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
Norfolk review
CSP: Norfolk
Published: May 2025
Year of death: 2020
Extracted: 25 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 a perpetrator's extensive history of violent and coercive control across multiple relationships, alongside systemic failures in inter-agency information sharing, risk assessment, and professional curiosity, which collectively led to missed opportunities to safeguard the victim and children.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| R1 | It is recommended that a regular audit of domestic abuse cases is undertaken to evidence the use of the Pre-Birth Protocol/Joint Assessment of children and young people to ensure joint decision-making and understanding of the impact of domestic abuse on unborn babies, children, and young people. | Cambridgeshire Community Services (NHCP) |
| R10 | It is recommended that the Probation Service reinforces the current requirement of UPW supervisors to update records, relating more specifically to what he/she did/said during sessions. This could significantly increase the quantity and quality of information known about individuals and would be particularly beneficial with SA UPW cases, where contact with probation officers is often more limited. Probation managers should undertake case dip samples to ensure that records are made and appropriately detailed. | Probation Service |
| R11 | It is recommended that, in these instances, that regular and structured Planned Telephone Contacts be made until termination. This will ensure that the current situation and risk of serious harm be monitored accurately for the entire duration the cases are open. | Probation Service |
| R12 | It is recommended that policies and procedures are reviewed to ensure that absent parents are contacted when referrals are received, if appropriate, and they are given the opportunity to give their view. | Children's Social Care |
| R13 | It is recommended that CSC reinforces the guidance and that were appropriate children are seen alone and potentially away from the home to gather their views and that there is a plan of action to achieve this. | Children's Social Care |
| R14 | It is recommended that parents/carers that are potential victims of abuse are seen alone so that they can talk freely about their experiences. This is something that now features in the Domestic Abuse Toolkit (April 2022). | Children's Social Care |
| R15 | It is recommended that schools and colleges are included in multi-agency risk planning to support a shared understanding of risk | Norfolk County Council, Education Department |
| R16 | Both HS1 and PS2 suggested that the information contained within the police reports can be confusing or limited and it is recommended that a single point of contact for Operation Encompass would be a beneficial further improvement. | Norfolk County Council, Education Department | Norfolk Constabulary |
| R17 | It is recommended that support for schools and colleges is developed where the content of reports is confusing and/or thresholds for statutory interventions for children are not met and parents are not willing to engage with voluntary services, but children continue to experience the devasting consequences of parental conflict and domestic abuse and violence | Norfolk County Council, Education Department |
| R18 | It is recommended that a system is put in place to ensure that schools and colleges are involved in the immediate planning following include serious incidents such as murder of a parent or carer. | Norfolk County Council, Education Department |
| R19 | It is recommended that the ICB supports a primary care system wide review of health visitor/social worker escalation processes and establish effective protocols, as necessary | Norfolk and Waveney Integrated Care Board |
| R2 | It is recommended that practitioners need to be able to demonstrate that they have contributed to the assessment process jointly with children services including the seeking of the outcome of assessments and challenging decision making when there is a professional disagreement. | Cambridgeshire Community Services (NHCP) |
| R20 | It is recommended that the ICB supports a primary care system wide review of responses to notifications of domestic abuse and high-risk concerns and establish effective protocols as necessary | Norfolk and Waveney Integrated Care Board |
| R21 | It is recommended that the ICB works in partnership with specialist services to ensure the availability of domestic abuse training | Norfolk and Waveney Integrated Care Board |
| R22 | It is recommended that the ICB includes domestic abuse (identification/response etc) in the primary care adult safeguarding exemplar policy | Norfolk and Waveney Integrated Care Board |
| R23 | It is recommended that the ICB to supports practices to each establish a domestic abuse champion and ensure that a supportive network is created to maintain and develop this role. | Norfolk and Waveney Integrated Care Board |
| R24 | It is recommended that when a victim indicates that they are considering withdrawing their statement the IDVA (where engaged in a case) is advised so that specific support can be provided. | Norfolk Constabulary |
| R25 | It is recommended that officers across Norfolk Constabulary are reminded of the need to inform partner agencies when additional information is obtained. | Norfolk Constabulary |
| R3 | It is recommended that HCP ensure that the identification of the pathway for care is reviewed as part of the ongoing service review | Cambridgeshire Community Services (NHCP) |
| R4 | It is recommended that staff are supported to discuss healthy and unhealthy relationships with both parents/carers and to support their understanding of the impact of domestic abuse on children. | Cambridgeshire Community Services (NHCP) |
| R5 | It is recommended that staff are supported to discuss the manipulation by perpetrators on their day-to-day practice within supervision, team meetings and training. | Cambridgeshire Community Services (NHCP) |
| R6 | It is recommended that these tools are revisited considering any published guidance alongside the Domestic Abuse Act 2021 which emphasises that children should be considered as victims of domestic abuse. | Cambridgeshire Community Services (NHCP) |
| R7 | It is recommended that practitioners should, seek the child’s voice and reflect their lived experience in cases where there are elements of coercive control and view the children as victims of domestic abuse. | Cambridgeshire Community Services (NHCP) |
| R8 | It is recommended that all staff, including support staff and those responsible for supervising IP placements undertake domestic abuse training. The training should ensure that staff are fully trained and confident in their ability to identify any signs of domestic abuse, along with an understanding of how and where to share this information appropriately. This should be an ongoing process to ensure that all new staff receive training. | Probation Service |
| R9 | The review is aware that since the commencement of this case, ‘Think this, Do this’ guidance aimed at increasing staff curiosity around safeguarding has been implemented but it is recommended that further training is provided to all staff in professional curiosity, including support staff, UPW staff and operational partners including those responsible for supervising IP placements. | Probation Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||