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

Somerset review

CSP: Somerset Published: October 2024 Year of death: 2021 Extracted: 20 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 disjointed interagency communication, inconsistent identification and response to domestic abuse, and a lack of professional curiosity regarding the victim's multiple and intersecting vulnerabilities, including mental health, substance misuse, homelessness, and prior domestic abuse. Agencies did not always provide intersectional, victim-focused, or trauma-informed support.

Home Office classifications

43 tags

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

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - panic attacks
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • 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 housing 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 - supervised by mental health 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 - 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

20 recommendations pulled from the report · 5 matched to organisations in the index

Recommendation 1

Addressed to Safer Somerset Partnership

Increasing awareness among professionals on the links between and impacts of mental health, self-harm and/or suicidal ideation, with domestic abuse.

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

Recommendation 2

Addressed to Safer Somerset Partnership

Responding to domestic abuse, so that agencies and professionals are equipped and confident to exercise professional curiosity, in a meaningful, empathic, and trauma-informed way.

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

Recommendation 3

Addressed to Safer Somerset Partnership

Identifying and responding effectively to vulnerabilities, resulting from the intersection of protected characteristics, such as gender and disability.

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

Recommendation 4

Addressed to Safer Somerset Partnership

Recognising co-occurring family violence, as a risk factor for domestic abuse, specifically, the parallels between domestic abuse of intimate partners with the abuse of other relatives.

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

Recommendation 5

Addressed to Safer Somerset Partnership

Recognising disclosures of problem-gambling by prior/current domestic abuse victims as an important opportunity to provide support and to refer to specialist agencies.

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

Recommendation 6

Addressed to Safer Somerset Partnership

For any provider with a Local Authority issued contract to have a domestic abuse policy and procedure in place, as well as confirmation that training on domestic abuse will be provided to staff.

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

Recommendation 7.2.3

Addressed to NHS Somerset ICB

Remind GP practices to ensure a request for counselling is accompanied by a review of mental health and any risks e.g., of self-harm.

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

Recommendation 7.2.4

Addressed to NHS Somerset ICB

When dealing with sleep problems there should be evidence of a more holistic assessment e.g., including mental health and social circumstances as well as a pain review.

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

Recommendation 7.2.5

Addressed to NHS Somerset ICB

When someone with complex presentation does not return initial attempts to make contact for a medication review that may impact on the risk that person may be exposed to as a result of lack of the review, further attempts to establish contact should be evidenced by the GP practice.

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

Recommendation 7.2.6

Addressed to Somerset NHS Foundation Trust

Somerset NHS Foundation Trust to continue to move forward with embedding routine enquiry within mental health services, including how and where this is recorded.

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

Recommendation 7.2.13

Addressed to Arc Inspire

Better communication / sharing of information with external agencies. Rationale To support the clients’ needs. Sharing of information.

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

Recommendation 7.2.14

Addressed to Arc Inspire

Domestic abuse staff training. Rationale To improve/gain knowledge and skills of their awareness of domestic abuse and violence.

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

Recommendation 7.2.15

Addressed to Somerset Drug and Alcohol Service

Closer link with housing provider. Rationale: We may have been able to reduce the risk for Amber by raising with housing.

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

Recommendation 7.2.16

Addressed to Somerset Drug and Alcohol Service

At the start of a new treatment episode, the most recent treatment episode to be reviewed by keyworker. Rationale: Highlight identified risks or safeguarding concerns that may warrant further action

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