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
Gloucestershire review
CSP: GloucestershirePublished: October 2025Year of death: 2021Extracted: 16 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review highlights a complex interplay of domestic abuse, mental health issues, substance use, and child removal, which exacerbated the victim's distress and increased suicide risk. It also identifies significant barriers to disclosure and help-seeking, including cultural and language factors, and a lack of system cultural competency.
Home Office classifications
38 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - died by suicide
Victim - alcohol misuse
Victim - housing issues
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - post traumatic stress disorder (ptsd)
Victim - self harm
Victim - had been a victim of an abuser before
Victim - immigration involvement
Children - under 18 shared parental responsibility (victim and perpetrator)
Children - under 18 shared parental responsibility (between victims)
Children - under 18 shared parental responsibility (between perpetrators)
Children - subject to child protection or domestic abuse prior to homicide
Children - removed into care
Perpetrator - alcohol misuse
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
Perpetrator - known to probation services as a domestic abuse perpetrator
Perpetrator - supervised by probation services
Perpetrator - immigration involvement
Aggravating factors - separation
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
DHR process - police recommendations
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - idva or other domestic abuse support service recommendations
DHR process - probation services recommendations
DHR process - housing services recommendations
DHR process - technology systems 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 - other recommendation themes
Extracted recommendations
16 recommendations pulled from the report · 8 matched to organisations in the index
Addressed to
Gloucestershire Domestic Abuse Support Service (GDASS)
GDASS will encourage staff to clearly express and document curiosity relating to other parties connected to clients (in relation to the perpetrator being referred to as the lodger). Whilst it is not clear that a relationship had formed during the support period, it would have been useful to have had any queries or concerns about the lodger documented so that this could be more explicit in writing this report.
Practitioners should consider Police checks and sharing of relevant risk information to agencies at the termination of a sentence as standard practice for all cases regardless of level of risk. Decision making in this regard should be recorded on the Probation case notes system (n-delius) and included in the final risk assessment (OASys).
Foreign Nationals should be considered for an interpreter and this consideration logged on the Probation case notes system (n-delius) and included in the risk assessment (OASys).
Where a victim is identified as being a Foreign National communication for initial contact i.e. letter should be sent in their native language to encourage response and make the offer of the service clear to them.
Addressed to
Police | Office for the Police and Crime Commissioner
The Police and Office for the Police and Crime Commissioner should review resource for the police and crisis team partnership to ensure it meets the demand needs and incorporated specific recognition of more complex cases where the individual may require an interpreter.
It is therefore recommended that there is an opportunity to use systemic practice to review work with parents who are not engaged in court proceedings or where they are not having contact with their children in care.
Addressed to
Gloucestershire Health and Care NHS Foundation Trust
For GHC services to always consider a translator if there is any doubt that a service user may have difficulty with understanding due to a language barrier. If a suitable translator is unavailable, document and plan about the need for re-assessment with a translator present.
Addressed to
Gloucestershire Health and Care NHS Foundation Trust
For all GHC services to consider asking clients/patients about domestic abuse, and when appropriate they do so, documenting each time in records the conversation around this. This is in line with the GHC Domestic Abuse Policy 2021 in which ‘All Trust colleagues ask about domestic abuse as part of the core Assessment, and to maintain records according to guidance and policy’.
Addressed to
Gloucestershire Health and Care NHS Foundation Trust
GHC practitioners involved with child protection process to ensure that they receive the minutes of any meetings and upload them to the children’s health records ensuring that there is an accurate copy of the children’s plan and evidence of the meeting for practitioners to refer back too.
Addressed to
Local Domestic Abuse Partnership Board (LDAPB) | Gloucestershire Suicide Prevention Partnership
The Local Domestic Abuse Partnership Board (LDAPB) should consider therapeutic pathways for victims of domestic abuse to ensure access to trauma-informed mental health related support. This could be discussed jointly with the Gloucestershire Suicide Prevention Partnership.
All agencies from the panel to review their practice and pathways in to the services they offer to ensure there is practical support available for victims of domestic abuse so they have the best opportunity to access specialist services (such as mental health related support or domestic abuse services) should they choose to.
Addressed to
Local Domestic Abuse Partnership Board (LDAPB) | Gloucestershire Suicide Prevention Partnership
The LDAPB should work with the Gloucestershire Suicide Prevention Partnership to conduct a thematic review of local suicide DHRs and based on the findings consider recommendations to develop specific risk assessment and support pathways for victims at risk of suicide.
Addressed to
Department for Levelling Up, Housing and Communities | Central Government departments | Domestic Abuse Commissioners Office
The Department for Levelling Up, Housing and Communities should review with wider Central Government departments and the Domestic Abuse Commissioners Office the impact the statutory duty to provide support within safe accommodation has on community-based provision to ensure Local Authorities have adequate resource to commission wider support such as therapeutic support and specialist support for marginalised communities (particularly who may have limited safe accommodation options and thus only ever seek support within the community).