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

Reigate and Banstead review

CSP: Reigate and Banstead Published: June 2023 Year of death: 2017 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 report identifies systemic failures in understanding coercive control and its impact on the victim, leading to missed safeguarding opportunities and inadequate support. Challenges in inter-agency information sharing and assessment processes further exacerbated the victim's vulnerability, particularly after the removal of her children.

Home Office classifications

37 tags

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

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • 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 school as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - sexual abuse
  • 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 - housing services 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 - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

13 recommendations pulled from the report · 7 matched to organisations in the index

Recommendation P-Recommendation 1(2

Addressed to Police

It is recommended that all police officers and police staff involved in the response to / investigation of incidents of domestic abuse ensure that accounts are obtained from the children involved/witnessing incidents with the appropriate expert advice and assistance.

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

Recommendation P-Recommendation 2(3

Addressed to Police

It is recommended that once incidents of DA have been referred to the Safeguarding Investigation Unit, an experienced investigator reviews the historical as well as current Police involvement with the individuals. This will help inform investigative and risk management strategies.

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

Recommendation P-Recommendation 3(4

Addressed to Police

It is recommended that where possible, incidents that are linked (same individuals, same domestic situation) are allocated to one investigating OIC. This will ensure single oversight of all reported incidents and help inform risk management strategies.

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

Recommendation Recommendation Eight

Addressed to ASC MASH | Children C-SPA

SSAB and SSCP to produce safeguarding referral guidance (adult and children) for organisations whose sole purpose is not safeguarding e.g. housing associations, drug and alcohol services, and to raise awareness of its availability.

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

Recommendation Recommendation Five

Addressed to ASC

ASC professionals to ensure (through Safeguarding Training and supervision) that the importance of timeliness in decision making is emphasised following receipt of a safeguarding enquiry referral.

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

Recommendation Recommendation Nine

Addressed to RBBC CSP

RBBC CSP to highlight the need for the Home Office to consider updating the Multi Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (2016 to include specific guidance where a person may have taken their own life.

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

Recommendation Recommendation One

Addressed to Police | ASC | CSC

Professionals must understand the increased risk when children are removed, especially when a parent is experiencing domestic abuse, has other risks and has increased vulnerability. Support for the parent should be provided both before the children are removed and afterwards. Individual agencies to ensure their staff are trained understand and support the parent, including the management of risk. This will be scrutinised by the SSAB and SSCP, giving assurance to the SAB / SCP that the agencies have implemented this training.

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

Recommendation Recommendation Seven

Addressed to Surrey Domestic Abuse Management Board (DAMB)

The MARAC process to be reviewed to ensure that information regarding relevant risks for a service user is passed safely and promptly to any involved service, including Primary Care e.g. GPs. Thia was also a recommendation in the Coroner’s report from the Inquest October 20.

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

Recommendation Recommendation Three

Addressed to SCSA | ASC | SSCP | SSAB

The Children Service Academy (SCSA), SSCP and SSAB will ensure that staff working with vulnerable adults, children and families have an in depth understanding through DA training including coercive controlling behaviour, the trauma impact of CCB, the increased risks including stalking, grooming of family members and professionals, retaliatory violence / resistance and an understanding of the links between substance abuse, mental health issues and domestic abuse. Through training, those professionals working in adult social care must have the tools to understand the needs of a victim suffering from domestic abuse, substance abuse and mental health issues.

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

Recommendation Recommendation Two

Addressed to SCSA | SSCP | SSAB

The Surrey Children Services Academy (SCSA), SSCP and SSAB will develop a training programme and guidance information on Professional Curiosity which will be available to all agencies including the charity, community and faith sectors. Agencies to review improved understanding of professional curiosity in supervision.

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