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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

24 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

32 recommendations pulled from the report · 26 matched to organisations in the index

Recommendation 1

Addressed to Suffolk Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Cambridgeshire Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2a

Addressed to Suffolk Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2b

Addressed to Suffolk Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2c

Addressed to Suffolk Police

DASH risk assessments. Ensure DASH risk assessments are consistent and timely including any DASH reviews. (234) By September 2022

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2d

Addressed to Suffolk Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2e

Addressed to Suffolk Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2f

Addressed to Suffolk Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2g

Addressed to Suffolk Police

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2h

Addressed to Suffolk Police

Ensure Officers collate evidence and complete intel reports in a consistent and timely manner and in accordance with regulations and procedure. By June 2022

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Suffolk Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Cambridgeshire Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4a

Addressed to Cambridgeshire Police

All Domestic abuse reports will be quality assured to ensure that a DVPN has been considered.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4b

Addressed to Cambridgeshire Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Western Suffolk Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5a

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

All CPFT staff should complete a Datix if they have domestic abuse concerns disclosed to them by a service user.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5b

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

Staff should document safeguarding concerns on System 1/other relevant medical record in a detailed manner cross referencing the Datix report number.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5c

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

Staff should have awareness that they can contact the Named Nurse for Safeguarding/CPFT Safeguarding team to raise and discuss domestic abuse concerns.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5d

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

Staff should have an awareness of and be able to complete a DASH assessment.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5e

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

Staff should be aware of Domestic Abuse (risk types of, how to recognise and support, sign posting etc).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5g

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

Staff should be aware of consent-based referrals and when to override consent (public interest, threat to life & limb, risk to children etc).

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5h

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

CPFT should provide regular up to date training in line with Trust policy.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5i

Addressed to Cambridgeshire and Peterborough NHS Foundation Trust

CPFT should provide regular one to one and group supervision for staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6a

Addressed to Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care

When a partner is in attendance at the appointment, ensure a record of partners’ names or as a minimum, their initials are recorded

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6b

Addressed to Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care

Consider Did Not Attends – use of a ‘Frequent DNA Register’ which could be linked to a Safeguarding adult register.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6c

Addressed to Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care

Record safeguarding incidents on connected accounts i.e. parent and child

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6d

Addressed to Cambridgeshire and Peterborough Clinical Commissioning Group Primary Care

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Suffolk Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Suffolk Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 9

Addressed to Cambridgeshire IDVA Service

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 10

Addressed to Cambridgeshire Police

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.

Verified wording from the published review · Original review (PDF) ↗