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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

10 recommendations pulled from the report

#	Recommendation	Addressed to
1	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.	Avon and Somerset Police
2	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.	Avon and Somerset Police
3	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.”	Safer Somerset Partnership \| Avon and Somerset Police \| Clinical Commissioning Group
4	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.	Somerset NHS Foundation Trust
5	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.	Safer Somerset Partnership
IMR_Police_1	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.	Avon and Somerset Police
IMR_PrimaryCare_1	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	GP Practice
IMR_PrimaryCare_2	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.	GP Practice
IMR_PrimaryCare_3	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.	GP Practice
IMR_PrimaryCare_4	Sleep issues should be explored in greater detail to check for any underlying causes including mental health issues and domestic abuse.	GP Practice
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗