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

Dorset review

CSP: Dorset Published: August 2023 Year of death: 2019 Extracted: 25 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
Agencies overlooked the victim's risk of familial domestic abuse, influenced by age and gender stereotypes. Gaps in inter-agency information sharing, MARAC processes, and risk assessments for the perpetrator contributed to missed opportunities to safeguard both victims.

Home Office classifications

51 tags

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

  • Victim - mental ill health
  • Victim - serious or life limiting illness
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - was a carer
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - neurodiverse condition diagnosis
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - serious or life limiting illness
  • 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 probation services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • 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 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 - probation 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

25 recommendations pulled from the report · 23 matched to organisations in the index

Recommendation 1

Addressed to Safer Somerset Partnership | Dorset Community Safety Partnership

That Safer Somerset Partnership and Dorset Community Safety Partnership widely disseminate the learning from this review locally but also consider preparing a briefing derived from the learning from this case and circulating it nationally.

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

Recommendation 2

Addressed to Safer Somerset Partnership | Dorset Community Safety Partnership

That Safer Somerset and Dorset Community Safety Partnerships make use of the learning from this review to raise public awareness of familial domestic violence and abuse.

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

Recommendation 3

Addressed to Safer Somerset Partnership

That Safer Somerset Partnership seeks assurance that the MARAC process is effectively supported and co-ordinated.

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

Recommendation 4

Addressed to Safer Somerset Partnership

That Safer Somerset Partnership seeks assurance that all partner agencies which could have a role to play in safety planning for the victims of domestic violence and abuse are involved in that safety planning.

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

Recommendation 5

Addressed to Safer Somerset Partnership | Dorset Community Safety Partnership

That Safer Somerset Partnership and Dorset Community Safety Partnership jointly write to the Home Office to recommend a review of guidance in respect of MARAC to MARAC referrals to include consideration of such referrals when a perpetrator moves between areas.

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

Recommendation 6

Addressed to Safer Somerset Partnership

That Safer Somerset Partnership seek assurance that where Avon and Somerset Constabulary have intelligence or evidence that a perpetrator of high risk domestic abuse keeps weapons (of any sort), that this information is shared with the IDVA and other services, in order to facilitate effective safety planning.

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

Recommendation 7

Addressed to Dorset Community Safety Partnership

That Dorset Community Safety Partnership reviews the Data Sharing Agreement with the Ministry of Justice - which would enable Magistrates Courts to contribute to future DHRs - when the agreement is complete and shares it with the Home Office .

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

Recommendation 8

Addressed to Safer Somerset Partnership

That Safer Somerset Partnership obtains assurance from Avon and Somerset Constabulary that the review of relevant information on their pocketbook system has fully addressed the learning rising from this review in respect of dealing with breaches of Court imposed bail conditions.

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

Recommendation 9

Addressed to Safer Somerset Partnership | Dorset Community Safety Partnership

That Safer Somerset and Dorset Community Safety Partnerships review the role of GP practices in addressing domestic violence and abuse, in particular the information which is shared with them and the extent to which the information they hold is shared with the MARAC process.

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

Recommendation 10

Addressed to Safer Somerset Partnership

That Safer Somerset Partnership seeks assurance that in discharging their responsibility to engage with service users holistically in order to anticipate and prevent the escalation of future needs, Adult Social Care also enquires about domestic abuse including familial domestic abuse.

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

Recommendation 11

Addressed to Safer Somerset Partnership | Dorset Community Safety Partnership

That Safer Somerset and Dorset Community Safety Partnership write to the Home Office to alert them to the issue so that they can liaise with the Ministry of Justice and consider what action is necessary.

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

Recommendation A1

Addressed to Avon and Somerset Constabulary

Audit VA records where there is a recorded positive outcome to provide assurance that the Police National Computer is accurate.

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

Recommendation A2

Addressed to Avon and Somerset Constabulary

Review and update the Domestic Violence Disclosure Scheme in line with the amendments from the Domestic Abuse Bill. This review should include how the use of the Domestic Violence Disclosure Scheme is promoted across the organisation, including when to instigate applications on a ‘Right to Know’ basis, as well as the `Right to Ask’ process.

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

Recommendation A3

Addressed to Dorset Police

Data Quality - Force Review Officer to issue a communication through ‘Lessons Learned’ bulletin reinforcing the importance of data quality.

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

Recommendation A4

Addressed to Dorset Police

Understanding of Adult at Risk and Domestic Abuse reporting - Dorset Police will use this incident as a case study for the second round of vulnerability training which is scheduled for June 2020.

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

Recommendation A6

Addressed to National Probation Service

NPS to review system for obtaining call out information from police forces outside Avon and Somerset Area

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

Recommendation A7

Addressed to NHS Somerset Clinical Commissioning Group

Disclosure of suicidal thinking during a (pharmacy) medication telephone review should be shared with another clinician (GP) and decisions and actions documented.

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

Recommendation A8

Addressed to NHS Somerset Clinical Commissioning Group

The GP as Primary Health Care Provider should be included in information sharing for high risk domestic abuse incidents which relate to their patients, both victims and perpetrators (e.g. police domestic abuse notifications and MARACs)

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

Recommendation A9

Addressed to Somerset Council Adult Social Care

Safeguarding Service and Somerset Direct to ensure they are not declining Safeguarding referrals based on consent and advising people to re-refer as per adults wishes.

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

Recommendation A10

Addressed to Somerset Council Adult Social Care

Staff to form a decision based on presenting information, not previous decisions made. They need to take into consideration the accumulation of concerns to reassess levels of risk.

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

Recommendation A11

Addressed to Somerset Council Adult Social Care

Safeguarding Adults Service to ensure they have oversight of enquiries even if they do not identify any other active role in protection planning.

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

Recommendation A12

Addressed to Somerset Council Adult Social Care

Safeguarding service to ensure they respond to referrers at the point of triage.

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

Recommendation A13

Addressed to Somerset Council Adult Social Care

Locality Teams to undertake assessment of need when there is sufficient information to suggest an adult has needs for care and support. Not to request or rely on other agencies making initial assessments.

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

Recommendation A14

Addressed to Somerset Council Adult Social Care

A visit to be undertaken to Dorothy by Safeguarding Adults Service for welfare visit.

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