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

East Sussex review

CSP: East Sussex Published: September 2024 Year of death: 2015 Extracted: 48 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 highlights fragmented referral pathways for domestic abuse victims, the invisibility of fathers in service engagement, and a need for enhanced professional curiosity and training across agencies, particularly in healthcare and housing, to improve identification and response to domestic abuse.

Home Office classifications

44 tags

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

  • Victim - substance misuse
  • Victim - housing issues
  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicide attempts
  • 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
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • 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 - housing 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

48 recommendations pulled from the report · 27 matched to organisations in the index

Recommendation 1

Addressed to East Sussex Safer Communities Partnership

The East Sussex Safer Communities Partnership Review pathways so that victims of domestic abuse incidents (not just crimes) are offered a referral to a domestic abuse specialist service.

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

Recommendation 2

Addressed to Office of the Police and Crime Commissioner | East Sussex Safer Communities Partnership

Office of the Police and Crime Commissioner and the East Sussex Safer Communities Partnership: Review the current commissioning arrangements for standard risk victims, identifying how to ensure that all victims are able to access help and support from a domestic abuse specialist service and consider how these services are communicated and offered in keeping with the findings of this review and input from the victim’s sister.

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

Recommendation 3

Addressed to East Sussex Safer Communities Partnership

East Sussex Safer Communities Partnership Explore if there are any improvements that could be made to link those using, or at risk of, using violence and abuse with national helplines such as the one run by Respect as a possible link to support and advice at what could be a critical time. All front-line providers should be reminded of or made aware of this provision of service at a minimum.

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

Recommendation 4

Addressed to East Sussex Safer Communities Partnership

East Sussex Safer Communities Partnership The East Sussex Safer Communities Partnership should review the provision of community based support for those using, or at risk of, using violence and abuse who are not able to access programmes through existing statutory provision.

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

Recommendation 5

Addressed to Hastings and Rother Clinical Commissioning Group

Hastings and Rother Clinical Commissioning Group Work with the lead commissioners for specialist services (East Sussex County Council, Safer East Sussex Team) and providers (the East Sussex Healthcare NHS Trust and CGL specialist service) to evaluate the impact of the HIDVA pilot and, if it is successful, sustain and embed this provision locally.

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

Recommendation 6

Addressed to Eastbourne, Hailsham and Seaford Clinical Commissioning Group | NHS High Weald Lewes Havens Clinical Commissioning Group

Eastbourne, Hailsham and Seaford Clinical Commissioning Group and NHS High Weald Lewes Havens Clinical Commissioning Group If the HIDVA pilot is successful, review the findings in order to consider its wider rollout in other Acute Settings across East Sussex.

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

Recommendation 7

Addressed to Hastings and Rother Clinical Commissioning Group

Hastings and Rother Clinical Commissioning Group Work with the lead commissioners for specialist services (East Sussex County Council, Safer East Sussex Team) and providers (specialist services) to evaluate the impact of the IRIS pilot and, if it is successful, sustain and embed this provision locally.

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

Recommendation 8

Addressed to Eastbourne, Hailsham and Seaford Clinical Commissioning Group | NHS High Weald Lewes Havens Clinical Commissioning Group

Eastbourne, Hailsham and Seaford Clinical Commissioning Group and NHS High Weald Lewes Havens Clinical Commissioning Group If the IRIS pilot is successful review the findings in order to consider its wider rollout across East Sussex.

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

Recommendation 9

Addressed to Office of the Police and Crime Commissioner

Office of the Police and Crime Commissioner As part of regular contract monitoring reviews, ensure that victims are contacted within agreed timescales and are given up to date and accurate information related to local and national services.

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

Recommendation 10

Addressed to East Sussex Safer Communities Partnership

East Sussex Safer Communities Partnership Ensure that the development of online, downloadable tools for professionals and victim/survivors and their families are developed as planned which will build on the Safety Netting work developed to date.

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

Recommendation 11

Addressed to Sussex Police | Office of the Police and Crime Commissioner

Sussex Police and the Office of the Police and Crime Commissioner Continue to improve the referral pathways for victims in contact with the police who are deemed to be a standard risk so that adequate information is shared, the consideration of the victim’s experience of intervention and support is fully considered and the safety of the victim is prioritised for both crime and non-crime domestic abuse incidents.

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

Recommendation 12

Addressed to Affinity Sutton

Affinity Sutton Ensure the IT systems at Affinity Sutton and processes are able to delineate domestic abuse as separate from other tenancy issues or anti-social behaviour to allow for repeat incidents or concerns to be easily understood.

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

Recommendation 13

Addressed to Affinity Sutton

Affinity Sutton Enhance provision of training to include more distinct modules on domestic abuse and to ensure that contracts with ASB action reflect the domestic abuse policy and procedures and to include this review in training to ensure that child safeguarding concerns are appropriately addressed.

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

Recommendation 14

Addressed to Affinity Sutton

Affinity Sutton Identify how to disseminate information to tenants about the support available to those who experience abuse at home.

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

Recommendation 15

Addressed to East Sussex Housing Operational Group

East Sussex Housing Operational Group Review the findings relating to Affinity Sutton, in particular the general need to take a proactive approach to identifying domestic abuse and not conflating it with anti-social behaviour, and seek assurance in relation to the standard of practice by other housing providers.

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

Recommendation 16

Addressed to East Sussex Housing Operational Group

East Sussex Housing Operational Group Review practice related to the minimum standards for housing providers such as those promoted by the Domestic Abuse Housing Alliance14 (endorsed in the national VAWG strategy).

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

Recommendation 17

Addressed to Safeguarding Adult and Children’s Board

Safeguarding Adult and Children’s Board Ensure that housing providers are engaged within the local processes for assurance, including the Safeguarding Adults Board Strategic Assurance Tool and Local Safeguarding Children Board Section 11 audits to ensure that safeguarding practice is monitored and addressed.

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

Recommendation 18

Addressed to Sussex Partnership NHS Foundation Trust

The training that the PCLDS service receive may not fully equip them to deliver global assessment of risks with patients who have a history of serious offending and specialist Be Aware and Respond to Abuse (BARTA) or RESPECT training in this area may have improved the risk formulation in this case

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

Recommendation 19

Addressed to Sussex Partnership NHS Foundation Trust

An enhanced screening format may have highlighted future risk more effectively

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

Recommendation 20

Addressed to Sussex Partnership NHS Foundation Trust

PCLDS staff should routinely document the alleged offence as part of the assessment to enable other professionals to have an awareness of patients’ previous contact with criminal justice system.

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

Recommendation 21

Addressed to East Sussex Healthcare NHS Trust

A&E staff require greater professional curiosity regarding accidents that occur in women who are pregnant as this is known to be a highly vulnerable period.

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

Recommendation 22

Addressed to East Sussex Healthcare NHS Trust

To ensure that on all occasions when a woman is seen with a physical injury or multiple presentations with non-specific concerns that the healthcare professional exercises professional curiosity and asks the question about domestic abuse.

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

Recommendation 23

Addressed to Primary Care Services

Consideration should be given within Primary Care to: Increased professional curiosity with regards to presence of partner and other family members and dynamics of those relationships.

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

Recommendation 24

Addressed to Primary Care Services

Consideration should be given within Primary Care to: Increased professional curiosity when patients present with non-specific symptoms that may be indicative of DVA.

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

Recommendation 25

Addressed to Primary Care Services

Consideration should be given within Primary Care to: Routine screening regarding DVA during Primary Care consultations.

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

Recommendation 26

Addressed to Primary Care Services

Consideration should be given within Primary Care to: Increased awareness and recognition of potential indicators of DVA and knowledge of referral routes.

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

Recommendation 27

Addressed to Primary Care Services

Consideration should be given within Primary Care to: Signposting in surgery waiting areas to DVA services in the locality.

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

Recommendation 28

Addressed to Eastbourne, Hailsham and Seaford Clinical Commissioning Group | Hastings and Rother Clinical Commissioning Group | NHS High Weald Lewes Havens Clinical Commissioning Group

Designated nurse Safeguarding Adults will engage with primary care colleagues to promote awareness of local domestic abuse resources, signposting to services and training opportunities available.

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

Recommendation 29

Addressed to East Sussex Healthcare NHS Trust

To increase professional awareness of men/other people within a family, particularly for women with an identified vulnerability and document this.

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

Recommendation 30

Addressed to Sussex Police

First Responders should use effective victim questioning/interviewing of the victim to gather comprehensive information to enable accurate completion of the DASH and ask probing questions where the victim clearly states there is controlling, coercive etc. behaviour. This will also assist with identifying the correct level of risk.

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

Recommendation 31

Addressed to Sussex Police

Statements from victims of Domestic Incidents should contain details of their relationship history. Not only will this give a clear picture of the relationship but will also assist with the identification of level of risk.

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

Recommendation 32

Addressed to Sussex Police

Staff to be reminded to continue taking positive action in arresting offenders and to ensure that a DVPN/DVPO is considered for all cases.

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

Recommendation 33

Addressed to Sussex Police

Staff to be reminded about the referral process to NCDV for applications of non-molestation orders.

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

Recommendation 34

Addressed to Sussex Police

All current Domestic Abuse training should be mandatory for First Responders, Secondary Investigators, relevant Specialist Units and teams.

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

Recommendation 35

Addressed to Sussex Police

Supervisors and Specialist Officers should ensure that they review all the material collated as part of the investigation to ensure that the level of risk has been correctly assessed.

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

Recommendation 36

Addressed to Sussex Police

This should include National Centre for Applied Learning Techniques intranet training that is widely available to all staff.

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

Recommendation 37

Addressed to Sussex Police

Staff that have not completed mandatory training must take personal responsibility to ensure they complete this as part of their CPD. To include officers that have transferred department/s or missed the first round of training.

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

Recommendation 38

Addressed to Sussex Police

Supervisors and Specialist Officers should ensure that they review all the material collated as part of the investigation to ensure that the level of risk has been correctly assessed.

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

Recommendation 39

Addressed to East Sussex County Council

MASH and TAF administrative processes and systems should be informed by any learning from this DHR.

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

Recommendation 40

Addressed to East Sussex County Council

The specification and monitoring of the new integrated Health Visiting and Children’s Centre service should be informed by any learning from this DHR.

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

Recommendation 41

Addressed to East Sussex County Council

Staff to be reminded of the need to check the accuracy of family names, details and contact numbers.

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

Recommendation 42

Addressed to East Sussex County Council

SCARF referrals should be recorded on the adults as well as the children’s electronic casefiles for future reference.

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

Recommendation 43

Addressed to East Sussex County Council

Details of the children of young people referred to the service should be recorded as well as the parent.

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

Recommendation 44

Addressed to Victim Support

To receive the DASH RIC from Sussex Police to enable the service to have a more accurate picture of risk prior to contact with standard risk victims (this will also allow Victim Support to more accurately identify Medium and High Risk Cases which should be referred to Specialist Domestic Abuse Services).

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

Recommendation 46

Addressed to Victim Support

Review the information provided about the sources of help and support locally, including the National Domestic Violence Helpline and local specialist services.

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

Recommendation 47

Addressed to Affinity Sutton

All neighbourhood housing officers are reminded that any incidents that are reported to them directly, that fall under ASB or domestic abuse procedures, are logged accordingly.

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

Recommendation 48

Addressed to Affinity Sutton

The Antisocial Behaviour Procedure is amended to say; if the ASB complaint includes domestic arguing, the investigating officer should consider and investigate whether there is domestic abuse and document in their investigation what they have done and the outcome of this investigation. If domestic abuse is suspect, then they should refer to the Domestic Violence Policy and Procedure for guidance.

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