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
Sheffield review
CSP: Sheffield
Published: June 2025
Year of death: 2020
Extracted: 27 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' failure to consistently identify inter-adult family violence and coercive control, alongside inconsistent information sharing and missed opportunities for risk assessment and addressing substance misuse, particularly concerning male victims.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | All Agencies should recognise the importance of ensuring ethnicity and other protected characteristics are recorded. All Agencies should provide additional guidance and training around recording and sharing personal information, including protected characteristics. | All Agencies |
| 1 | Continued training packages for dealing with non-engagement, and the barriers faced specifically due to cultural differences. Training to include working alongside community leaders to enhance SYP profile and the perceptions of Police as a force to help those in need. | South Yorkshire Police |
| 1 | To build upon the ongoing training as part of the safeguarding champions network awareness around the impact of ACEs and adopting trauma informed practice. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 1 | Sheffield CCG to encourage GP Practice staff to adapt their ‘did not attend’ policy to consider the impact of not accessing health care appointments on the health of adults who may lack capacity and children. | Sheffield Clinical Commissioning Group |
| 1 | The Housing and Neighbourhoods Service is in the process of developing a ‘tenancy ready course’ to help new tenants understand how to manage their tenancy with the help of a support worker. This will hopefully support vulnerable tenants and reduce incidents of non-engagement between the Housing and Neighbourhood Service and tenants. | Sheffield City Council - Housing & Neighbourhood Services |
| 10 | All Agencies should recognise the importance of multi-agency working and follow agreed protocols around information sharing in order to assess risk. | All Agencies |
| 11 | All Agencies to disseminate to Professionals the ‘Standing Together Against Domestic Violence’ (Sharp-Jeffs and Kelly, 2016) guidance, as part of their professional development strategies. | All Agencies |
| 12 | Where domestic abuse may be suspected, Professionals should seek to create a safe space (including the use of interpreters as necessary), in order to provide opportunity for vulnerable victims to disclose what may be happening in confidence. | All Agencies |
| 13 | Health Visitors (working for Sheffield Children’s NHS Foundation Trust (SCFT) or Sheffield Health and Social Care Trust) should routinely submit a DASH (Domestic Abuse, Stalking, Harassment, and ‘Honour’ Based Abuse) risk assessment where domestic violence or abuse is identified or suspected, including inter-family violence. | Sheffield Children’s NHS Foundation Trust | Sheffield Health and Social Care Trust |
| 14 | All Agencies are encouraged to build upon the professional development to date and support professionals around identifying and supporting victims who may be subject of coercive control. | All Agencies |
| 15 | SYP should ensure a DASH risk assessment is completed in all domestic abuse incidents, even when the victim is refusing to engage. | South Yorkshire Police |
| 16 | The Partnership to review the support available to male victims of domestic abuse, particularly men with protected characteristics; and reassure themselves specialist independent support is accessible to victims, who may be reluctant to come forward. | The Partnership |
| 17 | SYP should ensure any person arrested for a ‘trigger’ offence should be the subject of a mandatory drug test and assessment, we well as being offered the support of a drug referral worker. | South Yorkshire Police |
| 18 | STHFT should ensure patients are signposted for specialist support when they are exhibiting evidence of alcohol and drug misuse. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 2 | STHFT should ensure there are effective monitoring and audit arrangements in place to provide reassurance that where a child safeguarding (or vulnerable adult) referral is raised that safeguarding concerns are noted during initial assessment. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 2 | SYP have stated they will explore whether the DA Matters training could be expanded to include cultural differences. | South Yorkshire Police |
| 2 | To raise awareness through levels 2 and 3 Safeguarding training of the ‘Think Family’ approach when undertaking assessments. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 3 | All Agencies to consider the evidence of the links between adverse childhood experiences, family violence and youth offending and put in place strategies to mitigate the risk. | All Agencies |
| 3 | Operational update / brief around the importance of completing a DASH and even submit where DA is suspected, this is regardless of whether the victim engages and assists by answering the questions. | South Yorkshire Police |
| 3 | ED staff to be offered domestic abuse training to include recognition, routine and selective enquiry, use of the DASH risk assessment document and the MARAC referral process. IDAS have offered training and are wanting to link in with ED staff to raise awareness. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 4 | SYP should build upon the training to date, and support professionals in identifying and responding to inter-adult violence / domestic abuse between siblings. | South Yorkshire Police |
| 4 | The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for considering parallel safeguarding and DA referrals. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 5 | STHFT should build upon the training to date and support professionals working within the Emergency Department(s) using selective enquiry or professional curiosity. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 6 | STHFT to raise awareness and understanding of professionals to ensure where domestic abuse is disclosed, within the Sheffield Teaching Hospital, a DASH should be submitted. Within the Emergency Department(s) a Domestic Abuse Communication Form should be used by health professionals. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 7 | The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for considering parallel safeguarding and DA referrals. | Sheffield Teaching Hospitals NHS Foundation Trust |
| 8 | As part of the ongoing review of ‘Did Not Attend’ strategy and policies, Sheffield CCG to consider whether they have the capacity to review the risk where patients demonstrate a consistent lack of engagement. | Sheffield Clinical Commissioning Group |
| 9 | SCCG should build upon the training to date, and support professionals, in identifying and responding to inter-adult violence / domestic abuse between siblings. | Sheffield Clinical Commissioning Group |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||