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

Dorset review

CSP: Dorset Published: June 2023 Year of death: 2016 Extracted: 24 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 identified inconsistent risk assessment, particularly regarding perpetrator suicide threats and stalking, and inadequate information sharing between agencies. Failures in police response to the victim's calls and breaches of bail conditions, alongside insufficient victim support like not providing a replacement mobile phone, were also key concerns.

Home Office classifications

47 tags

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

  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • 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 social services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by mental health services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health 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
  • DHR process - awareness raising recommendation themes

Extracted recommendations

24 recommendations pulled from the report · 17 matched to organisations in the index

Recommendation 1

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership make use of this review as a case study to inform single and multi-agency training with a particular emphasis on understanding factors which increase the risk of homicide including threats of suicide by the perpetrator and attempts by the victim to end the relationship and the presence of stalking.

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

Recommendation 2

Addressed to Dorset Community Safety Partnership | NHS England | Dorset CCG | Dorset HealthCare NHS Trust

That Dorset Community Safety Partnership shares this DHR report with NHS England and Dorset CCG as commissioners and Dorset HealthCare NHS Trust as providers of the custody nurse service (formally known as the Criminal Justice and Liaison Service) so that they can consider the learning from this case in the further development of that service.

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

Recommendation 3

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership obtain assurance that the Public Protection Notice (PPN) process enables a broader assessment to be carried out which includes the identification of any care and support needs the person may have.

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

Recommendation 4

Addressed to Dorset Community Safety Partnership | Dorset Police

That Dorset Community Safety Partnership obtains assurance that Dorset police make use of intelligence about a perpetrator’s previous behaviour in assessing the risk that perpetrator may present to a current victim.

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

Recommendation 5

Addressed to Dorset Community Safety Partnership | Dorset Police

That Dorset Community Safety Partnership obtain assurance from Dorset Police that they reassess risk to the victim at point at which a suspected domestic abuse perpetrator is granted bail.

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

Recommendation 6

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership works with other relevant partnership boards to agree a standard process for sharing information about risk through the SCARF (now PPN) process.

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

Recommendation 7

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership obtains assurance from partner agencies that they have systems in place to assure themselves that their staff comply with domestic abuse policies.

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

Recommendation 8

Addressed to Dorset Community Safety Partnership | Dorset Police

That the Dorset Community Safety Partnership seeks assurance from Dorset Police that the Niche system enables the police to effectively flag cases involving victims of domestic abuse.

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

Recommendation 9

Addressed to Dorset Community Safety Partnership | Dorset Police

That Dorset Community Safety Partnership obtain assurance from Dorset Police that they have fully complied with the IPCC recommendation that victims of domestic abuse are not left without an ability to make emergency calls.

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

Recommendation 10

Addressed to Dorset Community Safety Partnership | Dorset Police

That Dorset Community Safety Partnership obtain assurance from Dorset police that victims of domestic abuse are always promptly provided with information about alleged perpetrator bail conditions.

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

Recommendation 11

Addressed to Dorset Community Safety Partnership | Dorset Police

That Dorset Community Safety Partnership obtain assurance from Dorset Police that any breach of pre-charge bail conditions by suspected perpetrators of domestic abuse will always be always dealt with effectively in order to safeguard victims.

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

Recommendation 12

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership obtains assurance from all partner agencies that they fully incorporate a whole family approach to their domestic abuse policies.

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

Recommendation 13

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership emphasises the responsibility of professionals for addressing domestic abuse concerns when the learning from this case is disseminated.

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

Recommendation 14

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership assess the adequacy of the support available to adults, young people and children affected by a domestic homicide of a family member or friend and raise any concerns with relevant agencies.

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

Recommendation DCCG1

Addressed to NHS Dorset Clinical Commissioning Group

To continue to raise awareness of domestic abuse in primary care as per the Royal College of General Practitioners Guidance for General Practices- Responding to domestic abuse.

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

Recommendation DHC1

Addressed to Dorset HealthCare University NHS Foundation Trust

To improve the Community Mental Health Team (CMHT) awareness of the support and advice available from the Safeguarding Adults team.

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

Recommendation DHC2

Addressed to Dorset HealthCare University NHS Foundation Trust

Strengthen the record keeping practices to ensure all notes are validated in a timely fashion and safeguarding discussions are appropriately recorded.

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

Recommendation DHC3

Addressed to Dorset HealthCare University NHS Foundation Trust

Criminal Justice Liaison and Diversion Service (CJLDS) to identify and record incident numbers to promote information sharing with the police.

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

Recommendation DHC4

Addressed to Dorset HealthCare University NHS Foundation Trust

To explore the possibility of providing e-learning on Domestic Abuse for all staff members.

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

Recommendation DHC5

Addressed to Dorset HealthCare University NHS Foundation Trust

Safeguarding Children’s level 3 training to be undertaken by all CMHT staff.

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

Recommendation DHC6

Addressed to Dorset HealthCare University NHS Foundation Trust

CJLDS to review screening of vulnerable people associated to the patient on initial assessment and record discussion held with the police.

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

Recommendation DHC7

Addressed to Dorset HealthCare University NHS Foundation Trust

CJLDS to review and screen court lists for victims of crime and ascertain whether they are open to DHC services.

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

Recommendation DHC8

Addressed to Dorset HealthCare University NHS Foundation Trust

To improve the CMHT awareness of the support and advice available from the Trauma Evaluation and Response Team (TEaR)

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

Recommendation DP5

Addressed to Dorset Police

Dorset Police to develop a flagging/review process for domestic abuse incidents featuring this threat which will prompt a review of the threat.

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