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
Norfolk review
CSP: Norfolk
Published: October 2025
Year of death: 2020
Extracted: 44 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 systemic failures in hearing the victim's voice, a lack of a "Think Family" approach, and insufficient professional curiosity by services. It highlights inadequate recognition and risk assessment of adult family domestic abuse, particularly for older adults, and issues with information sharing and the safe use of assistive technology.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | To avoid delays in the completion of a Domestic Homicide Review where an IOPC inquiry is taking place concurrently, the IOPC concluding report should be expedited promptly, and made available to the DHR Panel within 6 months of the verdict concluding the criminal trial to enable all relevant information to be included in the Review. Where the IOPC cannot conclude its report within this time it should write to the relevant DHR chair and Community Safety Partnership chair with a full explanation of the delays and a deadline for completion. | Independent Office for Police Conduct |
| 1 | Domestic abuse training which includes intimate partner abuse and adult family abuse across the whole age range, and includes the impact on children, should be of a consistent content and standard, and mandatory for all public facing staff in the following services.* Professional curiosity should be at the core of all training and, as is expected when children are present at the scene of a domestic abuse incident, training should include the need to check on the wellbeing of vulnerable adults present in the household. 1. Norfolk County Council services (provided or commissioned) involved in welfare, caring services, and safeguarding. 2. Community Health Care Services 3. Secondary Healthcare Service 4. Voluntary sector services commissioned by the local authority and CCG i.e., those supporting older people, carers, those living with addiction and/or mental ill-health including dementia/Alzheimer’s disease. 5. Housing officers (District Council and Housing Associations) A significant amount of current training is CPD accredited. This should be maintained and any new training programme should aim to be CPD accredited where appropriate to enable staff to evidence their continuing professional development. The Community Safety Partnership Board will be responsible for the governance of this recommendation. * It is recognised that Police and Probation have national level approved training with which they have to comply, and GP practices work within their NHS contract obligations therefore this training cannot be mandated. However, we are sure they would be welcome to attend county multi-agency domestic abuse training if resources allow. | Norfolk County Council services (provided or commissioned) involved in welfare, caring services, and safeguarding | Community Health Care Services | Secondary Healthcare Service | Voluntary sector services commissioned by the local authority and CCG | Housing officers (District Council and Housing Associations) |
| 10 | To ensure reported improvements in offering carer’s assessments described to the DHR Panel is maintained, an annual audit of carer assessments offered, carer assessments taken up, and outcome of the support provided should be undertaken and reported annually to the director for Adult Social Care and the Adult Safeguarding Board. | Adult Social Care |
| 11 | That the Approved Mental Health Professional report (AMHP) template to be updated to improve visibility and clarity of the risk assessment section with the aim of making this vital information plainly visible to clinicians throughout the patients journey in Mental Health Services both in hospital and community based. | Adult Social Care |
| 12 | Mental Health Service contingency plans should take a ‘Think Family’ approach and be shared with related parties/carers having been written in plain English and avoiding professional jargon to ensure it is accessible to enable families and/or carers to fully understand the steps to take when required. This should include relevant contacts and phone numbers, and guidance on information required when reporting serious concerns. | Norfolk & Suffolk Foundation NHS Trust |
| 13 | The Early Intervention Team should confirm back after any meetings with the next of kin in a quick memo (email or letter) any agreed actions/key information discussed by both sides. This could be a simple copy and paste of any notes taken. (family member recommendation). | Norfolk & Suffolk Foundation NHS Trust |
| 14 | That Norfolk Constabulary examine its policy on risk assessment in cases of familial domestic abuse incidents to ensure the focus on the alleged victim/complainant is not lost, and officers are supported in their professional judgement in risk assessing such cases. | Norfolk Constabulary |
| 15 | Local Authority Housing Departments when making enquiries to establish the status of a homeless applicant claiming to have been excluded from home, should ensure that the person said to have excluded them, and/or the accommodation owner should be spoken to independently to confirm whether they freely agree for the applicant to return, or to confirm they are excluding them. | Local Authority Housing Departments |
| 16 | The University Counselling and Mental Health Service should examine its threshold for deciding when the enhanced welfare check and assessing a student in person is used and ensure decision making is informed by information from all support services, and academic departments involved in the student’s University life, plus external sources who have provided information such as family or guardians if relevant and appropriate. | University of Manchester |
| 17 | Whilst work has been done in SCCE about carers, and to remind adult social care staff to be reminded of the importance of identifying carers and providing information and referring to Carers Matters Norfolk for a carers assessment, it is recommended that ASSD has an increased focus on carers and the need to identify carers and refer for a carers assessment or provide information. | Adult Social Care |
| 18 | That there is a presentation at the AMHP Forum about learning from this IMR to include verbally handing over safeguarding concerns for others in the patient’s home when the person is admitted to hospital and recording this on LAS. | Adult Social Care |
| 19 | The trust will explore the possibility of additional scenario-based training in respect of mental capacity and application of the Act. | Norfolk & Suffolk Foundation NHS Trust |
| 2 | That NHS England examine the efficacy of mandatory dedicated domestic abuse training for all GPs as part of their continuing professional development to enable them to keep up to date with all aspects of domestic abuse and the support services available in their area. If possible, training time should be protected to enable GPs to attend. | NHS England |
| 2 | All services should reinforce within their policies and procedures, and in staff supervision, the importance of professional curiosity, what this entails in practice, and: (a) Practitioners and their managers should be reminded of the steps to take as described in Safeguarding training with the aim of achieving the fullest, corroborated information for assessments as possible. (b) Anyone expressing concern for another person during an assessment or interview should be asked for examples and to describe those concerns, and this must be recorded in detail. (c) If a vulnerable person who requires assistance to attend appointments misses two or more appointments active enquiries should be made directly with that person to establish the reason and to ensure their wellbeing. (d) Enquiring whether an adult for whom a referral is made has a Lasting Power of Attorney should be routine, written into procedures, and details recorded to ensue where relevant they are consulted. | Local Authorities | NHS Trusts | Police Forces | Education Institutions | Fire & Rescue Services | Voluntary and Private Sector Services |
| 20 | The trust will ensure that the mandatory domestic abuse, and safety planning and risk assessment training addresses assessment of risk relevant to all parties living within a household. | Norfolk & Suffolk Foundation NHS Trust |
| 21 | The panel concluded that contingency planning should have been more robust with additional information related to this shared with the family. Contingency planning within care plans should also be shared as required with involved services and related parties/carers. | Norfolk & Suffolk Foundation NHS Trust |
| 22 | That the Mental Health Trusts roll-out of DIALOG and DIALOG+ system be maintained and reviewed, and in due course audited to ensure social, cultural, familial, and other patient -based information can be built into care in Norfolk more effectively. | Norfolk & Suffolk Foundation NHS Trust |
| 23 | Contingency planning within care plans should also be shared as required with involved services and related parties/carers. | Norfolk & Suffolk Foundation NHS Trust |
| 24 | The Trust will strengthen arrangements for assessments of safeguarding and teams (in team meetings and in supervision) and strengthen the way that they engage with families to maintain their professional curiosity about the wider impact in families. The clinical team should reinforce their policy for `Think Family’. | Norfolk & Suffolk Foundation NHS Trust |
| 25 | Norfolk and Waveney ICB to share the most current version of the Self-neglect and Hoarding Policy published on the Norfolk Safeguarding Adult Board Website with all GP practices in Norfolk and Waveney. This will be shared in a future Safeguarding primary care bulletin which is shared every month with GP practices. Completed 30 May 2023, and June 2023 bulletin distributed. | Norfolk and Waveney Integrated Care Board (ICB) |
| 26 | Norfolk and Waveney ICB to launch a template Domestic Abuse policy for all GP practices in Norfolk and Suffolk to be shared in 2022. Completed: May 2023 | Norfolk and Waveney Integrated Care Board (ICB) |
| 27 | Norfolk and Waveney ICB to relaunch a revised policy template for Safeguarding Adults for all GP practices in Norfolk and Waveney to be shared in 2022. This to include a case-based scenario which covers assessment under the Mental Capacity Act (2005) and Autistic spectrum disorder in future Safeguarding Adult Level 3 teaching for primary care colleagues. Completed: May 2023 | Norfolk and Waveney Integrated Care Board (ICB) |
| 28 | A message should be included as part of the Norfolk Community Health and Care NHS Trust Safeguarding Newsletter to remind staff and raise awareness to be professionally curious when having discussions with patients about clutter and hoarding. It should be borne in mind that even after the environment being cleared and made ‘safe’ it is important to understand the triggers and root causes (if able) so that warning signs can be picked up as early as possible by both the patient and staff, and support strategies can be offered to the patient. This message should also be shared at each of the local Place Governance and Quality meetings. This should be completed by End October 2022. | Norfolk Community Health & Care NHS Trust |
| 29 | A message should be included as part of the Norfolk Community Health and Care NHS Trust Safeguarding Newsletter to remind staff and raise awareness to be professionally curious when appointments are repeatedly cancelled/not attended and the source of information for the cancellation is not the patient. Staff should not automatically conclude that there is abuse occurring, but they should explore to ensure there is no controlling behaviour occurring. This message should also be shared at each of the local Place Governance and Quality meetings. This should be completed by end October 2022. | Norfolk Community Health & Care NHS Trust |
| 3 | NICE guidelines on hospital discharge should be revised to include ensuring consideration of vulnerable persons residing in the accommodation the patient/service user is returning too; specifically in respect of any risks to others the patient/service user may pose to other occupants. The policy must outline the need to undertake and document assessment of risk or abuse; whether information should be shared with other residents or carers to maintain safety; whether a referral to the local safeguarding team/lead or MASH team should be considered, and if a referral to MAPPA or MARAC is needed, or consideration of a Potentially Dangerous Person (PDP) referral to local police. | National Institute for Clinical Excellence (NICE) |
| 3 | All services undertaking assessments should take a ‘Think Family’ approach and: (a) Use their full assessment skills and professional curiosity to ensure information for assessments, care plans and risk assessments is fully inclusive of all family members /family structure, plus any carers, and where relevant note who is the home owner or holder of a tenancy. (b) To ensure a ‘Think Family’ approach is embedded in organisational and cultural change at all levels, directors of services should ensure policies, training, and procedures promote this approach, clearly set out practice expectations, and audit this change in practice on a 6 monthly and then an annual basis. | Local Authorities | NHS Trusts | Police Forces | Education Institutions | Fire & Rescue Services | Voluntary and Private Sector Services |
| 30 | A piece of work should take place looking at and considering the development of a risk assessment relating to patients who do not attend appointments, or cancellations are made by people other than the patient themselves or there are safeguarding concerns. This could become part of the Safeguarding Adults Policy. The initial scoping of this risk assessment should be completed by end of July 2022. Any final risk assessment should be completed by the end of October 2022. | Norfolk Community Health & Care NHS Trust |
| 31 | Where concerns are raised about a student's behaviour and mental wellbeing, information should be gathered from all relevant pastoral, health support, and academic sources to inform a support plan. This should include the student’s tutor who will have an up to date picture of their attendance and progress. | University of Manchester |
| 32 | To bring clarity for staff regarding information sharing procedures when a family member raises concerns for the health and wellbeing of a student, but it is judged the circumstances do not meet the criteria for sharing personal information, the family member should routinely receive a follow-up phone call or email within 2 working days to confirm what actions were being taken. There will be very rare cases where this may be judged inappropriate (e.g. if the University is already aware that the student is estranged from their family) in which case this should be recorded. | University of Manchester |
| 33 | When a family member has raised concerns about a student’s wellbeing, notes of the information given by the family member and their concerns should be recorded, placed on the student’s file, and a summary of their concerns emailed to the family member to ensure the summary is an accurate representation of the concerns. | University of Manchester |
| 34 | Family members contacting the university with concerns about a student should have explained to them the limitations for sharing personal information about the student, when information can be shared, and the duties this places on the university’s ability to provide detailed feedback. The university should consider producing a pdf leaflet explaining their information sharing policy which can be emailed to family members to enable them to digest and understand the policy in their own time. Also explain what exceptions are available in case the family members believes that some of the criteria have been met, so they can ask for the decision to be reconsidered. | University of Manchester |
| 35 | That the University reviews the existing information provided on its website to ensure that there is a single, easily traced, and navigated pathway to make contact with concerns about a student 24 hours a day and that there is clarity about what anyone raising concerns can expect in terms of next steps. | University of Manchester |
| 36 | Non-intimate domestic abuse involving an Adult at Risk of Harm to be included in ongoing training events which are conducted yearly with all officers. This training should highlight professional curiosity and encourage officers to check on vulnerable adults within a domestic environment even when they are not the victim of the offence. This should highlight the specific terms relating to an Adult at Risk of Harm and increase officer RESTRICTED & CONFIDENTIAL 36 awareness of vulnerability, promoting completion of appropriate NCI (Non-Crime Investigations) and risk assessments. | Norfolk Constabulary |
| 37 | Non-Crime Adult Protection Investigations with an associated risk assessment should be completed at any domestic abuse incident where an Adult at Risk of Harm is present as well as when they are a victim. Force Policy to be amended to include this requirement and provide clear responsibilities and governance. | Norfolk Constabulary |
| 38 | The Norfolk Multi-Agency Safeguarding Hub will review any domestic abuse related Non-Crime Adult Protection Investigation and consider information sharing with partner agencies where Adults at Risk of Harm are present or reside at a domestic abuse incident but not given victim status. This information sharing protocol is already in place but will encourage referral and risk consideration for those vulnerable adults who may be present or residing in addresses where a domestic abuse incident takes place. This is the same as would occur for a child or young person who is deemed to be at risk. | Norfolk Multi-Agency Safeguarding Hub |
| 4 | The Department of Health & Social Care should consider a public health awareness raising campaign for secondary school aged children and young people with the aim of highlighting the negative impact on mental health of early and frequent cannabis use. | Department of Health & Social Care |
| 4 | All local health inpatient and residential social care providers: To review, and revise where necessary, the providers Discharge Policy to ensure it covers consideration of vulnerable persons residing in the accommodation to which the patient/service user is returning; specifically in respect of any risks to others the returning patient/service user may pose to other occupants. The policy must outline the need to undertake and document: (a) Assessment of risk criteria (risk of harm or abuse) (b) Actions including whether or not information should be shared with other residents, or carers to maintain safety and/or a referral to the local provider safeguarding team/lead or MASH team. (c) Also, to consider if a referral to MAPPA or MARAC is needed, or consideration of a Potentially Dangerous Person (PDP) referral to local police. Assurance of this action must be provided to: For Health providers – the ICB Adult Safeguarding Lead/team For Socials Care providers – the local authority Head of Integrated Quality Service/team. | All local health inpatient and residential social care providers |
| 5 | That the Department of Health & Social Care, Home Office and in collaboration with the Domestic Abuse Commissioner for England & Wales commission urgent research to examine the operation of Section 42 of the Care Act 2014 and the criteria enabling services to make enquiries, and its impact on being able to assess and safeguard a person who has mental capacity, but who may be experiencing coercive control which affects their ability to consent to an assessment and freely express their views. The results of the research should be used to inform the review being undertaken by DHSC to strengthen and clarify the Care Act 2014 guidance. | Department of Health & Social Care | Home Office | Domestic Abuse Commissioner for England & Wales |
| 5 | To reduce risk in adult family abuse cases it is strongly recommended that a task group is set up to investigate the use of a risk assessment tool by services when a safeguarding concern involves an allegation or risk of abuse within the family context which therefore meets the definition of domestic abuse. Where the safeguarding concern is about an older adult a suitably adjusted DASH risk assessment designed for older victims could be considered for use e.g. The All Wales Risk Identification Checklist (RIC) for MARAC Agencies or Cambridgeshire & Peterborough MARAC Referral Form and Risk Indicator Checklist for Older People (over 60). | Norfolk Community Safety Partnership | Norfolk Safeguarding Adults Board | Domestic Abuse and Sexual Violence Group |
| 6 | That statutory regulations governing Smoke and Cabon Monoxide Alarms be amended to include the requirement that all internet enabled alarms must be linked to a minimum of 2 devices to ensure alerts can be acted upon at all times. Manufacturers must ensure the system cannot become operational until this is done, and if a device has to be deleted at any time another must be installed simultaneously to enable the system to function continuously with the provision of a minimum of 2 separate individuals to receive alerts. | Department for Levelling Up, Housing & Communities |
| 6 | When services become aware during assessments that a person has habitually used cannabis from their early teens and they develop early onset psychosis symptoms, this should be factored into risk assessments. This is essential in cases of poly-substance misuse co-morbidity to ensure assessments are robust in assessing risk to others as well as risk to self. | Local Authorities | NHS Trusts | Police Forces | Education Institutions | Fire & Rescue Services | Voluntary and Private Sector Services |
| 7 | All services providing care and/or home safety advice to vulnerable adults should include the promotion of the County Council’s assistive technology equipment which includes telephone call centre back-up for emergencies when a family member or carer cannot be contacted. This information must always be included where a pendant alarm is recommended or provided. This practice should become routine by September 2023. | All services providing care and/or home safety advice to vulnerable adults |
| 8 | Websites including the Norfolk County Council assisted technology site, the Fire & Rescue Service home safety site, and other county websites which give home safety advice, to insert a prominently displayed message, strongly advising that at least two people’s phones, tablets or similar devices should be linked to wi-fi enabled smoke and carbon monoxide alarms to ensure fire alerts can always be received and acted upon immediately. Changes to websites should be in place by September 2023. | Norfolk County Council | Norfolk Fire & Rescue Service | Other County Websites |
| 9 | All statutory, voluntary, or private services’ practitioners and carers whose role includes home safety advice and where a service user has or are intending to install privately purchased wi-fi enabled fire alarms, should strongly advise that at least two devices should be linked to the alarms to ensure back-up if one device is unavailable to enable action to be taken immediately an alert is received. Giving this advice should be included in all relevant training for practitioners and carers. This recommendation’s message should be circulated and acted upon and included in training as soon as possible. | All statutory, voluntary, or private services’ practitioners and carers |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||