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: Winchester Published: November 2023 Year of death: 2019 Extracted: 6 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 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

Recommendation 1

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.

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

Recommendation 2

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.

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

Recommendation 3

Addressed to health providers

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.

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

Recommendation 4

Addressed to Priory Hospitals

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.

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

Recommendation 5

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.

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

Recommendation 6

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.

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