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

Liverpool review

CSP: Liverpool Published: March 2025 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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review identified a consistent failure across multiple agencies to recognise and respond effectively to domestic abuse disclosures, leading to inadequate risk assessments and poor information sharing, particularly concerning the link between domestic abuse, mental health, and suicide risk.

Extracted recommendations

20 recommendations pulled from the report

#	Recommendation	Addressed to
17.1.1	The learning from this review around the sharing of information between statutory and third sector agencies, should be used to inform work on the priority action within the recently launched Violence Against Women and Girls, Mayoral Strategy for Liverpool 2023 – 2026. “Improve and strengthen the relationship between the statutory sector and voluntary sector VAWG specialist and wraparound services”.	Liverpool Community Safety Partnership
17.1.2	That Liverpool Community Safety Partnership requests evidence and assurances from agencies, as to how the learning from this case has been disseminated and embedded into practice. This could be achieved through the submission of a report that details how the learning has been embedded and the outcomes of case audits to demonstrate professionals’ understanding.	Liverpool Community Safety Partnership
17.1.3	Current work to develop a new domestic abuse strategy for Liverpool should take into account the learning from this review, with particular reference to the use of professional curiosity and a ‘believe and verify’ approach when providing services to domestic abuse victims.	Liverpool Community Safety Partnership
17.1.4	That all agencies that have contributed to this review, should provide evidence to Liverpool Community Safety Partnership on how the learning on this case – around the indicators of increased risk of suicide, including where individuals no longer have contact and access with their children, and when this contact is ‘controlled’ due to the children living with and being cared for by others – has been disseminated and embedded into practice.	All contributing agencies
17.1.5	For the purposes of DHRs, the Home Office should seek to achieve agreement with relevant authorities on the provision of pertinent information within the Common Travel Area.	Home Office
17.1.6	That Liverpool Community Safety Partnership should share the learning from this review with CHAMPS Public Health collaborative, to inform their ongoing work on suicide prevention.	Liverpool Community Safety Partnership
17.2.1	Build confidence in the workforce for professional curiosity and routine questioning regarding indicators of domestic violence.	Mersey Care NHS Foundation Trust
17.2.10	Adult Social Care should implement a process whereby referrers are kept informed of decision-making throughout the safeguarding process – from initial referral up to and including the outcome of enquiries.	Liverpool City Council Adult Social Care
17.2.11	A presentation will be provided to the Liverpool Community Safety Partnership regarding the workstream to review the response to referrals from the police and ambulance service, and the implementation of wider changes to practice – to address the learning from this and other previous reviews.	Liverpool City Council Adult Social Care
17.2.12	Updated training level 3 package Adults.	Liverpool University Teaching Hospitals NHS Foundation Trust
17.2.13	Updated training level 3 package Child.	Liverpool University Teaching Hospitals NHS Foundation Trust
17.2.14	Bespoke training to AED, including safeguarding and homelessness referrals.	Liverpool University Teaching Hospitals NHS Foundation Trust
17.2.2	SGA duty service & supervision.	Mersey Care NHS Foundation Trust
17.2.3	Safeguarding Training to be updated to reflect messages and advice relating to the increased risk of suicide in victims of DA / parents where children have been removed to care.	Mersey Care NHS Foundation Trust
17.2.4	That all officers be reminded that evidence-led prosecution should be considered as soon as the victim indicates inability or unwillingness to support an investigation.	Merseyside Police
17.2.5	All incoming safeguarding concerns should be recorded as safeguarding concerns on Liquid Logic on the same day they are received.	Liverpool City Council Adult Social Care
17.2.6	LGA has created guidance on how to make decisions on safeguarding concerns. Adult Social Care should implement these guidelines to ensure a consistent and safe approach is taken when considering safeguarding concerns.	Liverpool City Council Adult Social Care
17.2.7	All ongoing safeguarding work should be recorded contemporaneously: that is, records should be created at the time or as soon as practicable. All adult safeguarding work must be recorded online in the adult safeguarding section of Liquid Logic or case notes.	Liverpool City Council Adult Social Care
17.2.8	Adult Social Care should ensure its staff develop a clear understanding of care and support needs in the context of ‘complex’ needs (mental health/substance misuse needs) and safeguarding criteria.	Liverpool City Council Adult Social Care
17.2.9	Adult Social Care must ensure its staff are aware of their duties under s11 Care Act 2014, whereby they must carry out a needs assessment if the adult is experiencing, or is at risk of experiencing, abuse or neglect, and how Section 11 should be applied in these circumstances.	Liverpool City Council Adult Social Care
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗