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

East Sussex review

CSP: East Sussex Published: June 2025 Year of death: 2019 Extracted: 18 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 highlights concerns regarding the unrecognised high risk posed by the perpetrator, the lack of cumulative assessment of safeguarding concerns for the victim, and insufficient multi-agency coordination and information sharing. It also notes challenges in supporting vulnerable individuals with complex needs who frequently move between areas.

Home Office classifications

44 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - physical disability
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - post traumatic stress disorder (ptsd)
  • Victim - self harm
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - physical disability
  • Perpetrator - mental ill health
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Aggravating factors - sexual abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service 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

18 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to CGL East Sussex Domestic Abuse Service

That practitioners are reminded of their responsibility to ensure that a MARAC referral is submitted when professional judgement identifies the need. Work undertaken whilst this review has been ongoing to remind all Practitioners that as the contracted service for domestic abuse in East Sussex, they have a responsibility to take action, inform the referrer of their professional judgement and their intention to submit a MARAC referral.

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

Recommendation 2

Addressed to CGL East Sussex Domestic Abuse Service

That staff are reminded of the need to use professional curiosity in assessment and case work. Discussions held should also be entered into case notes, including potential risk of harm or exploitation.

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

Recommendation 3

Addressed to East Sussex Adult Social Care and Health (ASCH)

ASCH finalise the legal advice so that they are clear on whether a record can be created if the alleged perpetrator is not known to ASC.

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

Recommendation 4

Addressed to East Sussex Adult Social Care and Health (ASCH)

That, in order to raise awareness of professional curiosity, a workshop on Professional Curiosity and Disguised Compliance is included in the national safeguarding conference and literature about professional curiosity is published on the ASCH Single Source.

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

Recommendation 5

Addressed to East Sussex Adult Social Care and Health (ASCH)

That all staff complete the domestic abuse e-learning and that the previous workshop provided to staff is updated and made available online.

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

Recommendation 6

Addressed to NHS Sussex Integrated Care Board

That there is a Sussex wide agreement of Safeguarding Template Consultation Recording and Coding. This would make the information management more useful within the consultation and in the analysis and communication of the information within the practice and beyond. If this were successfully implemented in Sussex, it could form the basis of a template for embedding in the general practice Base Information Systems (Emis and System1), that would allow for adoption of the coded dataset Nationally, making transfer of risk data standardised.

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

Recommendation 7

Addressed to NHS Sussex Integrated Care Board | Individual GP Practices

That all GP practices should assure themselves that they have a complex care mechanism for co-ordinating the care of high risk and vulnerable patients, with a way of identifying and tracking this cohort of patients.

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

Recommendation 8

Addressed to NHS Sussex Integrated Care Board

That the NHS Sussex Integrated Care Board continues to work towards a long term, sustainable solution to the issue of information sharing with GPs.

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

Recommendation 9

Addressed to East Sussex Healthcare Trust (ESHT)

That integrated patient and nursing assessment documentation should include domestic abuse and an adult safeguarding assessment page.

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

Recommendation 10

Addressed to East Sussex Healthcare Trust (ESHT)

That if patients disclose any history of domestic abuse this should be re-examined at each patient contact to assess risk.

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

Recommendation 11

Addressed to HomeWorks (now Brighton Housing Trust)

That Home Works reviews their practices to ensure that they are complying with the Pan-Sussex Safeguarding Policies and Procedures and access training as required.

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

Recommendation 12

Addressed to Lewes District Council – Tenancy Services (LDC)

That the council ensures that all work to be carried out because of domestic abuse is carried out as an emergency or within an agreed timescale.

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

Recommendation 13

Addressed to Lewes District Council – Tenancy Services (LDC)

That a housing specific Domestic Abuse Policy and Procedure is drafted so that all frontline services are clear about how they should manage cases of domestic abuse.

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

Recommendation 14

Addressed to NHS England

That a Digital Data recovery mechanism needs to be available for patient records that have failed to transfer. NHS England and NHS Digital need to work with General practice information system suppliers to provide a process for migrating and merging records that are fragmented.

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

Recommendation 15

Addressed to Refuge | Clarion Housing

Staff are reminded of the need to review the DASH risk assessment every four weeks or after an incident.

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

Recommendation 16

Addressed to Refuge | Clarion Housing

Staff are reminded that, when concerns are raised by other residents, these concerns may indicate a support need for other residents and that this should be sensitively explored.

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

Recommendation 17

Addressed to East Sussex Safer Communities Partnership (ESSCP)

That the CSP ensure that the nature and impact of ‘cuckooing’ is understood and recognised across organisations representing the multi-agency safeguarding network (Safeguarding Adults Board and East Sussex Safeguarding Children’s Partnership).

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

Recommendation 18

Addressed to East Sussex Safer Communities Partnership (ESSCP)

That this review links with other local reviews and to build upon recommendations in those reviews in relation to language used across agencies. As an example, in this case the term ‘dwarfism’ is used, in other reviews the term ‘sex worker.’ More appropriate language assists in setting the nature of interactions in a more trauma informed and empathetic setting.

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