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: KentPublished: May 2025Extracted: 18 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report identifies an underestimation of the psychological impact of domestic abuse and coercive control, inadequate inter-agency information sharing, and a lack of recognition of the link between domestic abuse and suicide, alongside concerns about perpetrator management.
Home Office classifications
50 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 - suicidal thoughts
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Victim - case heard at marac before homicide
Victim - immigration involvement
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - under 18 shared parental responsibility (between perpetrators)
Children - living with victim (including adult children)
Children - present at homicide (including adult children)
Children - subject to child protection or domestic abuse prior to homicide
Child - primary address same as victim
Perpetrator - alcohol misuse
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - post traumatic stress disorder (ptsd)
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
Perpetrator - known to probation 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
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - digital stalking
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - police recommendations
DHR process - health services recommendations
DHR process - probation services 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
18 recommendations pulled from the report · 6 matched to organisations in the index
Addressed to
Kent and Medway Suicide Prevention Panel | All agencies, Kent and Medway Safeguarding Adult’s Board and the Kent and Medway Children’s Multi agency Partnership.
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. All agencies to incorporate the above training within their pre- existing domestic abuse training.
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.
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.’
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.
Addressed to
Kent County Council, Integrated Children’s Services
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 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.
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.
Addressed to
Kent Police and the Probation service
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. Nathan had a restraining order against him; it would have been beneficial to the meeting to understand Nathan’s comments surrounding this and whether he is victim blaming. The information regarding him having PTSD would have also been beneficial to the meeting.
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.
Addressed to
All agencies, Kent and Medway Safeguarding Adult’s Board and the Kent and Medway Children’s Multi agency Partnership.
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.
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 Criminal Justice Team within Kent Police to identify a means of highlighting the fact that a victim of domestic abuses current address is not placed on the documentation for the CPS and therefore inadvertently read out in court proceedings.
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.
Addressed to
Kent and Medway Domestic Abuse and Sexual Violence Executive Group
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.
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.
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.