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

Carmarthenshire review

CSP: Carmarthenshire Published: October 2025 Year of death: 2018 Extracted: 21 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 identifies missed opportunities by health services to recognise and respond to domestic abuse, mental health issues, and alcohol use, exacerbated by the victim's age, rural isolation, and delays in initiating the review process.

Extracted recommendations

21 recommendations pulled from the report

#	Recommendation	Addressed to
1	To proactively support an increase in compliance with Ask and Act training in Primary Care who have not implemented IRIS by identifying enablers and barriers to improvement	Hywel Dda University Health Board
10	Ensure that a bespoke training programme relating to older people and domestic abuse is available to practitioners as part of the Regional Safeguarding Board’s workforce development programme	Violence against Women, Domestic Abuse and Sexual Violence Partnership
11	Develop a regional substance use, domestic abuse and mental health pathway for individuals who present with multiple needs	Regional Partnership Board
12	Improve the consistency of GPs and wider agencies identification and referrals for specialist substance use services	West Wales Area Planning Board
13	Improve the knowledge and confidence of practitioners working in Tier 1 services to have conversations with individuals about their substance use and options for support and interventions	West Wales Area Planning Board
14	Extend the Violence against Women, Domestic Abuse and Sexual Violence National Training Framework to non-relevant authorities	Welsh Government
15	IRIS to be mandated across all GP practices in Wales and resourced by Welsh Government in line with its commitments to early intervention and prevention in the National Violence against Women Domestic Abuse and Sexual Violence Strategy	Welsh Government
16	Scope responses of Health Boards and NHS Trusts to Domestic Abuse, particularly the implementation and compliance with Ask and Act	NHS Wales
17	Promote and include links to Ask and Act training on its learning platform57	Royal College of General Practitioners (Wales)
18	Develop and promote resources that support GP learning in respect of links between domestic abuse, mental health and substance use	Royal College of General Practitioners (Wales)
19	Include direction in the revised DHR guidance in respect of the sharing of information relating to individuals in cases where there has been no conviction or consent provided	Home Office
2	Routine enquiry to be expanded to all Minor Injuries and Accident Emergency Departments in Hywel Dda University Health Board	Hywel Dda University Health Board
20	Review terminology of ‘Domestic Homicide Review’ to reflect the range of deaths that fall within the criteria for a review	Home Office
21	Implement a clear communication strategy for new DHR Guidance to ensure awareness and understanding of changes and expectations	Home Office
3	Implementation of a compliance audit process for Ask and Act / Routine Enquiry	Hywel Dda University Health Board
4	Monitor compliance with Ask and Act training with evidence of measures made to address areas of poor compliance reported via operational delivery groups	Hywel Dda University Health Board
5	Evaluate the pilot of IRIS and HARK and consider ow this may be embedded across all clusters in Hywel Dda University Health Board	Hywel Dda University Health Board
6	To consider the links between menopause and domestic abuse within the development of the Health Board’s Menopause Pathway	Hywel Dda University Health Board
7	Develop a 7 minute briefing on the links between Menopause and Domestic Abuse and distribute with the Guidance document56 via the Health Board’s Safeguarding Intranet, Primary Care Network and relevant forums	Hywel Dda University Health Board
8	Share guidance and briefing with NHS Wales Safeguarding Team for circulation to all Safeguarding leads in Wales	Hywel Dda University Health Board
9	Ensure that a service/services that can provide a bespoke, tailored service to respond to the needs of older people who are experiencing domestic abuse are commissioned across the region	Violence against Women, Domestic Abuse and Sexual Violence Partnership
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗