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

Kent review

CSP: Kent Published: May 2025 Extracted: 19 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 agencies' underestimation of the psychological impact of domestic abuse, particularly the link between coercive control and victim suicide. It also identifies gaps in multi-agency information sharing and a lack of robust response to the perpetrator's ongoing controlling behaviour.

Extracted recommendations

19 recommendations pulled from the report

#	Recommendation	Addressed to
10	All agencies’ domestic abuse training is to be reviewed to ensure that coercive and controlling behaviour is highlighted to enforce the fact that the stretch of a perpetrator is far reaching to include the impact of economic abuse and where the offenders are in prison or subject to orders.	All agencies \| Kent and Medway Safeguarding Adult’s Board \| Kent and Medway Children’s Multi agency Partnership
11	The Probation Service to consider the findings from the three DHRs within Kent and Medway (Ann, Connie and Diana) which have raised significant concerns surrounding the identified lack of challenge by Responsible Officers and a practice of passive risk management and over reliance on the accounts provided by the perpetrator.	The Probation Service
12	The Criminal Justice Team within Kent Police to identify a means of highlighting the fact that the current address for a victim of domestic abuse is not to be placed on the documentation for the CPS and therefore inadvertently read out in court proceedings.	Criminal Justice Team, Kent Police
13	All agencies are to provide guidance to staff regarding the use of ‘victim blaming’ language within their interaction with victims and also within their written documentation.	All agencies
14	Training to take place with Coroners to identify the linkage with domestic abuse and potential suicide cases.	Chief Coroner
15	The DASVEG to review and consider the implementation of the J9 project or to liaise with Advocacy After Fatal Domestic Abuse (AAFDA) and Wearside Women in Need (WWIN) who are currently working on a new initiative with the aim of enabling family, friends and communities to better support the people close to them who are subjected to domestic abuse.	Kent and Medway Domestic Abuse and Sexual Violence Executive Group
16	The Head of Education Safeguarding to write to the schools within their area identifying the importance of good record keeping and the role of the Safeguarding Lead within their school.	Head of Educational Safeguarding
17	The NICE guidance regarding pain management is to be circulated to GPs within Kent and Medway with a request that they review their patients in light of the new guidance. This recommendation links into the Kent and Medway SAR David (2021) which also made a recommendation regarding the new NICE guidance.	Kent & Medway CCG
1a	Public Health Suicide Prevention Programme to develop and distribute briefing materials, in a variety of formats, highlighting the link between domestic abuse and suicide that can be used to raise awareness amongst agencies and professionals. To highlight the usage of the DA website as a means to promote training and signposting for support.	Kent and Medway Suicide Prevention Programme Team
1b	All agencies to incorporate the above training within their pre-existing domestic abuse training.	All agencies \| Kent and Medway Safeguarding Adult’s Board \| Kent and Medway Children’s Multi agency Partnership \| Kent Coroner’s service
2	To write to the National Suicide Prevention team in the Department of Health to make them aware about the growing number of deaths by suicide that are happening very close to court cases relating to domestic abuse.	Domestic Abuse Commissioner’s Office
3a	To highlight to the Government the huge gap regarding the link between suicide and domestic abuse.	Domestic Abuse Commissioner’s Office
3b	Although domestic abuse is mentioned as a risk factor within the national suicide strategy, neither suicide nor suicidality are mentioned within the Government’s most recent violence against women and girls (VAWG) or domestic abuse strategy. It seems clear that any meaningful integration of policy or practice across both spheres is lacking.	Home Office
4	The MARAC process should consider the risk of victim suicide following domestic abuse alongside the risk of homicide, where risk factors which indicate coercive controlling abuse, harassment and attempts to separate are present.	Kent and Medway MARAC steering group
5	Kent Integrated Children’s Services is developing a ‘spotlight on domestic abuse’ series which is a development programme which will look to develop knowledge in many aspects of domestic abuse, including coercive and controlling behaviour. It is recommended that this training programme is extended to include the link between domestic abuse and suicide.	Kent County Council, Integrated Children’s Services
6	Kent and Medway CCG to continue to develop the work with GPs surrounding attendance at MARACs and the importance of information sharing. Consideration to be given to the creation of the role of a MARAC liaison nurse’s role for general practice to allow for a more informed and effective decision making and safety planning process to take place.	Kent and Medway CCG
7	Upon completion and review/audit of the IRIS project, dependent of the findings, consideration is to be given to the rolling out IRIS within other parts of Kent and Medway.	Kent and Medway CCG
8	The MARAC process needs to consider that hearing current information surrounding the perpetrator, his background and mindset, can be beneficial as it can establish risk and dynamics. The perpetrator had a restraining order against him; it would have been beneficial to the meeting to understand the perpetrator’s comments surrounding this and whether he is victim blaming. The information regarding his mental health and drug misuse would have also been beneficial to the meeting.	Kent Police \| the Probation service
9	The MARAC process requires a review to make sure that it is more meaningful. Evidence has shown that because numerous victims are discussed within the one meeting there are often times when individual agencies who are relevant are not identified and invited. A more robust process needs to take place where a victim is treated as an individual and that the circumstances are looked at on an individual basis. The minute taking and actions review also requires a review to make sure that they are SMART and meaningful.	Kent and Medway MARAC Steering Group
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗