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
Nottingham review
CSP: Nottingham
Published: July 2025
Year of death: 2022
Extracted: 26 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
Agencies struggled to link the victim's declining mental health and suicidality with the sustained coercive control he experienced. Challenges included fragmented multi-agency coordination, inadequate risk assessment, and a lack of understanding of the intersectional impact of the victim's Autistic Spectrum Disorder and sexuality on his ability to seek help.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Nottingham Community Safety Partnership to ensure that an intersectionality review is undertaken at the outset of every Domestic Homicide Review, that the principle predominating protected characteristics are considered and the panel are provided with a view about those characteristics. | Nottingham Community Safety Partnership |
| 2 | Nottingham Community Safety Partnership’s partner agencies to develop professionals’ awareness of the impact upon decision making for people who have mental capacity and who are, or may be, experiencing coercion and control and interpersonal influence. | Nottingham Community Safety Partnership |
| 3 | Nottingham Community Safety Partnership to liaise with the Safeguarding Adults Board and Children Safeguarding Partnership Board to identify the multi-agency forums available in the area, their purpose, membership, access criteria and referral routes, and then raise awareness of these across partner agencies to ensure that approaches and responses are coordinated. | Nottingham Community Safety Partnership |
| 4 | Nottingham Community Safety Partnership and their partner agencies to ensure that current training includes the Suicide Timeline (to include the additional risk indicators based upon protected characteristics for example, ASD and LGBT). | Nottingham Community Safety Partnership |
| 5 | Nottingham Community Safety Partnership to share information with partner agencies about the support available to people with ASD in the Nottinghamshire area. | Nottingham Community Safety Partnership |
| 6 | Nottinghamshire Police to advise partners how to gather and document evidence when there is coercive controlling behaviour through forums such as MARAC. | Nottinghamshire Police |
| 7 | Equation and Juno Women’s Aid to promote the availability of local and national specialist LGBT domestic abuse support services with partner agencies. Including completing the LGBT Special Considerations Checklist alongside the standard DASH RIC | Equation | Juno Women’s Aid |
| 8 | Nottingham College to review their provision in relation to healthy relationships, men’s services and LGBT support. | Nottingham College |
| EMAS 1 | Professional curiosity to remain included in all aspects of ongoing safeguarding training. | East Midlands Ambulance Service |
| EMAS 2 | Ensuring the names of individuals on scene are documented to be reiterated in training and future communications; especially when behaviours of adults on scene are aggressive and intimidating. Body Worn Cameras are now in use at EMAS to ensure the safety of crews and EMAS service users. | East Midlands Ambulance Service |
| Equation 1 | Policies and procedures, staff induction/training/management is in place to ensure Referral timeframes are met. However, management can monitor Helpline capacity/waiting lists to ensure Equation has resources to meet this requirement. | Equation |
| Equation 2 | Caseworkers to be reminded/supported to explore/exhaust all safe means of contact with service users – covered in induction/training, team meetings, probation reviews, file audits and case management meetings. | Equation |
| Equation 3 | Caseworkers to be reminded/encouraged to cover work on each other’s cases when the caseworker is not available to ensure no unnecessary gaps in service delivery. | Equation |
| Human Flourishing Pr | For all members of the HFP be required to attend the suicide prevention and intervention course and Understanding and Responding to Domestic Abuse courses, commissioned by Nottingham City Council (or equivalent). | Human Flourishing Project |
| MARAC Steering Group | The Tomorrow Project to be invited to join the MARAC meeting as a discretionary member. | MARAC Steering Group |
| MARAC Steering Group | The MARAC Steering Group consider if there are other agencies that should be included in the MARAC membership. | MARAC Steering Group |
| NHFT 1 | The Local Mental Health Team (LMHT) and Crisis Resolution Home Treatment (CRHT) to have regular joint multi-disciplinary team discussion on complex cases and consideration to be taken to invite other agencies if relevant. | Nottinghamshire Healthcare NHS Foundation Trust |
| NHFT 2 | LMHT to complete the recommendations from the NHFT internal serious incident review. | Nottinghamshire Healthcare NHS Foundation Trust |
| NHFT 3 | LMHT and CRHT to complete internal DASH Training and understanding Routine Enquiry training. | Nottinghamshire Healthcare NHS Foundation Trust |
| NHFT 4 | LMHT and CRHT to identify a clinician to join the safeguarding champions network to help embed safeguarding processes and procedures into their clinical areas. | Nottinghamshire Healthcare NHS Foundation Trust |
| NHFT 5 | LMHT and CRHT team leaders and managers with supervisory responsibilities should access the safeguarding supervision offer that is available via the Trustwide Integrated Safeguarding Service. | Nottinghamshire Healthcare NHS Foundation Trust |
| Notts SVS 1 | In any situation where clients request online or telephone counselling, however they cannot access a confidential space for counselling, Notts SVS Services will ensure that face-face counselling is delivered in a venue and location that meets the client’s needs e.g., GP, Community Venue, Notts SVS Services counselling rooms. Face-face counselling is currently available to all clients requiring this and the client’s preference is noted at their assessment and revisited when they are allocated to a therapist. | Nottingham Sexual Violence Support Service |
| Notts SVS 2 | Notts SVS Services workers, when sending emails will consistently state the DPMS ID and Flag on all internal communications with a requirement for the worker receiving the email to acknowledge receipt of the email to the sender and to update the sender once an action has been completed. Notts SVS Services workers that send emails with client actions will monitor these emails for a response and follow up within 5 working days if a response has not been received. Notts SVS Services Managers will ensure that all workers are aware of the above requirements and will monitor for compliance. | Nottingham Sexual Violence Support Service |
| NUH 1 | Escalate need for read only access to mental health system (RIO) for NUH patients seen by CAMHS, DPM and RRLP to support communication and information sharing to effectively safeguard. | Nottingham University Hospital |
| NUH 2 | Work with the Trust communication team to share the new professional curiosity video with all staff. | Nottingham University Hospital |
| Tomorrow Project 1 | The service recommends having additional professionals involved in the MARAC process. There would be great benefit to ensuring all services involved in such cases have access to all the information, allowing for better and more meaningful collaborative working. | The Tomorrow Project |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||