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: SomersetPublished: August 2023Year of death: 2020Extracted: 10 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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 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.
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.”
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.
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.
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.
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
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.
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.