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

Cumbria review

CSP: Cumbria Published: October 2025 Year of death: 2022 Extracted: 12 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 concerns including missed opportunities for routine domestic abuse enquiry, inconsistent use of risk assessment tools, and challenges in multi-agency collaboration for individuals with complex needs, particularly those with substance misuse and mental health issues.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
7.1.1	Implementing a standardised multidisciplinary approach for people with multiple complex needs across all agencies within Cumbria would be beneficial.	Recovery Steps Cumbria
7.1.10	The senior leadership must invest in and support organisations to adopt a trauma-informed strategy. The leadership group develops the plan for a trauma-informed organisation. This will entail consideration of patient participation, clinical and non-clinical staff training, and establishing a safe environment.	All Partner Agencies
7.1.11	The three boards have developed guidelines for practitioners to strengthen and cultivate their curiosity around their practice. The guidance must be evaluated, and mechanisms put in place to assess its impact, including staff and patient feedback on its use.	Cumbria Safeguarding Children Partnership \| Safer Cumbria \| Cumbria Safeguarding Adults Board
7.1.12	Responding to domestic violence is everyone's responsibility. To enable organisations to carry out their responsibilities effectively, all staff must obtain the necessary training to identify victims/survivors and ensure they receive the support required. This will necessitate the implementation of information-sharing protocols and efficient systems for recording and directing victims/survivors to the appropriate services. Organisations must be able to efficiently extract the necessary data to guarantee compliance with this obligation.	All Partner Agencies
7.1.13	Safer Cumbria to collaborate with the Cumbria Safeguarding Adults Board to raise awareness among system-wide practitioners about dependent with impaired mental capacity and executive functioning.	Safer Cumbria \| Cumbria Safeguarding Adults Board
7.1.2	System-wide training regarding upskilling practitioners on substance misuse, to be delivered by Recovery Steps Cumbria.	Recovery Steps Cumbria
7.1.3	Standardised use of the RIC within Recovery Steps Cumbria as an evidenced-based screening tool for Domestic Abuse.	Recovery Steps Cumbria
7.1.4	A System-wide review of the application of the Mental Capacity Act and safeguarding powers for dependent drinkers is required.	Recovery Steps Cumbria
7.1.5	Training will be offered on domestic abuse and routine enquiries to educate staff on the importance of routinely asking patients about their safety.	North Cumbria Integrated Care NHS Foundation
7.1.6	The clinical area involved in non-reporting of safeguarding concerns will be encouraged to complete face-to-face Safeguarding Adults level three, and compliance will be reviewed via the Safeguarding team and shared with care group leads.	North Cumbria Integrated Care NHS Foundation
7.1.7	NCIC will continue working on the trust initiative—how safe do you feel? and embed it firmly into practice.	North Cumbria Integrated Care NHS Foundation
7.1.8	NCIC would like to improve the information-sharing process with substance misuse services when those attending our emergency care department are in crisis.	North Cumbria Integrated Care NHS Foundation
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗