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: Kent Published: April 2023 Year of death: 2012 Extracted: 13 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 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

Recommendation 6.1

Addressed to Kent Police

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.

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

Recommendation 6.2

Addressed to Kent Police

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.

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

Recommendation 6.3

Addressed to Kent Police

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.

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

Recommendation 6.4

Addressed to Kent Police

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.

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

Recommendation 6.5

Addressed to Kent Police

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.

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

Recommendation 6.6

Addressed to Kent Police

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.

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

Recommendation 6.7

Addressed to Kent Police

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.

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

Recommendation 6.8

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.

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

Recommendation 6.9

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.

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

Recommendation 6.10

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.

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

Recommendation 6.11

Addressed to Clinical Commissioning Group (CCG)

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.

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

Recommendation 6.12

Addressed to Clinical Commissioning Group (CCG)

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.

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

Recommendation 6.13

Addressed to Clinical Commissioning Group (CCG)

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.

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