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: May 2025
Year of death: 2022
Extracted: 12 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 poor inter-agency communication and delayed, uncoordinated responses from police and mental health services to the victim's escalating distress and stalking, contributing to missed opportunities for safeguarding and prosecution.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 9.1 | The police (working with the Police and Crime Commissioner) provide assurance to CitySafe and the Domestic Abuse Partnership Board that training on stalking prevention orders and the national stalking and harassment protocol has been provided to all frontline officers. They should also report on take-up by police staff of Mersey Care and LCC’s suicide prevention training offer. | Merseyside Police | Police and Crime Commissioner |
| 9.10 | The Partnership may find it beneficial to review guidance on the MARAC referral pathway to remind practitioners they are lawfully entitled (and may have a duty of care) to utilise powers under s42 Care Act to bring together practitioners with the adult at risk to formulate shared understanding of needs, risks and agree interim safety plans. | Citysafe Partnership |
| 9.11 | Review stalking/harassment risk assessment so there is more weight given to psychological impact, particularly for those who have existing mental health conditions which, research confirms, escalates the risk of suicide. | Citysafe Partnership |
| 9.12 | Merseyside Police should provide an assurance report to the Partnership in respect of the timeliness of referrals to the CPS in respect of stalking and harassment cases and, if this identifies systemic issues in respect of delay, devise an action plan to remedy this. | Merseyside Police |
| 9.2 | The police and PCC to agree data it will provide to the partnerships, on: timeliness of stalking and harassment investigations. involvement of professional support networks where victims have EUPD to ensure a trauma-informed approach. referrals by the police under VRPF1 or MARAM called by police staff for vulnerable victims/ perpetrators for stalking/ harassment. | Merseyside Police | Police and Crime Commissioner |
| 9.3 | The Partnership, working with domestic abuse providers, police and PCC, provide a practitioner’s briefing (taking into account the published CPS guidance) with descriptors so that victims and perpetrators (as well as practitioners) know how to distinguish between the different offences, what information to share to evidence legal thresholds for each type of offence and how these interface with civil powers so that victims and practitioners are empowered to prevent ongoing harm and perpetrators can more quickly be held to account. This should also highlight existing processes for multi-agency risk management (including s42 Care Act duties and MARAM) and referral pathways for existing services in Liverpool (including those offered by MDVS) to support victims of stalking and the ‘make a change’ intervention programme . for perpetrators | Citysafe Partnership | Merseyside Police | Police and Crime Commissioner | Crown Prosecution Service | Merseyside Domestic Violence Service |
| 9.4 | The Partnership write to local courts liaison groups and the Chief Constable to seek assurance that recommendations from the joint Courts and Home Office review have been implemented. Particular regard should be had to the requirement that ‘forces consult with the victim or a stalking advocate when drafting conditions to ensure they are tailored to the victim’s case.’ | Citysafe Partnership | Merseyside Police |
| 9.5 | The Partnership (working with the Domestic Abuse Partnership Board) to explore options for a single point of access for people experiencing domestic abuse, include stalking/ harassment similar to SARC but for those experiencing domestic abuse, including stalking. | Citysafe Partnership | Domestic Abuse Partnership Board |
| 9.6 | ICB provide assurance that they will actively supporting the development of domestic abuse champions across primary care and secondary mental health trusts, with a specific focus on upskilling frontline practitioners to complete DASH/SASH risk assessments and, with reference to this case, that the onus is on practitioners to come together for a shared risk management plan so the burden is not on the victim to coordinate their care and progress the police investigation. | NHS Liverpool ICB |
| 9.7 | RLUH and Mersey Care should provide assurance to the Partnership that their discharge pathway from A&E and MHLT has been reviewed to strengthen transfers of care and support cohesive and collaborative safety and care planning between the patient and services on each side of the transfer. | Royal Liverpool University Hospital Trust | Mersey Care NHS Foundation Trust |
| 9.8 | Mersey Care Trust provide assurance that staff within CMHT, CRHT and MLHT have completed suicide prevention training in line with the Trust’s suicide prevention policy. That relevant assessment and, particularly the extended care plan for those with EUPD, have been updated to include specific questions regarding suicide risk factors, domestic abuse (stalking and harassment) and emergency contact are included within safety plans. The Trust should consider, as part of their action plan for this review, timetabling within 2023/24 workplan an audit of case files from CMHT, CRHT and MLHL to explore if safety plans comply with their Personality Disorder and safeguarding policies as well as good practice expectations. | Mersey Care NHS Foundation Trust |
| 9.9 | Partner agencies working with Merseyside Police should produce a briefing on powers of entry and the information required to trigger those powers if a person’s welfare requires checking. In preparation for the role out of ‘Right Person; Right Care’ all partners agencies should highlight their own organisational duty of care to conduct welfare checks of service users who might be a risk, rather than relying on police to carry these out in all situations. | Merseyside Police | Liverpool City Council | Mersey Care NHS Foundation Trust | Royal Liverpool University Hospital Trust | NHS Liverpool ICB |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||