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: February 2026
Year of death: 2022
Extracted: 13 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
Key concerns include limited opportunities for the victim to speak alone, a lack of routine domestic abuse enquiry, and unaddressed carer fatigue. Mentions of assisted suicide were not consistently identified as suicide risk, impacting multi-agency follow-up.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 18.1.1 | A multi-agency learning briefing will be developed to include information and reflective questions about suicide risk, including questions to ask when patients/service users indicate an intention to access Dignitas. | Norfolk Community Safety Partnership | Norfolk Safeguarding Adults Board | Public Health Norfolk |
| 18.1.2 | A multi-agency learning event will be delivered, addressing approaches to safety planning - as recommended by NICE and NHSE - when patients/service users disclose suicidal ideation. | Norfolk Community Safety Partnership | Norfolk Safeguarding Adults Board | Public Health Norfolk |
| 18.1.3 | Multi-agency guidance to be developed, to assist staff who are called to be engaged with a Statutory Review. | Norfolk Safeguarding Adults Board |
| 18.2.1 | To raise awareness of Dignitas to general practice staff and the importance of conducting a risk assessment if a person raises issues of suicidal ideation or assisted dying. | Primary Care | Norfolk and Waveney Integrated Care Board |
| 18.3.1 | To review information within the level 3 safeguarding training package, to include more detail about domestic abuse in older people and impact on carers. | Norfolk and Norwich University Hospitals NHS Trust |
| 18.3.2 | To introduce targeted bespoke training to different departments at NNUH. | Norfolk and Norwich University Hospitals NHS Trust |
| 18.3.3 | The hospital Trust’s safeguarding policy, which includes the identification of carer’s burnout, will be introduced across out-patient services. | Norfolk and Norwich University Hospitals NHS Trust |
| 18.4.1 | Review of electronic patient admission documentation to help in identifying the needs of carers including signposting to appropriate support services. | Cambridge University Hospital Trust |
| 18.5.1 | A review will be undertaken, to identify how individuals are asked about their options, when their care is self-funded, and contact is via an informal advocate. | Norfolk County Council – Adult Social Care |
| 18.5.2 | Periodic Care Act training will include details on how adult social care can support people who are self-funding. | Norfolk County Council – Adult Social Care |
| 18.6.1 | For Domestic Abuse, safe enquiry questions to become part of everyday practice within NCHC and be incorporated into the SystmOne templates, including prompts around ensuring patients are given the opportunity to be seen alone. | Norfolk Community Health and Care |
| 18.6.2 | For NCHC to provide awareness and support to staff to enable them to identify carers fatigue and understand the safeguarding implications of this on the patient and carer. | Norfolk Community Health and Care |
| 18.6.3 | For NCHC to explore if improvements can be made to the SystmOne recording visibility between teams who are accessing different SystmOne units. | Norfolk Community Health and Care |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||