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
Buckinghamshire review
CSP: Buckinghamshire
Published: March 2025
Year of death: 2021
Extracted: 43 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 highlights systemic failures in identifying and responding to complex domestic abuse, including elder abuse and child-to-parent abuse, alongside the perpetrator's unmanaged mental health, substance misuse, and autism spectrum disorder, leading to missed opportunities for intervention.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Safer Buckinghamshire Partnership to seek evidence-based assurance from key partner agencies that practitioners understand how older adults and/or those with care and support needs may experience coercive control and that the law is being fully utilised to safeguard them. | Safer Buckinghamshire Partnership |
| 2a | As parents experiencing child-to-parent abuse are less likely to identify their experiences as domestic abuse and less likely to seek support and protection from the abuse, Safer Buckinghamshire Partnership to raise awareness with the public and with partner agencies, about the nature of child-to-parent abuse and the help that is available | Safer Buckinghamshire Partnership |
| 2b | Safer Buckinghamshire Partnership to seek assurance from police, social care, health and specialist domestic abuse and substance misuse agencies that increasing numbers of parents experiencing child-to-parent abuse are being identified, supported and protected and that they are adopting a multi- agency collaborative approach to the issue | Safer Buckinghamshire Partnership |
| 3 | Buckinghamshire Integrated Care Board to consider the pathway between GP Practices and One Recovery Bucks in order that there is a more seamless route between the two services than merely signposting patients. | Buckinghamshire Integrated Care Board |
| 4a | Buckinghamshire Council Housing Services and Oxford Health NHS Foundation Trust to provide assurance to Safer Buckinghamshire Partnership concerning how the revised Memorandum of Understanding: has ensured that the mental health needs of homeless people within temporary accommodation are identified, supported and where necessary, disputes escalated to resolution | Buckinghamshire Council Housing Services | Oxford Health NHS Foundation Trust |
| 4b | Buckinghamshire Council Housing Services and Oxford Health NHS Foundation Trust to provide assurance to Safer Buckinghamshire Partnership concerning how the revised Memorandum of Understanding: that the embedded mental health worker is effectively supervised and supported in real time when individuals present themselves with acute mental health issues | Buckinghamshire Council Housing Services | Oxford Health NHS Foundation Trust |
| 4c | Buckinghamshire Council Housing Services and Oxford Health NHS Foundation Trust to provide assurance to Safer Buckinghamshire Partnership concerning how the revised Memorandum of Understanding: that the embedded worker has clear guidance on where information should be recorded across both systems | Buckinghamshire Council Housing Services | Oxford Health NHS Foundation Trust |
| 5 | All Safer Buckinghamshire Partnership agencies, and those involved in this review, to ensure that domestic abuse policies are up to date, or, for those without one, to ensure a policy is developed. The policy must be accompanied by regular and mandatory training on domestic abuse. | Safer Buckinghamshire Partnership |
| 6 | Safer Buckinghamshire Partnership to share an update with the bereaved family in 12 months’ time, concerning what has changed as a result of the domestic homicide review and subsequent action plans. | Safer Buckinghamshire Partnership |
| ASC1 | Reinforce and refresh Safeguarding training for all staff with a focus on domestic abuse and dealing with coercive and controlling behaviour and including economic abuse in the context of deputyship for finances, | Buckinghamshire Council Adult Social Care |
| ASC2 | Greater emphasis across the service of the principles of Making Safeguarding Personal (MSP) | Buckinghamshire Council Adult Social Care |
| ASC3 | Greater emphasis across the service of the principles of Making Safeguarding Personal and ensuring that practitioners enable safe disclosures of domestic abuse during section 42 enquiries, including seeing individuals alone; asking directly about domestic abuse; seen in different settings where possible; consideration given to the use of advocates | Buckinghamshire Council Adult Social Care |
| GP1.1 | To develop practice responses so that sensitive and routine enquiry is undertaken into domestic abuse where indicators of domestic abuse are present, irrespective of the sex of the individual | GP Practice 1 |
| GP1.2 | To develop practice responses so that individuals presenting with problematic alcohol use are advised about, and encouraged to use, alcohol treatment services | GP Practice 1 |
| GP1.3 | To develop practice responses so that the value of a carer’s assessment is routinely discussed with individuals caring for others, and referrals to the local authority made where accepted | GP Practice 1 |
| GP2.1 | To raise awareness with Practice staff that dementia symptoms can be a veil for domestic abuse | GP Practice 2 |
| GP2.2 | To develop practice responses so that mental capacity assessments are considered when services for memory loss are declined | GP Practice 2 |
| GP2.3 | To develop practice responses so that individuals are seen alone for at least part of the consultation when indicators of domestic abuse are present in order that any disclosures could be made or routine questioning on domestic abuse undertaken | GP Practice 2 |
| GP2.4 | To develop practice responses so that the potential for economic abuse is considered when applications for Lasting Power of Attorney are being made | GP Practice 2 |
| GP2.5 | To develop practice responses so that GPs are alerted in future consultations to allegations of domestic abuse through effective coding and recording of domestic abuse | GP Practice 2 |
| GP3.1 | To develop GP awareness of drug seeking behaviours and ensure that they are alert to the risk of addictions for patients being prescribed opioid medication, considering referrals to One Recovery Bucks before prescribing where there is a history of drug use. If alternative pain relief is not issued, to ensure that decisions to prescribe opioid medication are reviewed and that firm boundaries are put in place from the start of the prescribing period. | GP Practice 3 |
| GP3.2 | To review the systems in place that alert the GP Practice to Out of Hours, and vice versa, of each other prescribing and risk monitoring to ensure that there is not over-prescribing, particularly of medication that can lead to addictions. | GP Practice 3 |
| GP3.3 | To review the system within the Practice whereby repeated notifications from the Ambulance Service about drug seeking behaviours did not raise the need to alert a GP to review the patient | GP Practice 3 |
| GP3.4 | To develop practice responses so that third party information received and alerting to safeguarding risks for a patient is acted upon and adult safeguarding referrals made when needed. | GP Practice 3 |
| HOU1 | Details of an applicant’s known history of violence are systematically provided to temporary accommodation providers before referred and placed with them | Buckinghamshire Council Housing Services |
| ICB1 | To develop the domestic abuse primary care pathway in order that sensitive and routine enquiry is systematically undertaken into domestic abuse, across Buckinghamshire GP Practices, where indicators of domestic abuse are present, irrespective of the sex of the individual. In order to develop the domestic abuse pathway, and meet the ambitions of Making Every Contact Count, the Partnership to consider Domestic Abuse Statutory Guidance (2021) which promotes the Whole-Health Model to domestic abuse incorporating: “Findings from the Pathfinder Project highlighted that health professionals feel better able to enquire about domestic abuse if their Integrated Care System and primary care networks supported the placement of Independent Domestic Violence Advisors (IDVAs) or other accredited domestic abuse peer advocacy programme. These specialised trauma-informed services might then be best placed to follow up with any disclosures of abuse; a greater understanding of local referral pathways; specialist recovery and peer advocacy services to which they can refer or signpost victims, survivors or perpetrators dependent upon their unique situation.” (para 293) “Implementing the IRIS (Identification and Referral to Improve Safety) Programme. IRIS is an evidence-based intervention to improve the general practice response to domestic abuse through training, support to practice teams and having a DA specialist embedded in practices. It is nationally recognised as best practice and has informed NICE guidance” (para 306) | Buckinghamshire Integrated Care Board |
| OH1 | Improve how actions from Section 42 or other safeguarding reviews involving Oxford Health are recorded and monitored centrally. | Oxford Health NHS Foundation Trust |
| OH2 | Improve joint working with One Recovery Bucks | Oxford Health NHS Foundation Trust |
| OH3 | Improve how Rough Sleeper Initiative embedded MH practitioner role is managed. | Oxford Health NHS Foundation Trust |
| OH4 | Review how Oxford Health contributed to the multi-agency approach, communicated, shared information escalated issues. | Oxford Health NHS Foundation Trust |
| ORB1 | That all areas of the Risk Assessment are completed; where elements are not completed a rationale for this should be documented within the Risk Assessment. | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| ORB2 | That where a service user / patient is known to be open to mental health services / other services; that, with the service user’s consent that organisation is informed off the service user’s engagement with ORB either by writing or in an email format and that the ORB requests a summary including diagnosis and treatment from the named relevant mental health service. ORB Clinical Summaries should be shared with named mental health services as standard practice | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| ORB3 | that the risk assessment is an accurate reflection of case note entries when describing risk. Where a service user/patient verbalises a threat, ORB staff should discuss the need to react in a socially acceptable and legal manner, educate them of the potential consequences of any threatening or aggressive behaviour and inform any associated agencies of the potential risk. Risk assessment should be updated to accurately reflect risk | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| ORB4 | Keyworker to confirm any medication changes with the prescriber and to record these within the service user/ patients case notes and care plan. Keyworker and other ORB staff who have contact with the service user / patient to observe and monitor for any changes in mental health and to ask the service user / patient to describe any mental health symptoms at appointments. Any significant changes to be shared with prescriber / mental health service. Consent to share information with health services should be sought at the point of initial assessment. | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| ORB5 | that bloods should ideally be taken prior to commencing Espranor and if not possible then taken a soon as possible after prescribing is initiated. | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| ORB6 | Service users/patients should be reminded of the need to attend appointments and to fully participate in their recovery programme. Full compliance with the ORB Did Not Attend procedures. | One Recovery Bucks (Midland Partnership NHS Foundation Trust) |
| SCAS1 | Include the importance of considering safeguarding for people who make frequent calls requesting controlled drugs and who display drug-seeking behaviours within the new training package. | South Central Ambulance Service NHS Foundation Trust |
| SCAS2 | Learning from the review will be shared with staff to inform future practice | South Central Ambulance Service NHS Foundation Trust |
| TVP1 | To provide Safer Buckinghamshire Partnership evidence- based assurance that: Adult protection reports are recorded on Niche and tasked accordingly | Thames Valley Police |
| TVP2 | To provide Safer Buckinghamshire Partnership evidence- based assurance that: Adult protection notifications are consistently submitted | Thames Valley Police |
| TVP3 | To provide Safer Buckinghamshire Partnership evidence- based assurance that: Domestic abuse is being identified for vulnerable adults, either child to parent, or in relation to caring, investigated and appropriate safety measures put in place | Thames Valley Police |
| TVP4 | To provide Safer Buckinghamshire Partnership evidence- based assurance that: Consistency in completion of the DOM5 (DASH) | Thames Valley Police |
| TVP5 | To provide Safer Buckinghamshire Partnership evidence- based assurance that: Background checks are systematically being taken when reports of neglect or abuse are received by Contact Management and callers are not only signposted to Adult Social Care when indicators of neglect or abuse are present. | Thames Valley Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||