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: Guildford Published: April 2023 Year of death: 2012 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 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

Recommendation 3.140(a)

Addressed to Surrey Police

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;

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

Recommendation 3.140(b)

Addressed to Surrey Police

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;

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

Recommendation 3.140(c)

Addressed to Surrey Police

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;

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

Recommendation 3.140(d)

Addressed to Surrey Police

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

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

Recommendation 3.140(e)

Addressed to Surrey Police

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.

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

Recommendation 3.141

Addressed to Home Office

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.

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

Recommendation 4.81(a)

Addressed to Hampshire Police

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;

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

Recommendation 4.81(b)

Addressed to Hampshire Police

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;

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

Recommendation 4.81(c)

Addressed to Hampshire Police

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;

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

Recommendation 4.81(d)

Addressed to Hampshire Police

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.

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

Recommendation 5.47(a)

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;

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

Recommendation 5.47(b)

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;

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

Recommendation 5.47(c)

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;

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

Recommendation 5.47(d)

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

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

Recommendation 5.47(e)

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.

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