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: July 2023 Year of death: 2018 Extracted: 11 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 a lack of trauma-informed practice, insufficient understanding of coercive control and its impact on victims with complex needs (EUPD, substance misuse), and missed opportunities for effective multi-agency collaboration and information sharing among agencies involved with the victim.

Home Office classifications

49 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 - mental ill health
  • Victim - depression
  • Victim - psychosis
  • Victim - self harm
  • Victim - suicidal thoughts
  • 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 - under 18 shared parental responsibility (between victims)
  • 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 - alcohol misuse
  • 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 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 housing services as a domestic abuse perpetrator
  • Perpetrator - known to school as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • 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 - school recommendations
  • DHR process - community safety partnership 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

11 recommendations pulled from the report · 5 matched to organisations in the index

Recommendation 1

Addressed to Kent Community Safety Partnership

The panel support recommendations emerging from other Kent Reviews which pertain to the evaluation of MARAC purpose and processes.

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

Recommendation 2

Addressed to Kent CSP

Development of a secure professionals’ virtual networking “Domestic Abuse Hub” within the Kent and Medway Domestic Abuse Website – to aid sharing of knowledge and referral pathways.

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

Recommendation 4

Addressed to KMSAB | KCC Learning and Development

Domestic abuse training to include the effects of coercive control on victims.

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

Recommendation 5

Addressed to KCC Public Health

A multi-agency learning event focusing on trauma informed practice, which raises awareness about responding to victims in a trauma informed way.

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

Recommendation 6

Addressed to KCC Suicide prevention team

Suicide prevention team to link in with (AAFDA) to join the conversation regarding unexplained deaths.

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

Recommendation 7

Addressed to Kent Housing Group

Social landlords to include a section in their mutual exchange forms addressing the reason for a mutual exchange – if this reason is due to domestic abuse landlords should follow their safeguarding procedures.

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

Recommendation 8

Addressed to Home Office

Investigate the possibility of a central repository for unexplained deaths linked to domestic abuse.

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

Recommendation 9

Addressed to Kent Police | Education | K&M ICB | KMPT | Council A | Council B | KCC ICS | CENTRA | Rising Sun

All agencies and commissioned services, to adopt trauma informed approaches and/or discussions within their staff supervision.

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

Recommendation 10

Addressed to Kent Police | Education | K&M ICB | KMPT | Council A | Council B | KCC ICS | CENTRA | Rising Sun

All agencies and commissioned services to have provision for a trauma informed training offer, which is accessible to all staff, and includes practices for their specific client group.

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

Recommendation 11

Addressed to Kent Police | Education | K&M ICB | KMPT | Council A | Council B | KCC ICS | CENTRA | Rising Sun

For agencies to have a lead person/or team, with knowledge of trauma informed practices.

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