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

Somerset review

CSP: Somerset Published: August 2023 Year of death: 2020 Extracted: 10 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 identifies limited agency contact, unrecognised coercive control, and missed opportunities for professional curiosity regarding relationship difficulties and mental health. Concerns include inconsistencies in firearms licensing processes, inadequate information sharing between agencies, and the impact of rurality on isolation and access to support services.

Home Office classifications

28 tags

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

  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - died by suicide
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • 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
  • DHR process - other recommendation themes

Extracted recommendations

10 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

Addressed to Avon and Somerset Police

Avon and Somerset Police implement their own recommendation relating to the standard operating procedure for the firearms seizure. In so doing they should liaise with the appropriate policing and justice bodies nationally to ensure that the lessons learned from this review contribute to national practice.

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

Recommendation 2

Addressed to Avon and Somerset Police

Avon and Somerset Police should put in place a process to ensure that the NICHE system is used to record and flag individuals who have a firearms licence. The DHR panel notes that this is work in progress but recommend it is completed swiftly. Again the police should liaise with the appropriate policing and justice bodies national to ensure that the lessons learned from this review contribute to national practice.

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

Recommendation 3

Addressed to Safer Somerset Partnership | Avon and Somerset Police | Clinical Commissioning Group

The Safer Somerset Partnership, in conjunction with the Avon and Somerset Police and the Clinical Commissioning Group should liaise with NHS England/Improvement, the Department for Health and Social Care and the Royal College of GPs to consider what national guidance might be put in place to ensure a more consistent approach to GPs responses to police enquiries about an individual’s fitness to hold a firearms licence. This should align with the Governments revisions to UK gun laws announced in October 2021. The government has stated that “No one will be given a firearms licence unless the police have reviewed information from a registered doctor setting out whether or not the applicant has any relevant medical history – including mental health, neurological conditions or substance abuse.”

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

Recommendation 4

Addressed to Somerset NHS Foundation Trust

Somerset NHS Foundation Trust should clarify with organisational partners when their ASCC would usually notify a GP when they have conducted an assessment of an individual. This might only be when a person is at risk of harm to themselves or others, but at present there is no clarity about this. This is an area of practice that needs to be improved.

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

Recommendation 5

Addressed to Safer Somerset Partnership

The Safer Somerset Partnership should undertake work to establish what particular domestic abuse issues might be affected by the rurality of part of their area. They should then use this information to inform their public awareness campaigns and their local training offer.

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

Recommendation IMR_Police_1

Addressed to Avon and Somerset Police

Avon and Somerset Police should review the standard operating procedure/procedural guidance for firearms seizure and make safe processes to ensure that each part of the process is clearly and fully documented on Niche and recorded with BWV.

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

Recommendation IMR_PrimaryCare_1

Addressed to GP Practice

GP to consider more formal follow up of patients who may be presenting with depression and consider asking more in depth questions about domestic abuse in light of “stress” in the relationship

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

Recommendation IMR_PrimaryCare_2

Addressed to GP Practice

It may be helpful to provide further guidance to GPs about what information to disclose to the police regarding shotgun licencing. Consideration should be given as to whether it is appropriate to delegate this work to GP registrars depending on their level of training in this area.

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

Recommendation IMR_PrimaryCare_3

Addressed to GP Practice

Given that his (Jeremy’s) mood was sufficiently low to warrant medication it would have been appropriate to inform the police in respect of his shotgun licence as per their guidance. The mention of “relationship difficulties” could have prompted a discussion about domestic abuse.

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