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

Elmbridge review

CSP: Elmbridge Published: April 2023 Year of death: 2015 Extracted: 14 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 inter-agency communication and risk assessment, particularly regarding police response to the victim's initial domestic abuse disclosure, health services' engagement with the review, and the identification of child safeguarding risks. Missed opportunities for intervention and information sharing were noted.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
1	CSP analyse their existing response to domestic abuse and seek to develop a more complete and enhanced approach to this issue through the mechanism of a Coordinated Community Response to domestic abuse.	Elmbridge Community Safety Partnership
10	Integrate the Spiralling toolkit into PSHE (personal, social, health and economic) education.	Independent Secondary School
11	Request the Joint Commissioning Board to commission the IRIS programme within the area.	NHS General Practice in the local Borough
12	Debt advisory services to develop a system where those individuals with County Court Judgements (or similar) relating to debt are provided with information about domestic abuse support services and support to assist in the resolution of the case.	Debt advisory services
13	HM Government to develop the statutory guidance for DHRs to specifically include private medical care and oblige such organisations to participate in the DHR process.	HM Government
14	NHS England to respond to the gaps that emerge between private and national health care providers which may threaten the safety of adult and child survivors of domestic abuse.	NHS England
2	Develop and trial individual and community interventions using the concept of co-production, to enhance the borough’s response to victims of domestic abuse.	Elmbridge Community Safety Partnership
3	Ensure that the agreed intention of providing Police information about vulnerable people to relevant agencies, including schools is promulgated with urgency.	Elmbridge Community Safety Partnership
4	Undertake a cost-benefit analysis to establish the viability of implementing an additional referral pathway between police and Domestic Abuse Outreach services in cases where the DASH risk assessment system has not been successfully completed.	Elmbridge Community Safety Partnership
5	Deliver training for Contact Centre staff to ensure a sound grasp of the dynamics of domestic violence and to equip them with the skills and information necessary to respond appropriately to victims of domestic abuse.	Surrey Police
6	Develop for all frontline staff (including staff in contact centres and control rooms) clear referral pathways to specialist domestic abuse support services and related agencies.	Surrey Police
7	Provide enhanced risk identification and awareness training to ensure Public Protection Unit supervisors have adequately informed oversight of domestic abuse cases.	Surrey Police
8	Surrey Police to use this DHR process and the development from the recommendations to audit its policies and practice to ensure the developments are embedded in practice (within 6 months of publication of the report).	Surrey Police
9	Integrate domestic abuse awareness into safeguarding training for all staff (and ensure those staff already trained in safeguarding receive this training).	Independent Secondary School
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗