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
Doncaster review
CSP: Doncaster
Published: October 2025
Year of death: 2020
Extracted: 24 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 identified systemic failures in recognising and responding to the victim's long-term domestic abuse, including coercive control, and its link to her mental health and suicide risk. Agencies missed opportunities for comprehensive risk assessments and multi-agency coordination.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Domestic Abuse Case closure information should be shared with referring agencies, with consent from the client. | Doncaster Domestic Abuse Caseworker Service |
| 1 | To ensure all staff in Adult Social Care have received domestic abuse training, including risk assessment, within the past 3 years. | Doncaster Adult Social Care |
| 1 | Haven staff to undertake domestic abuse training. | Rethink Mental Illness |
| 1 | Where an individual is in receipt of secondary mental health services and moves to an area outside of the Trust boundaries, they should be referred to local services by the original Trust | Rotherham Doncaster & South Humber NHS Foundation Trust |
| 1 | Training for primary care staff to include learning from previous DHRs. | NHS South Yorkshire ICB (Doncaster) |
| 1 | Review the referral process for domestic abuse and scope the potential to use the Domestic Abuse, Stalking, Harassment and Honour-Based Violence (DASH) risk assessment tool to drive quality practice and provide a referral mechanism to the Multi-agency Risk Assessment Conference (MARAC) process. | Yorkshire Ambulance Service |
| 17.1 | All agencies involved in the review should provide Doncaster Community Safety Partnership with evidence of the training provided to staff in recognising and acting upon coercive and controlling behaviour. | Doncaster Adult Social Care | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust | South Yorkshire Police | Rethink Mental Illness | Rotherham Doncaster & South Humber NHS Foundation Trust | Nottinghamshire Healthcare NHS Foundation Trust | NHS South Yorkshire ICB (Doncaster) | Doncaster Domestic Abuse Caseworker Service | Yorkshire Ambulance Service | St Leger Homes |
| 17.2 | All agencies involved in the review should provide Doncaster Community Safety Partnership with evidence that information has been provided to staff on the links between domestic abuse and suicide. | Doncaster Adult Social Care | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust | South Yorkshire Police | Rethink Mental Illness | Rotherham Doncaster & South Humber NHS Foundation Trust | Nottinghamshire Healthcare NHS Foundation Trust | NHS South Yorkshire ICB (Doncaster) | Doncaster Domestic Abuse Caseworker Service | Yorkshire Ambulance Service | St Leger Homes |
| 17.3 | All agencies involved in the review should provide Doncaster Community Safety Partnership with evidence of the training and information provided to staff on suicide prevention. | Doncaster Adult Social Care | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust | South Yorkshire Police | Rethink Mental Illness | Rotherham Doncaster & South Humber NHS Foundation Trust | Nottinghamshire Healthcare NHS Foundation Trust | NHS South Yorkshire ICB (Doncaster) | Doncaster Domestic Abuse Caseworker Service | Yorkshire Ambulance Service | St Leger Homes |
| 17.4 | South Yorkshire Police should provide the Community Safety Partnership with a presentation outlining their implementation of recommendations 14 – 18 of the Vulnerability Knowledge and Practice Programme (VKPP) report – Domestic Homicides and Suspected Victim Suicides 2021 – 2022 Year 2 Report (December 2022). | South Yorkshire Police |
| 17.5 | The learning from this review should be shared with Doncaster Safeguarding Adult Board. | Doncaster Safeguarding Adult Board |
| 2 | Withdrawal of consent to support by clients, should be communicated to the referring agencies. | Doncaster Domestic Abuse Caseworker Service |
| 2 | To ensure all people waiting for Care Act assessments are contacted on a regular basis to inform risk assessment. | Doncaster Adult Social Care |
| 2 | All staff are to be reminded of the domains of abuse which may be experienced in domestic abuse (i.e. psychological). | Rotherham Doncaster & South Humber NHS Foundation Trust |
| 2 | Review of provision and uptake of suicide awareness training for primary care staff. | NHS South Yorkshire ICB (Doncaster) |
| 2 | Develop training and learning material to support staff around recognition of, and response to, domestic abuse and the referral options, to improve staff knowledge and confidence in supporting victims. | Yorkshire Ambulance Service |
| 3 | To share the lessons learnt from this DHR with Adult Social Care staff, to highlight any missed opportunities. | Doncaster Adult Social Care |
| 3 | Explicit dialogue within the 7 minute briefing relating to the links between domestic abuse and suicide should be evident. | Rotherham Doncaster & South Humber NHS Foundation Trust |
| 3 | Developing Domestic Abuse Guidance for Doncaster primary care staff. | NHS South Yorkshire ICB (Doncaster) |
| 3 | This will be evidenced by audit of the quality and volume of referrals in respect of domestic abuse. | Yorkshire Ambulance Service |
| 4 | Where there are explicit threats or statements made in relation to the encouragement or assisting of a suicide, advice should be sought from the Safeguarding Team. | Rotherham Doncaster & South Humber NHS Foundation Trust |
| 4 | Review and update the YAS policy ‘Domestic Abuse: Management Guidance’, to reflect the strengthened pathways for assessment and referral. | Yorkshire Ambulance Service |
| 5 | Recognition of domestic abuse and then subsequent actions to take / referral onto appropriate services or agencies. | Rotherham Doncaster & South Humber NHS Foundation Trust |
| 6 | All staff will be reminded of the need to consider domestic abuse within the context of safeguarding, including seeking guidance from the Safeguarding Team and utilising protection planning. | Rotherham Doncaster & South Humber NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||