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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The review highlighted a lack of coordinated multi-agency responses to the victim's complex vulnerabilities and repeated domestic abuse, with agencies failing to holistically assess cumulative risks or fully recognise the perpetrator's danger. Challenges in information sharing and identifying individuals repeatedly at risk were also noted.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
1	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 DA 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.	CGL
10	That if patients disclose any history of domestic abuse this should be re-examined at each patient contact to assess risk.	East Sussex Healthcare Trust (ESHT)
11	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.	Home Works (now Brighton Housing Trust)
12	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.	Lewes District Council – Tenancy Services
13	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.	Lewes District Council – Tenancy Services
14	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.	NHS England \| NHS Digital
15	Staff are reminded of the need to review the DASH risk assessment every four weeks or after an incident.	Clarion Housing
16	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.	Clarion Housing
17	That the CSP ensures 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).	East Sussex Safer Communities Partnership
18	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.	East Sussex Safer Communities Partnership
2	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.	CGL
3	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.	East Sussex Adult Social Care and Health (ASCH)
4	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.	East Sussex Adult Social Care and Health (ASCH)
5	That all staff complete the domestic abuse e-learning and that the previous workshop provided to staff is updated and made available online.	East Sussex Adult Social Care and Health (ASCH)
6	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.	NHS Sussex Integrated Care Board \| Local Medical Committee
7	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.	Individual GP Practices \| NHS Sussex Integrated Care Board
8	That the NHS Sussex Integrated Care Board continues to work towards a long term, sustainable solution to the issue of information sharing with GPs.	NHS Sussex Integrated Care Board \| MARAC Support Team
9	That integrated patient and nursing assessment documentation should include domestic abuse and an adult safeguarding assessment page.	East Sussex Healthcare Trust (ESHT)
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗