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
Winchester review
CSP: WinchesterPublished: November 2023Year of death: 2019Extracted: 6 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
Agencies primarily focused on the perpetrator's self-harm risk, potentially overlooking indicators of risk to others and failing to adequately explore concerning statements. The review identified missed opportunities for routine domestic abuse enquiry, particularly for adolescent-to-parent abuse and coercive control, and insufficient engagement with non-residential parents.
Home Office classifications
21 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - mental ill health
Victim - depression
Children - under 18 shared parental responsibility (between victims)
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 - different gender identity from birth
Perpetrator - mental ill health
Perpetrator - psychosis
Perpetrator - self harm
Perpetrator - suicidal thoughts
Perpetrator - suicide attempts
Perpetrator - died by suicide
Aggravating factors - coercive or controlling behaviour
DHR process - health services recommendations
DHR process - community safety partnership recommendations
DHR process - identification of risk recommendation themes
DHR process - policy recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
6 recommendations pulled from the report · 1 matched to organisations in the index
Addressed to
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Foundation Trust should review CAMHS engagement with non-residential parents when assessing or providing treatment to patients so as to glean a fuller understanding of their life and needs.
Addressed to
Hampshire Clinical Commissioning Groups | Safeguarding Children Partnership | Safeguarding Adults Boards | health providers
The Hampshire Clinical Commissioning Groups, Safeguarding Children Partnership, Safeguarding Adults Boards and health providers (whether NHS or private) should, as a matter of urgency, agree a consistent policy and practice to support routine and targeted enquiry for all forms of domestic abuse which ensures that every opportunity is taken to identify where such abuse may be being perpetrated and to signpost or offer services appropriate to need.
Where possible, health providers health providers involved in this review should assure themselves that in assessing risk to others, their tools and practices embrace all assessments, presentations, ideations and views of third parties to triangulate any expressed or reported risk so as to effectively establish the risk level and the management plan aimed to reduce it.
Priory Hospitals review how it assesses, diagnoses and communicated ADOS assessments so that their outcome is properly communicated to patients, families (where appropriate) and other professionals so that ongoing support can be provided.
Addressed to
Winchester Community Safety Partnership
The Winchester Community Safety Partnership should develop a communications strategy which has the ambition of ensuring that the nature of domestic abuse, in all its forms (including ‘adolescent to parent’ abuse and coercive control) is recognised and the reach and accessibility of both statutory and specialist support services is such that people in every community are clear on where to seek help for themselves and others in a way which meets their needs.
Addressed to
Winchester Community Safety Partnership
Winchester Community Safety Partnership should support provider services, across all sectors, in accessing guidance to help them adjust services to meet the needs of agender and non-binary clients assuring the implementation of those adjustments is relevant to their sector. This should include raising awareness of staff and providing appropriate training as needed.