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

Welwyn Hatfield review

CSP: Welwyn Hatfield Published: August 2023 Year of death: 2017 Extracted: 40 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 systemic failures in recognising the victim as a repeat victim of domestic abuse by multiple perpetrators, leading to her suicide due to coercive control. Agencies demonstrated a lack of professional curiosity, inadequate risk assessment, and insufficient information sharing, resulting in missed opportunities for intervention and specialist support.

Home Office classifications

39 tags

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

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - mental ill health
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • 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 - case heard in court
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - post traumatic stress disorder (ptsd)
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • 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 - probation services recommendations
  • DHR process - housing services 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

40 recommendations pulled from the report · 28 matched to organisations in the index

Recommendation 1

Addressed to Home Office

An allocated lead at the Home Office is responsible for establishing a national fund to enable a package of therapeutic and advocacy support to be put in place for child survivors of Domestic Homicide and suicide linked to domestic abuse. The Home Office to report back to Hertfordshire County Council on this recommendation and its implementation.

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

Recommendation 1

Addressed to Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service

All Agencies involved with this review to report that they are now sharing information on a consistent basis with pathways and checks in place to ensure the right information is being shared. Agencies to confirm they are sharing historic as well as current information about domestic abuse.

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

Recommendation 2

Addressed to Home Office

That the Home Office issue guidance that repeat victims of multiple perpetrators are treated as a special category of domestic abuse victim/survivor with automatic escalation to MARAC; that the DASH risk assessment is amended to reflect this change with guidance and training in place.

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

Recommendation 2

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership to roll out an agreed community awareness and training programme over the next 12 months with the aim of increasing awareness amongst all communities of domestic abuse and the role organisations, family and friends can play in tackling and reporting domestic abuse.

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

Recommendation 3

Addressed to Home Office

National Tier 1 training to include the importance of developing the professional curiosity skills of students, using domestic abuse case studies and national guidance to assist in improving this skill. This recommendation is linked to issues arising following the lack of professional curiosity used which impacted on decision making and professional judgement in this case.

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

Recommendation 3

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership to publish, publicise, and maintain updated lists of organisations who can offer help and support to victims and survivors, ensuring these are available to communities across the County.

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

Recommendation 4

Addressed to Hertfordshire Constabulary | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Hertfordshire Children’s Services

Police, Health Services and Children’s Social Care increase their awareness of the role of the different third sector and specialist organisations in Hertfordshire, including therapeutic trauma services and ensure they refer their clients/patients/service users appropriately into these services.

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

Recommendation 5

Addressed to Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service | Hertfordshire Domestic Abuse Partnership

Statutory and voluntary sector agencies involved with this review to confirm that they include a trauma-informed approach to their work with victims/survivors and train and support their staff in this approach.

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

Recommendation 6

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership to develop a policy which recognises the particular vulnerability of repeat victims of multiple perpetrators and ensures they are treated as a special category with referral into MARAC and specialist outreach support to ensure they can engage with services.

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

Recommendation 7

Addressed to Hertfordshire Children’s Services | Hertfordshire Adult Care Services

Children’s and Adult Care Services to include in their safeguarding training an awareness of the link between domestic abuse, substance use, mental ill health and trauma and the services available for those impacted including counselling and therapeutic support.

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

Recommendation 7

Addressed to Hertfordshire Children’s Services | Spectrum CGL | IDVA teams

Children’s Services, CGL and the IDVA teams to work together to develop a joint understanding of alcohol dependency and domestic abuse which is reflected in policy, training, and support pathways.

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

Recommendation 8

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership ensures all agencies are aware of their changed responsibility under the Domestic Abuse Act 2021

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

Recommendation 9

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership considers establishing community-based support for domestic abuse perpetrators and that a report, outlining successes elsewhere and the cost of a programme, is presented to the CSP.

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

Recommendation 10

Addressed to Hertfordshire County Council | Hertfordshire Constabulary | Hertfordshire Children’s Services | East and North Hertfordshire NHS Trust | Hertfordshire Community NHS Trust | Clarion Housing | National Probation Service | Hertfordshire Domestic Abuse Partnership

Agencies involved in this review to check their policies, communications, training, and records to ensure they avoid victim blaming which prevents the professional from seeing the whole history of abuse.

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

Recommendation 11

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership facilitates training which includes learning about: a) Domestic abuse and suicide b) Attempted strangulation as an indicator of the escalation of domestic abuse with risk of homicide and suicide.

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

Recommendation 12

Addressed to Hertfordshire Domestic Abuse Partnership

Hertfordshire Domestic Abuse Partnership to review services across the County with a view to ensuring therapeutic support is available to all survivors of domestic abuse, including children.

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

Recommendation a

Addressed to Hertfordshire Constabulary

Schools are currently notified of domestic abuse incidents. This has not yet been extended to under-fives. This recommendation to be implemented alongside safeguarding reorganisation plans.

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

Recommendation a

Addressed to Hertfordshire Children’s Services

To share the reflections gained in this IMR with the workforce (by way of a learning bulletin) and in particular the impact of repeat victimisation from multiple partners.

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

Recommendation a

Addressed to East and North Hertfordshire NHS Trust

The need for a Trust-wide holistic and robust domestic abuse policy which examines the signs of domestic abuse, barriers to disclosure and gives clear guidance on safe and effective domestic abuse enquiry (including specific guidance on ‘asking the question’ and question framing).

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

Recommendation a

Addressed to Hertfordshire Community NHS Trust

HCT policy review to be finalised and to ensure there is adequate response to domestic abuse victims who have been subject to abuse from different partners

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

Recommendation a

Addressed to Hertfordshire Constabulary | Probation Service

The Police provide Probation with domestic abuse history alongside other information for Court. Police and Probation to discuss and implement this recommendation.

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

Recommendation b

Addressed to Hertfordshire Constabulary

Recommend that Officers discontinue the use of ‘Domestics’ and ‘Domestic Disputes’ and use the term ‘Domestic Abuse’.

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

Recommendation b

Addressed to Hertfordshire Children’s Services

To consider additional ways of supporting victims/survivors including young parents who are experiencing substance use and domestic abuse to ensure they can access support.

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

Recommendation b

Addressed to East and North Hertfordshire NHS Trust

Areas within the Trust, such as Adult ED, Maternity, Community Paediatrics, Gynaecology, Plastics & Orthopaedics to have an enhanced provision of domestic abuse training which supports the development & understanding of the purpose of routine domestic abuse enquiry within those areas and equips staff with knowledge and experience in the recognition, response, and risk assessment of domestic abuse. This training will also focus on case scenarios regarding how to create an environment to support safe enquiry.

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

Recommendation b

Addressed to Hertfordshire Community NHS Trust

HCT Domestic Abuse training to be updated to ensure that greater awareness is raised regarding coercive control and victim suicide.

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

Recommendation b

Addressed to Probation Service

As a matter of good practice all offenders at Court interview stage are asked about their relationship status, previous relationships, and the quality of those relationships.

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

Recommendation c

Addressed to Hertfordshire Constabulary

Children are seen by officers in domestic abuse call outs and where appropriate, spoken to individually and separately from the perpetrator.

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

Recommendation c

Addressed to Hertfordshire Children’s Services

Hertfordshire Children Services contacts the carers of the three children in this case and establishes whether they have access to the therapeutic resources needed to support the three children. If this is not the case that they establish a fund to enable the children to access the support, they need.

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

Recommendation c

Addressed to East and North Hertfordshire NHS Trust

Further review of the Specialist Health Visitor assessment tool; to incorporate domestic abuse routine enquiry as a standard for each initial assessment, to gather family functioning/dynamics and identification of men in children’s lives.

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

Recommendation d

Addressed to Hertfordshire Constabulary

Information shared with Children’s Services and within MASH to include any domestic abuse and other violence, including abuse involving previous partners of both the perpetrator and the victim.

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

Recommendation d

Addressed to East and North Hertfordshire NHS Trust

The review supports the recommendation of community services employed by East & North Hertfordshire NHS Trust to have read access to community records (System one) to enhance communication and information sharing with universal services.

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

Recommendation e

Addressed to Hertfordshire Constabulary

Information is passed to all victims of domestic abuse about domestic abuse support services and victims are encouraged to contact services for support.

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

Recommendation e

Addressed to East and North Hertfordshire NHS Trust

Information sharing between specialist HV service and community services – a review of current information sharing practices in place should take place.

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

Recommendation f

Addressed to Hertfordshire Constabulary

Special consideration to be given to escalate repeat victims of multiple perpetrators to MARAC.

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

Recommendation f

Addressed to East and North Hertfordshire NHS Trust

Development of domestic abuse care bundles: domestic abuse care bundles are a bundle of information/documentation which will support a clinician where there is a suspicion of disclosure of domestic abuse. This will include the domestic abuse pathway, clinical photography prompts, body maps & literature for safety planning and onward referrals to IDVA and safeguarding services.

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

Recommendation g

Addressed to Hertfordshire Constabulary

Training to include the danger of attempted strangulation as an indicator of escalation of abuse.

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

Recommendation g

Addressed to East and North Hertfordshire NHS Trust

Trust-wide annual domestic abuse audit to be commenced, examining efficacy of domestic abuse enquiry, recognition, and responses to domestic abuse. This will be the foundation for future training and service improvements.

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

Recommendation h

Addressed to Hertfordshire Constabulary | Probation Service

The Police provide Probation with domestic abuse history alongside other information for Court. Police and Probation to discuss and implement this recommendation.

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

Recommendation h

Addressed to East and North Hertfordshire NHS Trust

Development of domestic abuse champions within each department within the trust, who will receive additional local training on domestic abuse, risk assessment and safety planning, to help develop knowledge from the ‘ground up’. The role of the domestic abuse champion will be to support the frontline staff on domestic abuse identification, domestic abuse enquiry and to ensure the victim & their children get the right and appropriate support in a timely manner.

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

Recommendation i

Addressed to East and North Hertfordshire NHS Trust

Domestic Abuse awareness raising throughout the organisation (e.g., screensavers, active participation in awareness days and regular internal communications) alongside the above recommendations will provide a further reinforcement.

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