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
Central Bedfordshire review
CSP: Central Bedfordshire
Published: February 2025
Year of death: 2022
Extracted: 23 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 found that domestic abuse, including stalking and coercive control, was a significant factor in the victim's suicide. It highlighted concerns regarding multi-agency responses, including overshadowing of domestic abuse by mental health issues, unconscious bias due to the victim's past as a perpetrator, and gaps in information sharing and coordinated safeguarding.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | A review of legislation to reflect all domestic abuse victims are informed of a perpetrators’ impending release from Prison following any length of custodial sentence. This must include a stated process and organisational responsibility. A change in legislation of this kind will provide the opportunity for further safety planning and risk assessment, knowledge to the victim to prevent fear of the unknown and complete the cycle of victim engagement and focus from the beginning of the Criminal Justice system to the end. | government_dept |
| 10 | Bedfordshire Police to integrate a system of flagging or alerts created on the Athena database to highlight and prioritise summary only offences where the STL may be applicable. This will provide an additional layer of assistance to notify the investigating officer in order to complete files and communicate with the CPS to ensure a decision is made on prosecution prior to this date and it does not expire. | Bedfordshire Police |
| 11 | Bedfordshire Police are to re-emphasise the importance of following policies and processes that have been implemented for the recording, investigation and prosecution of domestic abuse related offences to their staff and officers of all ranks. This will ensure that, if adhered to, it will expedite investigations so that the statutory time limits do not expire in the future and eradicate investigations being investigated in isolation when there is a repeat victim or perpetrator. | Bedfordshire Police |
| 12 | MARAC within Bedfordshire to identify a local interim process for the escalation of non-completed actions whilst awaiting the outcome of the National recommendation at 2. Actions are tasked for a reason and this will ensure a review that they are completed and provide an escalation process for non-compliance whilst MARAC remains non-statutory. | MARAC |
| 13 | Domestic abuse training by ELFT IDVA to be implemented as compulsory for all Care Coordinators. This will enhance knowledge of those working directly with clients in order to correlate domestic abuse with their mental health issues and risk assess appropriately on disclosure. | ELFT |
| 14 | ELFT to review the Bedfordshire and Luton Directorate induction programme to incorporate suicide prevention training and domestic abuse and for this to be delivered to all community, crisis, and inpatient staff and Care Coordinators. This will provide awareness and early integration of the two matters across a range of staffing roles. | ELFT |
| 15 | CBC Housing to ensure all staff provide an out of office automatic reply on their emails and phone messaging service to include hours of work and provide support service information for those in crisis. This will provide clarity for those contacting in an emergency that they will not receive an immediate reply and provide an immediate pathway for support. | CBC Housing |
| 16 | CBC Housing to ensure the requirement for immediate referrals are written into their policy and procedures where there is an immediate safeguarding issue or immediate risk of harm. This will negate any delay in referrals whilst the officer is trying to make contact with the client and make other agencies aware in a timely manner. | CBC Housing |
| 17 | CBC Housing to revise procedures to ensure that all data from each department within Housing is researched on request during a DHR. This is to ensure all relevant information is forwarded when requested in order to be reviewed appropriately by the panel prior to the completion of the overview report. | CBC Housing |
| 18 | Bedfordshire Police to ensure that the Cultural Intelligence training is delivered to all staff and officers and is on-going. Part of this delivery is to include the awareness of overshadowing and unconscious bias with multi-complex individuals. This will ensure that all staff and officers have the required awareness to act holistically and take all information into consideration when risk assessing and dealing with individuals who may have mental health issues, be suffering from domestic abuse, medical issues or substance abuse and ensure that they are all considered when determining the most appropriate response and support. | Bedfordshire Police |
| 19 | Suicide Prevention group of Public Health BLMK to coordinate and collaborate with partners on a consultation process to implement a working agreement between agencies for professional discussions to take place following agreed trigger points of multiple attempts to die by suicide. This is to provide a practical collaborative approach to prevent those who have attempted to die by suicide on more than one occasion, an individual plan to support their individual needs and complexities. | Public Health BLMK |
| 2 | As a safeguarding function, it is strongly recommended that the MARAC should be placed on a statutory footing. This would enable robust management, reporting, action ownership and accountability at the outset. | government_dept |
| 20 | ELFT to review the ongoing support services for those discharged from hospital following multiple attempts to die by suicide. ELFT state that changes in service provisions and offers that differ from patient to patient may prove difficult to change as it will mainly be based on budget and capacity but this is an area that need to be explored as to what can practically be implemented and can dovetail into recommendation 19. | ELFT |
| 21 | ELFT to communicate to Crisis workers that the notes should be read whenever practicable prior to speaking to a patient and how asking an open question or them to repeat their history may impact on them. This will ensure they have an informed approach when speaking to a patient and potentially conducting a risk assessment but may be able to ask the questions in a manner where the patient knows that they have shown due diligence in reading their notes prior to the meeting. | ELFT |
| 22 | Bedfordshire Police to increase awareness of the Home Office Crime Recording Rules in relation to investigating all crimes and considering Coercive and Controlling behaviour for those DA cases that are graded at medium or standard risk. Also, to ensure there is a review procedure to ensure this is being correctly addressed. This will bridge the gap for those cases that are not high risk but require equal consideration and investigation of all relevant crimes in addition to the principal crime. | Bedfordshire Police |
| 3 | An interim local process to be agreed between Probation, Police and Support services to inform victims of domestic abuse of the imminent release from prison of their perpetrators following any length of custodial sentence whilst the National review takes place. This will ensure that the matter is addressed expeditiously for the short term and keeps victims informed whilst the National review takes place. | Probation | Police | Support services |
| 3a | Clear lines of responsibility need to be determined in relation to ownership, management and sharing of information specific to prison releases of domestic abuse perpetrators, notification to victims and reviewing safety plans. This will provide specifics within an agreed protocol to ensure there is no confusion as to who completes what action, negating any omission that may impact on the victim or their safety. This is a subsidiary recommendation to Recommendation 2. | Probation | Police | Support services |
| 4 | Bedfordshire Probation to include reminder information on managing domestic abuse cases in their communications to staff, focusing on the importance of pre-release planning and multi-agency working. This will assist as a reminder and any necessary training provided with the cases that fall under The Domestic Violence Crime and Victims Act (DVCVA) 2004, which the Victim Liaison team are responsible for. Also, for information sharing with other agencies when it does not. | Bedfordshire Probation |
| 5 | Discussion for pre-release domestic abuse intelligence checks to be requested by Probation for a 12-month period where there are known cases of domestic abuse. This would provide additional information to assist with safety planning and identification of victims that require contact and potential support. | Probation |
| 6 | Ensure minimum of annual meetings between Probation Head of Service and Police Lead for Public Protection to discuss collectively our approaches to domestic abuse cases. This will provide a collective approach and strategy and maintain the focus on the area of domestic abuse. | Probation | Police |
| 7 | Public Health to devise a bespoke training package for agencies enabling them to identify and understand the correlation between domestic abuse and mental health issues. This will assist with policy writing and protocols on a strategic level and also for front line, public facing professionals on an operative level. It will increase knowledge and awareness amongst the workforce to assist in: • Identification of suicide indicators • Prevent overshadowing and unconscious bias • Interpretation and identification of risks to individuals at the earliest opportunity • Enable effective interventions to be considered at the earliest possible stage. | Public Health |
| 8 | BLMK Public Health to integrate a domestic abuse specialist from the local region to sit on the Suicide Prevention Steering Group. This will provide representation and specialist advice in the area of domestic abuse within this group. | BLMK Public Health |
| 9 | Agencies to improve on a collaborative approach to supporting those who require safeguarding, particularly with multi-complex needs including: • Fostering relationships • Utilising existing multi-agency meetings for planning • Improving communication between agencies This will ensure that agencies who have trouble contacting ‘hard to reach’ victims via phone to introduce themselves have the opportunity to meet with them through already trusted professionals which may enhance the support and provide specialist support in other areas that they may not have had. It will also ensure that a holistic approach for more than one agency to prevent overshadowing and unconscious bias. | Police | NHS | Local Authority | Probation | Support services |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||