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
Western Suffolk review
CSP: Western Suffolk
Published: October 2025
Year of death: 2020
Extracted: 32 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 the victim's long history of domestic abuse across multiple relationships and her reluctance to engage with agencies, which hindered support efforts. It also identifies issues with inter-agency information sharing and the need for improved awareness of coercive control and alcohol misuse.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Suffolk polices’ processes for information sharing have developed and evolved through operational practice. Suffolk police should undertake a process of work to ensure that their processes for information sharing and cross-border working with colleagues in Cambridgeshire are robust and operationally effective in relation to domestic abuse. They should provide assurance to the CSP within six months of this report being approved by the CSP. They should conduct an annual review of these arrangements. | Suffolk Police |
| 10 | Cambridgeshire Police should review their practice in relation to the use of the provisions of both DVPN’s and DVPO’s to ensure they are well understood by officers across the constabulary as a valuable preventative tool and confirm via audits that they are being used effectively and appropriately in regard to Domestic Abuse. They should share their practice and learning with colleagues in Suffolk as a means of promoting collaborative learning and development. | Cambridgeshire Police |
| 2 | Cambridgeshire polices’ processes for information sharing have developed and evolved through operational practice. Cambridgeshire police should undertake a process of work to ensure that their processes for information sharing and cross-border working with colleagues in Suffolk are robust and operationally effective in relation to domestic abuse. They should provide assurance to the CSP within six months of this report being approved by the CSP. They should conduct an annual review of these arrangements. | Cambridgeshire Police |
| 2a | A programme of messaging across the Constabulary highlighting the positive action policy and ensuring that it is understood and implemented by all staff at all times. | Suffolk Police |
| 2b | DASH risk assessments. Ensure Officers check for previous DASH risk assessments and do not treat a domestic abuse incident in isolation. (104) By September 2022 | Suffolk Police |
| 2c | DASH risk assessments. Ensure DASH risk assessments are consistent and timely including any DASH reviews. (234) By September 2022 | Suffolk Police |
| 2d | DASH risk assessments. Suffolk Police are to undertake a process of work to ensure that their processes for information sharing in relation to DASH assessment outcomes and cross-border working with colleagues in Cambridgeshire are robust and operationally effective in relation to domestic abuse (240) (323) By September 2022 | Suffolk Police |
| 2e | Safeguarding Referrals. Ensure Officers know to complete and submit Safeguarding Referrals in a timely manner if children are present during attendance for a domestic incident (161) By June 2022 | Suffolk Police |
| 2f | Ensure Officers undertake all enquiries in accordance with regulations and procedure and all evidence is captured (mobile phone for download and analysis) and followed up in a timely manner. (233) By June 2022 | Suffolk Police |
| 2g | Ensure all enquiries including speaking with independent witnesses (neighbours) and taking witness statements are followed up and in a timely manner.(205) By June 2022 | Suffolk Police |
| 2h | Ensure Officers collate evidence and complete intel reports in a consistent and timely manner and in accordance with regulations and procedure. By June 2022 | Suffolk Police |
| 3 | Suffolk police should review their practice in relation to the use of the provisions of both DVPN’s and DVPO’s to ensure they are well understood by officers and effectively used. They should share their practice and learning with colleagues in Cambridgeshire as a means of promoting collaborative learning and development. | Suffolk Police |
| 4 | Cambridgeshire police should review their practice in relation to the use of the provisions of both DVPN’s and DVPO’s to ensure they are well understood by officers and effectively used. They should share their practice and learning with colleagues in Suffolk as a means of promoting collaborative learning and development. | Cambridgeshire Police |
| 4a | All Domestic abuse reports will be quality assured to ensure that a DVPN has been considered. | Cambridgeshire Police |
| 4b | Where suspects for domestic abuse are not proceeded against or where the victim declines to support action, VFD staff will critically assess what other safeguarding actions may be taken and advise and guide the reporting officers accordingly through the application process where a DVPN is a realistic opportunity. | Cambridgeshire Police |
| 5 | Although there was an understanding of issues relating to safeguarding and how to raise concerns, the panel was of the view that there would be benefit in highlighting the need for greater understanding of different organisational processes and when to raise a concern. In particular safeguarding, although considered, did not always appear to be a process, which would necessarily have led to any greater or more effective action to reduce risk to the victim. Local practice should be reviewed and compared with other similar local authority areas to determine where and how current processes, understanding and practice in safeguarding, both adults and children, can be improved. | Western Suffolk Community Safety Partnership |
| 5a | All CPFT staff should complete a Datix if they have domestic abuse concerns disclosed to them by a service user. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5b | Staff should document safeguarding concerns on System 1/other relevant medical record in a detailed manner cross referencing the Datix report number. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5c | Staff should have awareness that they can contact the Named Nurse for Safeguarding/CPFT Safeguarding team to raise and discuss domestic abuse concerns. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5d | Staff should have an awareness of and be able to complete a DASH assessment. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5e | Staff should be aware of Domestic Abuse (risk types of, how to recognise and support, sign posting etc). | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5f | Staff should know how to refer to the MASH. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5g | Staff should be aware of consent-based referrals and when to override consent (public interest, threat to life & limb, risk to children etc). | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5h | CPFT should provide regular up to date training in line with Trust policy. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 5i | CPFT should provide regular one to one and group supervision for staff. | Cambridgeshire and Peterborough NHS Foundation Trust |
| 6a | When a partner is in attendance at the appointment, ensure a record of partners’ names or as a minimum, their initials are recorded | Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care |
| 6b | Consider Did Not Attends – use of a ‘Frequent DNA Register’ which could be linked to a Safeguarding adult register. | Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care |
| 6c | Record safeguarding incidents on connected accounts i.e. parent and child | Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care |
| 6d | It is recommended that domestic abuse training for primary care providers covers the importance of asking the question about how things are at home for the individual at increased risk (particularly for frequent attenders and frequent non-attenders and those where we know there is a history of domestic abuse) and that they know what to do when a disclosure is made including appropriate signposting to support services. | Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care |
| 7 | Ensure that staff across the constabulary are aware of Stalking Protection Orders (SPO) as a valuable tool in providing protection control and sanction in regard to high-risk Domestic Abuse matters including how an order can be written authorised and obtained outside of the wider investigative process. Confirm via audit that it is being used effectively and appropriately in regard to Domestic Abuse. | Suffolk Police |
| 8 | Suffolk Police should review their practice in relation to the use of the provisions of both DVPN’s and DVPO’s to ensure they are well understood by officers across the constabulary as a valuable preventative tool and confirm via audits that they are being used effectively and appropriately in regard to Domestic Abuse. They should share their practice and learning with colleagues in Cambridgeshire as a means of promoting collaborative learning and development. | Suffolk Police |
| 9 | Ensure IDVAs signpost clients to appropriate group or one-to-one domestic abuse group programmes, recognising where an individual feels overwhelmed by professionals and appointments or does not feel confident in a group setting, including the Freedom programme and online programmes | Cambridgeshire IDVA Service |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||