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: KentPublished: June 2023Year of death: 2011Extracted: 8 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report highlights systemic failures in information sharing and multi-agency risk assessment, particularly concerning domestic abuse, mental health, and substance misuse. Agencies often lacked a full family picture, leading to missed opportunities for intervention and questionable child protection decisions.
Home Office classifications
48 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 - adjustment disorder
Victim - depression
Victim - psychosis
Victim - self harm
Victim - suicidal thoughts
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Victim - case heard at marac before homicide
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - under 18 shared parental responsibility (between perpetrators)
Children - subject to child protection or domestic abuse prior to homicide
Children - removed into care
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - anxiety
Perpetrator - depression
Perpetrator - psychosis
Perpetrator - suicidal thoughts
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 health 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 - attended drug and alcohol services
Aggravating factors - separation
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - housing services recommendations
DHR process - community safety partnership 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
Extracted recommendations
8 recommendations pulled from the report · 6 matched to organisations in the index
KCA and Greenwich Housing Service to review their policy/method of retention of records to ensure they are able to fully participate in future DHRs and other reviews.
Addressed to
Kent and Medway Community Safety Partnerships
To review the process for obtaining IMRs and information from agencies and develop an escalation process when an agency from outside Kent and Medway fails to participate in a DHR.
The Ministry of Justice to consider the creation of a good practice guide, including a check list for Probation Trusts for all HDC Assessments to include domestic abuse and child protection.
The Home Office to consider issuing guidance to police forces regarding transfer of information between police forces when victims and offenders involved in domestic abuse move.
Addressed to
Home Office | NHS National Commissioning Board | Clinical Commissioning Groups
The Home Office to work with the NHS National Commissioning Board and Clinical Commissioning Groups regarding publication of guidance for the commissioning and writing of IMRs from health providers, in particular developing a protocol for obtaining information from other areas.
Addressed to
Home Office | NHS National Commissioning Board | Clinical Commissioning Groups
The Home Office, the NHS National Commissioning Board and Clinical Commissioning Groups to develop a training programme for IMR authors from the health economy.
Home Office to issue guidance to Independent Chairs and Authors regarding involvement in a DHR of persons convicted of domestic homicide who have been victims of domestic abuse.
The Home Office consider developing guidance regarding the identification of a lead professional in cases of domestic abuse where there are other significant issues such as mental ill-health, alcohol or drug misuse especially when one or more of those issues affects both victim and offender. The process could be similar to the one that already exists in the Care Programme Approach for the mentally ill or in the Child Assessment Framework.