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: 2018 Extracted: 16 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 agencies' limited understanding and identification of economic and child-to-parent abuse, leading to missed opportunities for intervention and referrals. Inconsistencies in probation management and an underestimation of risk contributed to the perpetrator's continued offending.

Home Office classifications

45 tags

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

  • Victim - was a carer
  • Victim - carer for perpetrator
  • Victim - had been a victim of an abuser before
  • Children - present at homicide (including adult children)
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - supervised by mental health services
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic 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 - health services recommendations
  • DHR process - probation 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 - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

16 recommendations pulled from the report · 9 matched to organisations in the index

Recommendation 1

Addressed to East Sussex Safer Communities Partnership

East Sussex Safer Communities Partnership should promote public and professional awareness of economic abuse as a method of coercive control within domestic and familial abuse. They should seek assurance from its agencies that they have enacted the new definition of economic abuse within their policies and practice.

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

Recommendation 2

Addressed to East Sussex Community Safety Partnership

East Sussex Community Safety Partnership should seek assurance from its agencies that front-line practitioners are sufficiently supported through training, guidance and supervision to be able to respond effectively to child-parent abuse, irrespective of the various ages of those abusing and abused. Where gaps emerge, East Sussex Community Safety Partnership should consider what needs to be done collectively with agencies to raise the awareness and expertise of practitioners to respond to child-parent abuse.

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

Recommendation 3

Addressed to East Sussex Safer Communities Partnership

East Sussex Safer Communities Partnership should increase public awareness about child-parent abuse and the role of specialist domestic abuse services in supporting those affected

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

Recommendation 4

Addressed to Ministry of Justice

The Ministry of Justice is asked to consider whether a standard should be set for pre-sentence reports involving domestic abuse, including those pre-sentence reports which are required verbally and ‘on the day’, to routinely include evidence of police reports, necessitating the time being allocated for them to be carried out.

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

Recommendation 8.2.1

Addressed to Sussex Clinical Commissioning Groups

The CCG to continue to promote the importance of routine enquiry regarding domestic abuse across primary care.

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

Recommendation 8.2.1

Addressed to Sussex Clinical Commissioning Groups

Health professionals to have awareness of the impact of supporting a family member who has care and support needs. Further training for all staff to be considered on what the impact is on the wider family / carer / support system. Consider placing a flag or note on the electronic patient record system as a reminder to approach how the carer is feeling and to ask if they have any concerns regarding their personal safety.

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

Recommendation 8.2.2

Addressed to Kent and Medway Partnership Trust

Any disclosure of ‘a protective’ ‘restraining’ ‘police’ or other order including tags etc must be explored for the reason why this has been put in place, this includes making contact to the police to report a breach.

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

Recommendation 8.2.2

Addressed to Kent and Medway Partnership Trust

To increase confidence amongst KMPT staff regarding routine enquiry around domestic abuse.

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

Recommendation 8.2.4

Addressed to Maidstone and Tunbridge Wells NHS Trust

Identify actions in the updated version of the Domestic Abuse Policy and Procedure to inform staff what actions are required when a patient states they are going to be discharged to live with the perpetrator and there is a restraining order in relation to living or being near to the perpetrator, that staff should inform the police that this is likely/going to occur.

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

Recommendation 8.2.5

Addressed to National Probation Service Sussex

A further reminder to Sussex CDO’s that following breach hearings, if order continues, the CDO must make efforts to give a reporting appointment before the offender/ service user leaves court. CRC if asking for orders to continue, will also ensure appointments are detailed within the breach report where possible, or an appointment date advised once a breach hearing date is known either directly to NPS Court Team or to the CRC staff member attending Breach Court in support of the process. If an offender fails to attend a Breach hearing and subsequently attends on warrant, NPS Court staff must take all reasonable steps to secure an appointment date and time.

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

Recommendation 8.2.5

Addressed to National Probation Service Sussex

Court report writers to check call out information when the offending is linked to family members and or grievances involved. All court staff will over the following year will be undertaking unconscious bias training as provided by the Civil Service. As part of our continuous professional practice events, Court report writers will continue to apply reflective practice approaches to discuss potential risk issues around similar cases.

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

Recommendation 8.2.6

Addressed to Priory Group, Priory Hospital North London

During the discharge process, clarity should be given to family, carers and professionals in respect of risk. A telephone contact with the patient will be made within 48 hours of discharge and a discharge letter will be sent to all those involved with the patient’s care with 7 days.

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

Recommendation 8.2.6

Addressed to Priory Group, Priory Hospital North London

On admission, each patient should receive a comprehensive joint risk assessment by nursing and medical colleagues which needs to be documented on their care records. This will include an assessment of risk and establishment of observation level.

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

Recommendation 8.2.7

Addressed to Sussex Police

That Sussex Police conduct an audit to ensure that history markers are being applied consistently and appropriately in cases involving allegations of Domestic Abuse.

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