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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identifies missed opportunities by agencies to recognise and respond to inter-adult family violence, entrenched criminality, and substance misuse between the victim and the perpetrator. Inconsistent information sharing and a lack of professional curiosity hindered a holistic understanding of the complex, volatile relationship and associated risks.

Home Office classifications

36 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - honour based violence
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership 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

27 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

Addressed to All Agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to STHFT

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to All Agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to SYP

SYP should build upon the training to date, and support professionals in identifying and responding to inter-adult violence / domestic abuse between siblings.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to STHFT

STHFT should build upon the training to date and support professionals working within the Emergency Department(s) using selective enquiry or professional curiosity.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to STHFT

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to STHFT

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Sheffield CCG

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to SCCG

SCCG should build upon the training to date, and support professionals, in identifying and responding to inter-adult violence / domestic abuse between siblings.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to All Agencies

All Agencies should recognise the importance of multi-agency working and follow agreed protocols around information sharing in order to assess risk.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 11

Addressed to All Agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 12

Addressed to All Agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 13

Addressed to Sheffield Children’s NHS Foundation Trust (SCFT) | Sheffield Health and Social Care Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 14

Addressed to All Agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 15

Addressed to SYP

SYP should ensure a DASH risk assessment is completed in all domestic abuse incidents, even when the victim is refusing to engage.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 16

Addressed to The Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 17

Addressed to SYP

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 18

Addressed to STHFT

STHFT should ensure patients are signposted for specialist support when they are exhibiting evidence of alcohol and drug misuse.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCCG 1

Addressed to Sheffield CCG

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCCHNS 1

Addressed to Sheffield City Council - Housing & Neighbourhood Services (SCCHNS)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation STHFT 1

Addressed to Sheffield Teaching Hospitals Foundation Trust (STHFT)

To build upon the ongoing training as part of the safeguarding champions network awareness around the impact of ACEs and adopting trauma informed practice.

Verified wording from the published review · Original review (PDF) ↗

Recommendation STHFT 2

Addressed to Sheffield Teaching Hospitals Foundation Trust (STHFT)

To raise awareness through levels 2 and 3 Safeguarding training of the ‘Think Family’ approach when undertaking assessments.

Verified wording from the published review · Original review (PDF) ↗

Recommendation STHFT 3

Addressed to Sheffield Teaching Hospitals Foundation Trust (STHFT)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation STHFT 4

Addressed to Sheffield Teaching Hospitals Foundation Trust (STHFT)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SYP 1

Addressed to South Yorkshire Police (SYP)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SYP 2

Addressed to SYP

SYP have stated they will explore whether the DA Matters training could be expanded to include cultural differences.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SYP 3

Addressed to SYP

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.

Verified wording from the published review · Original review (PDF) ↗