · 15 matched to organisations in the index
training on the DASH risk assessment process is undertaken by all Surrey Police staff new to frontline duties or to the Public Protection Investigation Unit Supervisor role;
all Public Protection Investigation Unit Supervisors have received the requisite DASH risk assessment process training and are able carry out effective risk assessments, including the identification of cases that should be referred to a MARAC;
all officers employed in the role of Public Protection Investigation Unit or Central Referral Unit Supervisor carrying out DASH risk assessments recognise that domestic incidents involving either partner as a victim within the previous 12 months would meet the repeat incident criteria for a MARAC referral;
Police Public Protection Investigation Units report all incidents of domestic abuse that take place in Surrey involving persons who do not normally reside in the county to their home area police force using the intelligence reporting system; and
the definition of vulnerable adults (adults at risk) used by Surrey Police in its policies and procedures is amended to use the definition set out in the Surrey Safeguarding Adults Multi‐Agency Procedures, Information and Guidance 2011 and that appropriate guidance and training be provided to all relevant staff.
That the Home Office be made aware of issues raised by this review in relation to the lack of sharing of information between relevant forces on incidents of domestic abuse and be requested to ensure that a system is established at a national level to address this matter.
restraining orders are recorded and flagged on its database to highlight the existence of all live court orders to officers and staff, including those from other police forces;
it is made explicit to all frontline officers and staff that the requirement to complete DASH risk assessments includes domestic incidents where the victim is unable or unwilling to respond to the risk assessment questionnaire, in which case the officer or staff member should make the assessment using professional judgement taking into account the circumstances of the incident and by using historical information from recording systems;
when police officers deal with incidents between partners that take place in a public place, these are recognised and treated as domestic incidents and the relevant domestic abuse policy is applied, including the completion of risk assessments and the taking of positive action;
when domestic incidents occur in the Hampshire Police area involving one or more parties who live in another police force area, the details of the incident, including any risk assessments, should be reported to that other force to enable them to understand the full extent of the risk, provide appropriate support to the victim and recognise repeat offending by the perpetrator.
Addressed to
Frimley Park Hospital NHS Foundation Trust
ensure that notifications to patients’ GPs following attendances at the Emergency Department detail all relevant information, including safeguarding considerations and instances of alleged domestic abuse;
Addressed to
Frimley Park Hospital NHS Foundation Trust
ensure that staff within the Emergency Department record details of advice given to patients on available services, such as drug and alcohol and domestic abuse support;
Addressed to
Frimley Park Hospital NHS Foundation Trust
review the Emergency Department’s guidance to staff on safeguarding vulnerable adults to ensure that it is consistent with Trust‐wide policies and procedures;
Addressed to
Frimley Park Hospital NHS Foundation Trust
ensure that nursing and medical staff in the Emergency Department receive training on the safeguarding procedure for vulnerable adults, including the requirement to refer domestic abuse cases to the Trust’s Lead for Vulnerable Adults; and
Addressed to
Frimley Park Hospital NHS Foundation Trust
ensure that frequent attendees at the Emergency Department are identified as being at high risk to enable appropriate safeguarding procedures to be considered and implemented.