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

Kent review

CSP: Kent Published: September 2024 Year of death: 2020 Extracted: 9 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review highlights challenges in multi-agency safeguarding for alcohol-dependent individuals experiencing domestic abuse with co-occurring mental health issues, including inconsistent information sharing, adherence to procedures, and the impact of COVID-19. It also notes an underestimation of escalating risks, particularly when threats were made during auditory hallucinations.

Extracted recommendations

9 recommendations pulled from the report

#	Recommendation	Addressed to
1	Agencies should be aware which “Front Door” Service should be their first point of contact. ARMS and SPoA need to circulate their referral criteria.	KCC ASC \| KMPT
2	GPs practices should ensure they have robust processes in place to ensure that when information from other agencies directs an action for primary care that these requests can be promptly actioned. This should include the acknowledgement to referring agencies when a requested action cannot be met due to non-engagement.	Kent and Medway CCG
3	The police CRU should review their current procedures for facilitating Safeguarding Referrals to Health Care Professionals where these have not been assessed as ‘High Risk’ in a DARA Risk Assessment.	Kent Police
4	The threshold for GP summary referrals should be reviewed and due consideration given to including attendance at domestic abuse and/or alcohol dependent patients.	SECAmb
5	CJLDS practitioners should be encouraged to refer disclosures of auditory hallucination to Registered Practitioners or at least consult with them to get the necessary professional advice.	CJLDS (KMPT)
6	The current referral pathway for Alcohol Treatment Requirement/Drug Rehabilitation Requirement needs to be reviewed. This will include Information Sharing Agreements with key Statutory Partners to obtain information and intelligence to manage risk assessments and facilitate Safeguarding protection for service users’ families.	Forward Trust
7	The Dual Diagnosis assessment process should be reviewed, and a Multi-Agency Pathway developed (in conjunction with substance abuse experts).	KMPT \| Forward Trust
8	More effective multiagency working through stronger risk assessments and training for practitioners will identify and support, in a non-stigmatising way, vulnerable people who are experiencing alcohol harm. This can be achieved by a multi-agency seminar with key partners to discuss and explore alternative strategies and best practice to tackle this relatively small cohort of hard-to-reach people.	KCC Public Health
9	KCSP to ensure the MARAC Hub Manager is provided with this DHR, with a request it be considered during the development and implementation of new MARAC procedures	KCSP
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗