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
Exeter review
CSP: ExeterPublished: June 2023Year of death: 2018Extracted: 9 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identifies systemic failures in inter-agency collaboration, risk assessment, and the application of domestic abuse frameworks. Despite both the victim and the perpetrator having complex needs and agency support, the risk of homicide was not effectively mitigated, partly due to their disengagement.
Home Office classifications
47 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - alcohol misuse
Victim - substance misuse
Victim - housing issues
Victim - mental ill health
Victim - depression
Victim - psychosis
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Victim - immigration involvement
Children - removed into care
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - housing issues
Perpetrator - mental ill health
Perpetrator - neurodiverse condition diagnosis
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - psychosis
Perpetrator - serious or life limiting illness
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to mental health services as a domestic abuse perpetrator
Perpetrator - known to housing services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - managed by mappa
Perpetrator - supervised by mental health services
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family received draft report
DHR process - police recommendations
DHR process - health services recommendations
DHR process - housing services recommendations
DHR process - technology systems recommendation themes
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
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
9 recommendations pulled from the report · 9 matched to organisations in the index
Addressed to
Safer Devon Partnership | Devon Partnership NHS Trust | Devon County Council | Devon & Cornwall Police | Exeter City Council
Improve arrangements for the co-ordination across agencies of services for clients with complex needs, including those who, overall, have a high level of need or risk but may not meet individual service thresholds. (#355-#359, #361)
Addressed to
Devon Partnership NHS Trust | Together Drug & Alcohol Services
Improve communication and joint working arrangements between Devon Partnership NHS Trust and local drug and alcohol treatment providers for mental health patients with substance misuse problems. (#360)
Addressed to
Devon County Council | Devon Partnership NHS Trust
Review the nature and level of public agency commissioning of accommodation and associated support services for vulnerable adults in Devon to ensure appropriate facilities are available to meet needs safely at a choice of locations. (#364-#365)
Improve the handling of adult safeguarding referrals where there are difficulties obtaining consent to refer or where the referrer has serious concerns about the response. (#362-#363)
Addressed to
Devon Partnership NHS Trust | Devon County Council | Exeter City Council | Devon & Cornwall Police | Caraston Hall | Hollywell Housing Trust | Home Group | Rethink Mental Illness | Together Drug & Alcohol Services
Ensure that staff working directly with clients in all agencies providing or commissioning care or support for vulnerable people receive training, appropriate to their role and in line with the 2018 Inter Collegiate Guidance, on adult safeguarding including domestic and sexual violence and abuse. (#367-#369)
In managing structural and personnel changes, seek minimal effect on continuity of care for mental health clients, including liaison with other agencies involved with them. (#370)
Review the way in which Devon and Cornwall Police record, investigate and present evidence to the Crown Prosecution Service regarding assaults involving strangulation. (#348-#349)
In evaluating the Devon Partnership NHS Trust pilot of a community forensic team, take account of the views of partner agencies on how the team collaborates with their services. (#371-#372)
Addressed to
Devon Partnership NHS Trust | Devon County Council | Exeter City Council | Devon & Cornwall Police | Caraston Hall | Hollywell Housing Trust | Home Group | Rethink Mental Illness | Together Drug & Alcohol Services
Ensure there are arrangements by which staff at any level in agencies working with individuals who pose risks are alert to the potential use of multi-agency frameworks for managing them and can access information and advice on their use. (#368)