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

Norfolk review

CSP: Norfolk Published: April 2023 Year of death: 2017 Extracted: 31 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 identifies systemic failures across multiple agencies to protect the victim from a serial domestic abuser, including inadequate information sharing, underestimation of risk, and challenges in victim engagement, despite various safeguarding processes being in place.

Home Office classifications

45 tags

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

  • Victim - alcohol misuse
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - under 18 shared parental responsibility (between victims)
  • Children - living with victim (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • 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 social services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service 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 friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended perpetrator programme
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing 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

31 recommendations pulled from the report · 26 matched to organisations in the index

Recommendation 1

Addressed to Norfolk County Community Safety Partnership

It is recommended that, alongside the awareness raising campaigns undertaken in Norfolk, there are two specific campaigns recommended. The first targeted at young people to stress the message about healthy relationships and the second at hairdressers, beauticians etc. as potentially confidants of victims.

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

Recommendation 2

Addressed to Norfolk Constabulary

It is recommended that the publicity within Norfolk surrounding the DVDS Right to Ask scheme is reviewed, with a view to ongoing and targeting awareness raising campaigns. Consideration should be given to adopting, and publishing on the police website, the explanatory leaflet used by a number of forces.

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

Recommendation 3

Addressed to Norfolk Constabulary

It is recommended that when a Clare’s Law disclosure is pending, the police system Athena, should be updated so that any officer who goes into the record will see that there is an outstanding disclosure and can contact the specialist officers in the case.

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

Recommendation 4

Addressed to Leeway Domestic Abuse and Violence Services | Norfolk Constabulary

It is recommended that the impact of this post is evaluated in order that its value can be clearly seen.

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

Recommendation 5

Addressed to Home Office

It is recommended that evaluation of Clare’s Law is commissioned to assess its use and effectiveness in protecting victims

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

Recommendation 6

Addressed to Norfolk Constabulary

It is recommended that, where a person is reluctant to hear a disclosure, that it is referred back to the DVDS panel for consideration to be given to making the disclosure to a family member who may be in a position to offer some protection to the victim, subject to the points made above.

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

Recommendation 7

Addressed to Norfolk Constabulary

It is recommended that Norfolk Police reviews the way in which intelligence and information about the relationships of known repeat perpetrators is analysed and acted upon. It is further recommended that, as a matter of course, when intelligence of information is received about a known perpetrator being in another relationship an application under the DVDS is always and automatically made.

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

Recommendation 8

Addressed to Crown Prosecution Service (East of England)

It is recommended that the East of England Crown Prosecution Service review their practices for achieving evidence led prosecution without victim complainant (victimless prosecutions)

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

Recommendation 9

Addressed to Ministry of Justice

It is recommended that the Ministry of Justice review the adequacy of staffing in the National Probation Service to ensure realistic caseloads, so that there is effective monitoring of high risk offenders and public protection is not compromised

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

Recommendation 10

Addressed to National Probation Service

The National Probation Service has identified a number of service specific recommendations which this review recommends are undertaken: • To plan and implement effective measures to reduce caseloads and workload pressure on staff working at the relevant office • To widen and improve the recruitment campaign/package to encourage new applicants and experienced probation staff to relocate to the relevant office • To clarify the boundaries of all local measures introduced to reduce offender manager workloads with high risk offenders in the community

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

Recommendation 11

Addressed to NHS Norfolk and Waveney ICB

It is recommended that the existing programme of domestic abuse awareness raising across all GP practices in Norfolk is stepped up for adult safeguarding, to raise professional curiosity and knowledge of referral routes, signposting to specialist support agencies and triggers for and signs of abuse.

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

Recommendation 12

Addressed to NHS Norfolk and Waveney ICB

It is recommended that the pack provided to locum GPs by a practice includes information on how they can make sure patients ‘of concern’ are followed up. For example, where to direct a ‘patient task’ to make sure a follow up in the case of a DNA (Did Not Attend)

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

Recommendation 13

Addressed to NHS Norfolk and Waveney ICB

It is recommended that DNA (Did Not Attend) processes in GP surgeries are reviewed to ensure their effectiveness for safeguarding purposes

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

Recommendation 14

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that A&E staff are trained in domestic abuse, including how to ask the abuse question and how to complete the DASH form

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

Recommendation 15

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that consideration is given to a process that will allow A&E staff to check previous attendances for those attending with assault injuries. This will assist in a more holistic view of the patient presenting at A&E.

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

Recommendation 16

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that a ‘safeguarding’ box is added to Symphony as a mandatory reporting field. This should include if there are any safeguarding concerns and identify whether the concerns relate to a child, adult or domestic abuse

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

Recommendation 17

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that A&E staff are identified to train as Domestic Abuse Champions

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

Recommendation 18

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that domestic abuse information is displayed in public areas in the hospital, specifically toilets which should have contact details for charities and support services

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

Recommendation 19

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that, as suggested by a consultant in the Maxillo-Facial surgery department, a specific session on domestic abuse is included in the induction programme for all junior doctors joining the department

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

Recommendation 20

Addressed to Norfolk and Norwich University Hospital NHS Foundation Trust

It is recommended that the Hospital Trust considers Domestic Abuse Awareness becoming a mandatory training requirement for patient facing staff, acknowledging the pressures that exist for different mandatory training

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

Recommendation 21

Addressed to Norfolk County Council, Children’s Social Care

It is recommended that non-abusive, absent parents are informed of any concerns and involved in any assessments that are undertaken

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

Recommendation 22

Addressed to Norfolk County Council, Children’s Social Care

That children’s services review their process for sending out letters such as those sent to April to ensure that they are all case specific and written in light of the information available

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

Recommendation 23

Addressed to Norfolk County Council, Children’s Social Care

That children’s social care holds a series of workshops and communications is implemented to share the learning identified

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

Recommendation 24

Addressed to Norfolk County Council, Children’s Social Care

That procedures in the children’s social care department are reviewed to ensure the learning is captured in future practice

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

Recommendation 25

Addressed to Norfolk County Council, Children’s Social Care

That a specific learning event is held for those in the children’s social care who were directly involved in the case

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

Recommendation 26

Addressed to Circle 33 Housing Trust Ltd

It is recommended that customer services and repairs staff/contractors are reminded of Circle 33’s Safeguarding and Domestic Abuse policies and ensure that requests for repair or concerns raised by third parties, linked to actual or potential domestic abuse, are also recorded as a Safeguarding Alert and/or ASB case and passed to the Neighbourhood Team for further action

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

Recommendation 27

Addressed to Circle 33 Housing Trust Ltd

That Neighbourhood Officers at Circle 33 are reminded of the Domestic Abuse and ASB policies and their relevance to this case

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

Recommendation 28

Addressed to Clarion Housing Group

That each Neighbourhood Team in the Circle Group acquires equipment to provide additional security and reassurance to victims of domestic abuse e.g. door braces and alarms

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

Recommendation 29

Addressed to Clarion Housing Group

That the Clarion Group (Circle 33) considers a Community Safety Strategy which prioritises domestic abuse and identifies improvements to the current offer to its customers

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

Recommendation 30

Addressed to Norfolk County Community Safety Partnership | Home Office | Ministry of Justice

It is recommended that consideration is given to how the needs of the whole family can be managed effectively across the processes of MARAC (focusing on the victim), MAPPA (focusing on the offender) and safeguarding (focusing on the children involved)

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

Recommendation 31

Addressed to Ministry of Justice | Sentencing Council

That for serial and/or repeat perpetrators, where there is evidence regarding violent or serious harmful offending, this should automatically be considered as an aggravating factor and longer-term prison sentences should follow with mandatory rehabilitation courses whilst in prison.

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