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

Portsmouth review

CSP: Portsmouth Published: September 2024 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
The review identified inconsistent multi-agency responses to domestic abuse, missed opportunities for risk assessment and intervention, and a lack of routine screening for domestic abuse in health settings. It also highlighted the impact of coercive control, image-based sexual abuse, and the victim's complex needs, alongside difficulties in removing criminal content from social media.

Home Office classifications

37 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - known to workplace (employer) as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - sexual abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family supported by expert specialist advocate
  • DHR process - police recommendations
  • DHR process - social services 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

25 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1

Addressed to Southcoast Ambulance Service (SCAS)

All referrals made by 111 and the emergency operations centre to be referred electronically.

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

Recommendation 1

Addressed to CSP

The Domestic Abuse Strategy Group will monitor a repeat audit for all single agency actions in twelve months to check all actions have been completed.

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

Recommendation 1

Addressed to CSP

The panel supports the author to approach the Home Office to legislate for the removal of proven criminal content on social media platforms.

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

Recommendation 2

Addressed to SCAS

Highlight through internal communications SCAS responsibility when dealing with DA incidents and the interface with police.

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

Recommendation 2

Addressed to CSP

Universal health services revisit training and share information to health professionals regarding the importance of routine screening and asking the question of patients whether they are experiencing domestic abuse, as set out in the NICE guidelines.

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

Recommendation 2

Addressed to CSP

The panel supports the author to request government consider the recommendations within the Femicide Census in relation to the national VAWG strategy.

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

Recommendation 3

Addressed to SCAS

The author recommended the use of internal reviews for SCAS teams to learn from this incident. The author suggested receiving permission from family and staff and once typed seek authorisation from an Assistant Director to cascade learning to SCAS teams.

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

Recommendation 3

Addressed to Domestic Abuse Practitioners Forum

Using the victim’s story as a case study, Portsmouth’s multi- agency domestic abuse practitioner’s forum to consult with professionals on what needs to be done to change the culture within their own organisations and as coordinated partners in responding to domestic abuse. Particular attention will be given to unconscious/conscious bias with regards to the victim’s case and how she presented in relation to both her multiple and complex needs and the care she was afforded.

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

Recommendation 4

Addressed to Domestic Abuse Strategy Group

Audit content and frequency of training provided to individual agencies involved in this case to ensure training includes: • DASH risk assessment training • Homicide Timeline training • Trauma informed responses • Substance misuse and complex needs • Image based sexual abuse awareness • Counter allegations • Professional curiosity • Intersectionality

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

Recommendation 5

Addressed to Hampshire Constabulary

Hampshire Constabulary to ensure clear internal comms are repeated after the review to ensure officers are clear of the force policy with regards to mandating a timeframe for what constitutes a non- current domestic abuse report and remind officers the arrest/positive action policy is applicable in a non- current domestic abuse report.

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

Recommendation 5

Addressed to CSP

The panel recommends individual agencies involved in this review consider the Femicide Census recommendations in strategies and commissioning.

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

Recommendation 6

Addressed to Hampshire Constabulary

Hampshire Constabulary's crime data integrity scrutiny panel regularly check that reports of domestic abuse include reference to any counter-allegations. Hampshire Constabulary agreed to feedback provide regular evidence from the DA scrutiny panel to the CSP in relation to Portsmouth specific DVA data.

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

Recommendation 6

Addressed to CSP

The CSP considers whether to recommend the promotion of Report Harmful Content Charity for specialist commissioned services responding to domestic abuse and sexual violence.

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

Recommendation 7

Addressed to Hampshire Constabulary

The CSP would like to receive confirmation that the DA Matters training includes the impact of substance misuse in cases of domestic abuse. (see recommendation 8 below)

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

Recommendation 7

Addressed to CSP

The CSP to consider awareness raising campaigns with regards to technology related abuse for the general public and ensure that information on help seeking organisations is disseminated amongst professionals through training programmes and on communication portals.

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

Recommendation 8

Addressed to Hampshire Constabulary

Feedback to the CSP on the effectiveness of training related to domestic abuse, including the effectiveness of SafeLives DA Matters training.

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

Recommendation 8

Addressed to CSP

The CSP to consider the recently launched service, Findaway which supports family and friends when they are concerned about a loved one who is experiencing abuse.

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

Recommendation 9

Addressed to Hampshire Constabulary

Hampshire Constabulary as a part of ongoing Continuous Professional Development for custody officers and staff emphasise the significance and importance of a thorough pre-release risk assessment and that they routinely consider the impact of a domestic abuse incident for both victim and offender at point of release.

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

Recommendation 10

Addressed to Portsmouth Safeguarding Adults Board (PSAB)

Although the IMR author has confirmed that the auditing of this new process will commence in Spring of 2022, the panel will further recommend that the Portsmouth Safeguarding Adult board will take responsibility to oversee this change.

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

Recommendation 11

Addressed to Adult Social Care

Raise Awareness of the referral process for adults experiencing or at risk of Domestic Abuse. Training has been commissioned to promote Pan Hants guidance referencing raising safeguarding concerns.

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

Recommendation 12

Addressed to GPs – Surgeries Portsmouth

Primary Care to consider a review of their routine screening questionnaires to ensure it includes a question relating to the patient experiencing domestic abuse.

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

Recommendation 13

Addressed to GPs – Surgeries Portsmouth

Review of processes/policies/training in relation to patients requiring support with drug and alcohol misuse to ensure potential safeguarding issues are considered for all GPs surgeries in Portsmouth.

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

Recommendation 14

Addressed to Universal Health Services

In both Police and Probation services, domestic homicide reviews are dealt with by a central team whose role it is to compile IMR reports and liaise with review panels. This should be considered for health services so that professionals can retain their specialist focus where it is needed most, and future panels can receive high quality reports.

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