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: May 2023 Year of death: 2016 Extracted: 22 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 inconsistent domestic abuse classification by police, failures in inter-agency information sharing and safeguarding alerts, and issues with MARAC processes. It also highlights limited intervention for the victim's alcohol problems and a service gap for LGBT domestic abuse victims.

Home Office classifications

32 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - psychosis
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • 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 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 - supervised by probation services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • 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

Extracted recommendations

22 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1.

Addressed to Kent Police

In cases that have been referred to MARAC, where there is information that the victim is too frightened to report domestic abuse to them, Kent Police must actively seek to engage with the victim.

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

Recommendation 2.

Addressed to Kent Police

Kent Police must ensure that Public Protection Unit supervisors have considered all the available information before making decisions about MARAC actions and that they record their rationale.

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

Recommendation 3.

Addressed to Kent Police

Kent Police must ensure that officers working in Public Protection Units have an in depth understanding of how best to provide support to victims of domestic abuse.

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

Recommendation 4.

Addressed to Kent Police

Kent Police must ensure that an understanding of the MARAC repeat referral criterion forms part of their domestic abuse training programme.

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

Recommendation 5.

Addressed to Kent Police

In its domestic abuse training programme, Kent Police must highlight that once two people have had an intimate relationship, it will be domestic abuse if one inflicts upon the other, behaviour that is mentioned in the definition of domestic abuse, regardless of the passage of time.

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

Recommendation 6.

Addressed to Kent Police

Kent Police must ensure that police officers and police staff who may have contact with vulnerable people understand when safeguarding alerts should be made to Kent County Council Adult Services (KCCAS).

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

Recommendation 7.

Addressed to KCCAS

KCCAS must ensure that staff who might work on cases involving domestic abuse are aware of the criterion for the repeat referral of a case to the MARAC.

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

Recommendation 8.

Addressed to KCCAS

KCCAS must ensure that they have a robust system for communicating safeguarding information within their organisation and to other organisations.

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

Recommendation 9.

Addressed to CCGs in Kent and Medway

Clinical Commissioning Groups (CCG) should ensure that GPs are aware of the MARAC process, including the criterion for referring repeat cases.

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

Recommendation 10.

Addressed to NHS England

NHS England should ensure that the contractor responsible for storing archived GP records is aware of the requirement to provide the records in a timely manner when requested for a DHR.

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

Recommendation 11.

Addressed to CCGs in Kent and Medway

CCGs in Kent and Medway should provide guidance to GPs about providing records when requested as part of a DHR, taking account of Section 10 of the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews.

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

Recommendation 12.

Addressed to Town A Borough Council

Town A Borough Council must ensure that their Housing Area Managers are understand the provisions of the Kent and Medway MARAC Operating Protocol and Guidelines and how to make MARAC referrals.

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

Recommendation 13.

Addressed to Town A Borough Council

ABC should consider nominating an officer who will attend the MARAC in the absence of the Housing Options Officer.

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

Recommendation 14.

Addressed to KDAC

Kent Domestic Abuse Consortium (KDAC) should remind IDVAs when attempts to contact victims, whether successful or not, cannot be recorded contemporaneously on the database, full and accurate records of the time and content of calls should be made and added to the database at the earliest opportunity.

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

Recommendation 15.

Addressed to KDAC

KDAC members must agree a process that ensures the IDVA who has the greatest knowledge of a case attends the MARAC meeting when it is discussed.

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

Recommendation 16.

Addressed to KDAC

KDAC must ensure that before closing a case that was initially referred to a member organisation by another agency, the referring organisation should be asked if they have any further relevant information.

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

Recommendation 17.

Addressed to KMDASG

Kent and Medway Domestic Abuse Strategy Group (KMDASG) should consider publishing the Kent and Medway MARAC Operating Protocol and Guidelines online.

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

Recommendation 18.

Addressed to KMDASG

KMDASG should take the lead in encouraging appropriate agencies to become involved in chairing MARAC meetings.

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

Recommendation 19.

Addressed to KMDASG

KMDASG should agree a process that ensures minutes are taken at all MARAC meetings and include this in the Kent and Medway MARAC Operating Protocol and Guidelines.

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

Recommendation 20.

Addressed to KMDASG

KMDASG must establish a process that ensures all MARAC actions from the previous meeting have either been implemented or if not, the reasons why. A record must be kept of the results.

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

Recommendation 21.

Addressed to The Home Office

The Home Office should ensure that the definition of ‘personally connected’ in the Statutory Guidance for Section 76 of the Serious Crime Act 2015 is changed to ensure that all victims of domestic abuse are protected.

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

Recommendation 22.

Addressed to Kent CSP

The chair of the Kent Community Safety Partnership (CSP) should share this report with the chair of the Kent and Medway Safeguarding Adults Board.

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