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
Southampton review
CSP: Southampton
Published: June 2025
Year of death: 2020
Extracted: 18 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 significant failures in multi-agency information sharing and a lack of recognition of intra-familial violence, leading to inadequate risk assessments and a failure to safeguard the victim and family members.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 9.1 | Advice to be sought from the Home Office on the effectiveness of DASH as a risk checklist in cases where an adult child poses a threat to a parent. | Home Office |
| 9.10 | That all agencies in Southampton to have an action Plan in place to prepare for the introduction and need to implement the Domestic Abuse Act 2021. That this action plan includes a policy and process on the risk assessment and management of domestic abuse. This is a wide-ranging act which will have consequences for many agencies both within and outside of the DA sector. This will include many new duties to collect, store and share information and will require modification to current rules and methods of information storing and sharing. | Southampton City Council |
| 9.11 | This recommendation builds on the Southampton wide Carers Strategy which has been developed in an ongoing partnership with carers and whose governance sits with the Better Care Board (under the Health and Wellbeing Board). I. The Better Care Board (Health and Wellbeing Board) is assured that the staff (paid or unpaid) across the city can identify carers and know how to respond to their safety, wellbeing, and support needs, including sharing information with relevant services where this is needed. II. That the Southampton wide Carers Strategy includes an emphasis on carers and safeguarding, a focus on both the carer and the adult they care for, including why carers may be at risk of harm and what may prevent, reduce or stop the risk. The learning within the recent Carers and safeguarding: a briefing for people who work with carers | Local Government Association would support this. III. To support the effective safeguarding of carers the strategy should also include a link to guidance for frontline workers in speaking privately with carers, using an agreed list of questions that cover issues of coping, fear, threat and safety to ensure proper assessment and response to any identified areas of concern. IV. The 4LSAB Family Approach is due for revision and should be relaunched with a focus on identifying risk and needs of carers as well as adults with care and support needs. This includes an expectation of using the Multi Agency Risk Management framework and any other multi-agency forums for the management of any risks to carers/family members from the adult with care and support needs. | Better Care Board (Health and Wellbeing Board) | 4LSAB |
| 9.12 | Southern Health Foundation Trust agree the safeguarding pathway they are currently (as of June 2022) reviewing. This will provide a streamlined procedure for responding to safeguarding concerns. Including finalising the safeguarding module on the Rio recording system which will enable them to record safeguarding concerns if the Section 42 threshold has been met and the outcome of the safeguarding concern. | Southern Health NHS Foundation Trust |
| 9.13 | That all front facing workers and managers receive training that enables them to identify risks posed to family and carers in non-intimate familial relationships and ensure all workers understand and appropriately assess the impact of known risk factors such as substance abuse and poor mental health which may increase risk to family members. The Panel accept that this is a long-term project which will involve a cultural shift in how workers see and approach their work with the client/patient. It is anticipated that achieving this shift will involve four steps; 1) Raising the awareness of workers to non-intimate familial violence/control, 2) sourcing or developing the training material and 3) Committing to, providing, and resourcing the training, and 4) Embedding and ensuring that the learning is being applied in practice through clinical supervision and evidence in casework files. | Southampton City Council |
| 9.14 | That the Authority request that the Home Office commission the development of a brief and user-friendly Domestic Abuse assessment tool that can be used for non-intimate partner and inter family violence and abuse with confidence. | Southampton Safe City Partnership | Home Office |
| 9.15 | That Southern Health NHS Foundation Trust will seek to move recording of events and the presentation of service users from one which is primarily clinical, and evidence based to one that also includes an assessment of that evidence. | Southern Health NHS Foundation Trust |
| 9.16 | That all GP’s in the area are aware of and subscribe to the good practice identified in the Royal College of General Practice 2013 Policy document “Supporting carers in general practice: a framework of quality markers”. | Integrated Care Board |
| 9.17 | The CCG promote a consistent approach with Carers across the GP Surgeries they commission to include: - As a minimum all GP surgeries (if they do not already have in place) to develop a list of all patients who are also carers and to have a marker system so that such patients are identified automatically to both GP, reception and any other auxiliary nursing staff linked to the practice. To encourage all GPs in the area to develop a process to actively identify, refer, and support carers including children and young people, to reduce or prevent inappropriate caring responsibilities, because of taking on caring roles. To ensure all GP’s provide written advice to carers, including young carers, of their right to request a carer’s needs assessment. To ensure carers are encouraged to book a separate appointment for themselves to discuss what matters to them, including their own health and wellbeing needs. | Integrated Care Board |
| 9.18 | The SSAB and Southampton Safe City Partnership share all agencies assessment and management tools for when ‘Threats to Kill’ are made with a view to learning from each other and establishing what is best practice. | Southampton Safeguarding Adults Board | Southampton Safe City Partnership |
| 9.2 | That Southampton Local Authority harnesses the powerful messages expressed by this family concerning the impact the tragedy has had on them and their hopes for how families like theirs might be better helped in the future by working with them to produce a short video to be used by all agencies in their DA training for front line and associated workers. | Southampton City Council |
| 9.3 | That all agencies are explicit when risk assessing victims and family members about why an assessment is being undertaken and to be able to identify and evidence their assessment of the nature, level of seriousness and imminence of the risk they believe exists. If professionals believe victims to be minimising the risk posed by a family member, they should use their professional judgement to make HRDA referral in line with learning from the Standing Together research. | Southampton City Council | Solent NHS Trust | Integrated Care Board |
| 9.4 | That Southern Health NHS Foundation Trust review the format of its SI’s to reflect the whole person and does not frame the individual purely by any negative, criminal, or anti-social behaviour or other discriminatory identifiers. | Southern Health NHS Foundation Trust |
| 9.5 | That Southern Health NHS Foundation Trust review its ‘Carers Strategy’ to ensure that initial Psychiatric assessments are shared and communicated with the wider family where possible while working with and in event of serious events involving their family or the patient/client. This is in line with recent findings in the Domestic Homicide Project Spotlight Briefing #1: Adult Family Homicides Research January 2022 referred to earlier in this Review. Additionally, that in this, and in all future such cases to allocate an identified SPOC so that the family members can be communicated with sensitively and compassionately and to reduce re-traumatisation due to having to repeat their circumstances and background each time they speak to a member of staff. | Southern Health NHS Foundation Trust |
| 9.6 | That Southern Health NHS Foundation Trust ensure a distressed caller receives a follow up call or if not operationally possible a signposting to an appropriate agency at the time and that they secure a separate and confirmed assurance that the distressed caller has support from family or friends. | Southern Health NHS Foundation Trust |
| 9.7 | Commissioners of services to require as a condition of contract an assurance that such services offered are fit for purpose for this group of service users with mental health needs. And that the additional vulnerabilities of both client and carers and linked risks of domestic abuse are recognised and factored into any contract agreement, with a protocol (or agreed terms in the contract) in place to ensure service providers accept and respond to their duty to help to protect potential victims. | Integrated Care Board | Southampton City Council |
| 9.8 | All Health organisations’ Domestic Abuse Policies need to be embedded in practice and relate to staff as well as patients. This must go beyond intimate partner abuse, which is generally recognised but also to include intra familial violence, which as research and this specific case shows is not so well recognised or even known of. DA ‘complexities’ training should be mandatory for all grades of staff, and it should follow the ‘NICE’ guidelines. All frontline staff should be expected to sensitively enquire about DA, including the identification of potential perpetrators and any risks they may pose to carers and/or other family members. If risks have been identified, safety planning must follow. Information sharing within an integrated care pathway should support this. This should be a standard item in both clinical and safeguarding supervision. | Solent NHS Trust | University Hospital Southampton NHS Foundation Trust | Southern Health NHS Foundation Trust | Integrated Care Board |
| 9.9 | The Safer Cities Board and SSAB in light of this case review agency cohesion and joint working in the Southampton area. The Review heard of a complex landscape of agencies and Health bodies with often difficult and fractured lines of communication, a commitment should be made to undertake regular multi-agency audits of cases. This to be a shared venture with representatives from all relevant agencies participating and sharing information and recommendations from the learning. The learning from these audits to be shared with all relevant staff and stakeholders. | Southampton Safer City Partnership Board | Southampton Safeguarding Adults Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||