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

Bristol review

CSP: Bristol Published: August 2025 Year of death: 2019 Extracted: 14 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 highlights concerns regarding the perpetrator's deteriorating mental health, issues with medication compliance, and the need for improved inter-agency communication and risk assessment, particularly for individuals with a history of violence and mental illness. It also notes barriers to mental health support within the local Somali community.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
1	Take steps to ensure that Nilaari and ROADS, with appropriate consent provide updates about patient referrals to primary care (GP) and referrer (if not GP)	Public Health
18.1.1a	Training to ensure that officers know how and when to update occupant lists within Civica Cx (new BCC H&LS management system) for tenancy records and the importance of doing so in relation to financial impact on the tenant and in terms of managing tenancies/ homes. Also, confirm that all officers know the best place to share an authorisation note as done positively in Northgate previously in this case.	Bristol City Council Housing and Landlord Services
18.1.1b	The rent management service CCSS form to be reviewed to ensure relevant further questions are being sought with the customer. This is so that the form is doing as it was created and intended; to act as a method to support tenancy sustainment going forward with the tenant.	Bristol City Council Housing and Landlord Services
18.1.1c	Refresh with Internal Audit Team and H&LS sharing information practices and storing this correctly when BCC properties have actions undertaken e.g., in this instance a court order to prove occupancy.	Bristol City Council Housing and Landlord Services
18.1.3a	To raise awareness of complete PTSD pathway in Primary Care	Avon and Wiltshire Mental Health Partnership NHS Trust
18.1.3b	To identify link role within access services into local Somali community	Avon and Wiltshire Mental Health Partnership NHS Trust
18.1.6a	Training on ‘diagnostic overshadowing’ should be extended to call handlers in addition to Control Room supervisors. Please note that this recommendation has already been agreed by the Force Incident Manager and plans are in place to arrange protected time for call handlers to receive this training.	Avon and Somerset Police
18.1.6b	The Command-and-Control department should review call script questions and call handlers’ use of ‘off-script’ questions in relation to calls where mental health and weapons is a feature. The department should take appropriate action to improve in this area as required.	Avon and Somerset Police
2	Review the protocols for risk assessment and management, ensuring that (a) medicine compliance is considered for patients with a history of violence, (b) that post transition assessments are scheduled/conducted for this cohort, (c) fluctuations in patient insight are considered and (d) that this is explicitly documented in the handover between AWP and GP	Avon and Wiltshire Mental Health Partnership NHS Trust
3	Improve the understanding of the specific needs of the local Somali Community (SC) in respect of Mental Health that includes; - what enables/hinders the SC accessing support and that clearly identifies the gaps in provision.	Public Health
4	That the learning from this review is shared through mandatory safeguarding training to encourage increased professional curiosity when presented with potential client welfare concerns.	Bristol City Council Housing and Landlord Services \| Avon and Somerset Police
5	Seek to ensure that staff are aware of how to access medical information out of hours.	Avon and Somerset Police \| South Western Ambulance Service NHS Foundation Trust
6	Avon and Somerset Police to review call handling policy where there are multiple apparent risk factors and implement a systemic approach that mandates these calls being supervised.	Avon and Somerset Police
7	Avon and Somerset Police to review their systems of call handling to ensure that intelligence checks are carried out and recorded within the call handling system.	Avon and Somerset Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗