Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
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.
Original review (PDF) ↗
Source: Home Office DHR Library
Summary AI-generated
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.
Home Office classifications
35 tags
Source-supplied classifications used by the Home Office to catalogue this review.
- Victim - alcohol misuse
- Victim - mental ill health
- Victim - anxiety
- Victim - depression
- Victim - had been a victim of an abuser before
- Perpetrator - case heard in court
- Perpetrator - alcohol misuse
- Perpetrator - mental ill health
- Perpetrator - anxiety
- Perpetrator - depression
- Perpetrator - psychosis
- Perpetrator - suicidal thoughts
- Perpetrator - known to agencies as a domestic abuse perpetrator
- Perpetrator - known to police as a domestic abuse perpetrator
- Perpetrator - known to mental health services as a domestic abuse perpetrator
- Perpetrator - known to probation services as a domestic abuse perpetrator
- Perpetrator - attended drug and alcohol services
- Perpetrator - supervised by mental health services
- Perpetrator - supervised by probation services
- 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 consulted about terms of reference
- 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 - 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
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 7
The Dual Diagnosis assessment process should be reviewed, and a Multi-Agency Pathway developed (in conjunction with substance abuse experts).
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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.
Verified wording from the published review · Original review (PDF) ↗
Recommendation 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
Verified wording from the published review · Original review (PDF) ↗