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: 2012Extracted: 13 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 failures in information collation and sharing across agencies, leading to inadequate risk assessments and missed opportunities for intervention. It highlighted insufficient police investigations despite the victim's reluctance, and mental health practitioners not fully exploring domestic abuse indicators, particularly concerning escalating risk and firearms.
Home Office classifications
31 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - substance misuse
Victim - mental ill health
Victim - anxiety
Victim - had been a victim of an abuser before
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - depression
Perpetrator - suicidal thoughts
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
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 received draft report
DHR process - police recommendations
DHR process - health services recommendations
DHR process - identification of risk recommendation themes
DHR process - training recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
Extracted recommendations
13 recommendations pulled from the report · 12 matched to organisations in the index
When police officers are dealing with reports of domestic abuse, all relevant information must be recorded on the crime or secondary incident report, which will assist in ensuring a proper risk assessment is made. In particular, relevant information from the Computer Assisted Dispatch (CAD) should also be included on the crime or secondary incident report.
When a person, other than the victim, makes an allegation of domestic abuse to the police, then officers must make contact with not only the victim, but also the individual making the allegation to develop the whole picture. Officers should be reminded of their responsibility to achieve a proper standard of investigation and to ensure that appropriate evidence is captured from key witnesses, paying particular attention to interviewing family and friends.
Police officers and staff should be reminded that, following a report of domestic abuse involving a member of Kent Police (either as a perpetrator or victim), the Professional Standards Department should be informed, usually via a locally based supervisor of the rank of inspector or above.
Kent Police policy to be amended to direct that officers taking reports of domestic abuse perpetrated by a serving police officer/staff, or retired police officer/staff, should consider referring the victim to an independent domestic violence adviser (IDVA) or domestic abuse support worker.
When an alleged perpetrator of domestic abuse is also the holder of a shotgun or firearms certificate, Kent Police should ensure that a risk assessment in relation to the possession of firearms by suspected perpetrators takes place, and, in such cases, consideration should be given to removal of any firearms as a matter of urgency.
The planned review by Kent Police of the police central referral unit (CRU) should consider the capacity of the unit to carry out effective assessments of crime and secondary incident reports of domestic abuse graded as ‘standard’ risk. The review should also consider whether the assessment of such cases should be the responsibility of divisional supervisors rather than the CRU.
When a person is detained under section 136 of the Mental Health Act resulting from circumstances which may directly or indirectly relate to domestic abuse, Kent Police should record the details on a secondary incident form.
Addressed to
Kent and Medway NHS and Social Care Partnership Trust (KMPT)
When KMPT staff receive information that could indicate that a patient is a possible perpetrator of domestic abuse, they should seek further specialist advice about the most appropriate action to take. Evidence of this consultation and decision making must be recorded.
Addressed to
Kent and Medway NHS and Social Care Partnership Trust (KMPT)
When KMPT frontline practitioners identify that a client may be a perpetrator of domestic abuse, they will ensure that this is clearly identified on the KMPT risk assessment. Concerns will be discussed within supervision and multi-disciplinary team meetings.
Addressed to
Kent and Medway NHS and Social Care Partnership Trust (KMPT)
Following detention and assessment under section 136 of the Mental Health Act, when any indication of domestic abuse is identified by completing KMPT’s risk assessment process, a detailed letter should be sent to the client’s GP advising follow up.
Domestic abuse training is to be provided for GP surgeries, including competencies for all staff. Once the core competencies have been identified, training will be rolled out to all surgery and primary health care staff.
Domestic abuse training is to be delivered to all Clinical Commissioning Group (CCG) Board members, including required assurances, governance arrangements and domestic homicide review responsibilities.
CCGs to expedite the appointment of a named GP for adult safeguarding; the postholder would complete individual management reports on GPs’ practice for domestic homicide reviews.