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: KentPublished: April 2023Year of death: 2011Extracted: 5 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 significant failures in mental health service provision, including inadequate risk assessment, care planning, and Mental Health Act assessments. There was poor multi-agency communication, insufficient recognition of domestic abuse and adult safeguarding risks, and a lack of support for vulnerable carers.
Home Office classifications
33 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - was a carer
Victim - carer for perpetrator
Victim - housing issues
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Children - present at homicide (including adult children)
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - mental ill health
Perpetrator - psychosis
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 health services as a domestic abuse perpetrator
Perpetrator - known to mental health 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
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 supported by expert specialist advocate
DHR process - family received draft report
DHR process - police recommendations
DHR process - health services recommendations
DHR process - community safety partnership recommendations
DHR process - technology systems recommendation themes
DHR process - policy recommendation themes
DHR process - multi agency working recommendation themes
Extracted recommendations
5 recommendations pulled from the report · 3 matched to organisations in the index
There should be an identified clear communication protocol outside of the Kent Police custody environment for police to refer and be able to seek advice regarding mental health issues in the community.
Addressed to
Kent Community Safety Partnership | Medway Community Safety Partnership
Consideration of the creation of a multi-agency information sharing and assessment process to identify and manage people with mental health issues that present a potential safety risk to the public. (Individuals outside of existing protocols such as MARAC, MAPPA etc).
Addressed to
Kent and Medway Community Safety Partnership
The issue of GPs providing reports as opposed to IMRs conducted by an independent GP requires consideration by the Kent and Medway Community Safety Partnership with a view to raising it with the Home Office to consider including GPs in the DHR process.