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 SussexPublished: June 2025Year of death: 2019Extracted: 18 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.