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: 9 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 found that agencies could not have reasonably foreseen the homicide. However, it identified systemic failures in policies and procedures, staff training, and information sharing regarding disclosures of historical child abuse and domestic abuse perpetration, as well as issues with medical record management and case handovers.

Home Office classifications

19 tags

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

  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • DHR process - family contributed to dhr
  • 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 - technology systems recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes

Extracted recommendations

9 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to Kent NHS Community Healthcare Trust

Staff should be aware of their roles and responsibilities in the implementation of domestic abuse policies and procedures, and of the resources available to assist them.

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

Recommendation 2

Addressed to Kent Police

Consideration should be given to recording the rape complaint made against the perpetrator in 2000 in accordance with the Home Office counting rules for crime and incidents and to investigating the circumstances of it. If the decision is to do neither or one of these actions, the rationale should be clearly recorded.

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

Recommendation 3

Addressed to NHS England

When GP surgeries change their IT systems they must ensure that the medical records of current and previous patients are transferred from the old system to the new or that the records on the old system are archived in a way that makes them readily available.

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

Recommendation 4

Addressed to NHS England | Sussex NHS Partnership Trust | Kent & Medway NHS Social Care Partnership Trust | Surrey & Sussex Probation Trust

Agencies must have victim focussed policies and procedures in place to deal with disclosures made by patients/clients that they are victims of historical child abuse, both in terms of their own agency response and how they share the information. Staff must be aware of the policies and procedures, and where necessary trained in their implementation.

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

Recommendation 5

Addressed to NHS England | Kent County Council Specialist Childrens Services

Agencies must have victim focussed policies and procedures in place to deal with disclosures made by patients/clients that they are perpetrators of domestic abuse, both in terms of their own agency response and how they share the information. Staff must be aware of the policies and procedures, and where necessary trained in their implementation.

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

Recommendation 6

Addressed to Kent & Medway NHS Social Care Partnership Trust

When it is known or suspected that a patient presenting with mental health issues has received previous treatment from another agency for mental health issues, the patient’s medical notes relevant to that treatment should be obtained.

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

Recommendation 7

Addressed to Surrey & Sussex Probation Trust | Kent Probation Trust

Staff in supervisory positions should be trained in and understand the responsibility they have for checking the work of their staff to ensure that it has been completed in accordance with policies and procedures.

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

Recommendation 8

Addressed to Kent County Council Specialist Childrens Services

When information is received that premises in which children are living are being used for drug dealing, this information should be shared with the police.

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

Recommendation 9

Addressed to Kent County Council Specialist Childrens Services

Where the responsibility for a case is transferred from one Social Worker to another, the author of the Transfer Summary must ensure that the details contained within it are accurate and complete, particularly those that directly impact on the safety of children and/or staff.

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