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: 2020
Extracted: 29 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 identifying and responding to coercive control and economic abuse by the perpetrator, particularly while in prison and upon release. Key concerns include inadequate recording of third-party domestic abuse reports, poor inter-agency information sharing, and missed opportunities for routine domestic abuse enquiry by healthcare services.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | That the Ministry of Justice review processes and implements policies within the prison service to ensure that where a perpetrator has a known history of domestic abuse and/or violence and initiates further relationships with other parties this is processed through a Domestic Violence Disclosure Scheme process with the local Constabulary to where the perpetrator is located. This would ensure should the perpetrator be moved around the prison system this is managed appropriately. (To be monitored by Hackney CSP) | Ministry of Justice |
| 2 | That the Ministry of Justice ensures processes are in place to ensure that families of victims of homicide are provided with a written record of the Judge’s sentencing comments after a trial. (To be monitored by Norfolk CSP) | Ministry of Justice |
| 3 | That the Ministry of Justice and HM Prison Service establish that all commissioned Prison Health Services are required to provide a timely written discharge report with a transfer of notes to community services and primary care prior to or on release from custody. There should also be a requirement that commissioned health services support statutory reviews with reports of an acceptable professional standard. (To be monitored by Norfolk CSP) | Ministry of Justice | HM Prison Service |
| 4 | That Norfolk Constabulary commission a review of crime recording standards on cases of domestic abuse. This should include a review of calls to domestic incidents, and missing persons reports. Consideration should be given to the routine supervision of incidents, such as missing person reports to identify where abuse has gone unrecorded. The review should include dip sampling by representatives of the Norfolk CSP and local domestic abuse services to ensure transparency and public confidence. | Norfolk Constabulary |
| 5 | That the HM Prison Service and National Probation Service actively monitor the perpetrator whilst he is a serving prisoner. To assess communication and visits to manage potential risks on grooming and developing new relationships. The panel STRONGLY recommends that the perpetrator’s mail be monitored by HM Prisons in order to prevent harm and abuse. This should also be used to inform licence conditions. (To be monitored by Norfolk CSP) | HM Prison Service | National Probation Service |
| 6 | That housing services involved in the DHR review their policies and develop new practice to consider economic abuse when assessing housing needs. | Norwich City Council | L&Q Housing Association |
| 7 | That Norfolk CSP review any targeting awareness campaigns arising from the DHR into the death of “April” in 2019 and consider whether learning from this review can be used to develop work in that area. | Norfolk Community Safety Partnership |
| 8 | That Norfolk Constabulary review the progress on actions from DHR into the death of “April” in 2017 together with this case to ensure that all DVDS Right to Ask scheme enquires are recorded in a retrievable format. This should be supported by audit against incoming call data. | Norfolk Constabulary |
| 9 | That all agencies review policies and procedures to ensure that they include the provisions of the Domestic Abuse Act 2021. | East London NHS Foundation Trust | Hackney CCG for General Practitioner | L&Q Housing Association | Metropolitan Police Service | National Probation Service | Norfolk Community Health and Care NHS Trust | Norfolk Constabulary | Norwich City Council | Norwich GP | Ministry of Justice | HM Prison Service | Norfolk Community Safety Partnership |
| A | The ELFT Safeguarding Adults Team to provide some form of safeguarding supervision to the team involved in this case to help offer practitioners there an opportunity to discuss safeguarding concerns and reflect on cases through the lens of safeguarding adults. The ELFT Safeguarding Supervision Policy is currently being drafted up but it is hoped that once this is published, the Safeguarding Lead for Hackney will have a conversation with the Service Manager to understand how best safeguarding supervision can be delivered to this service. This could realistically start to take place in the next 3 months once the policy has been ratified. | East London NHS Foundation Trust (ELFT) |
| B | Review of Domestic Violence and Abuse Policies to ensure up to date information and correct local referral pathways reflected within the next three months. | Hackney CCG for General Practitioner (GP) |
| C | Review of safeguarding hand over in Primary Care specifically for post-prison registrations with a GP including history of violent offending, mental health and substance misuse. | Hackney CCG for General Practitioner (GP) |
| D | Registration form to be explicit in asking about illicit use of substances and offering onward referral to local services. | Hackney CCG for General Practitioner (GP) |
| E | All staff at the GP practice would benefit from a domestic abuse awareness update within the next three months. | Hackney CCG for General Practitioner (GP) |
| F | As a learning for L&Q further training is required to support our staff providing an empathetic approach when dealing with sensitive matters. | L&Q Housing Association |
| G | A review will be undertaken of our Succession Application form as to the information gathered and whether this needs to include more about the applicant’s history. | L&Q Housing Association |
| H | It is recommended that Central East (CE) Basic Command Unit Senior Leadership Team (SLT) remind all BCU Operations room supervisors of the importance of using professional curiosity when prioritising and assessing requests to assist other police areas to conduct missing person enquires and to ask for more detailed risk assessments if required. | Metropolitan Police Service |
| I | When high risk individuals are being released into community at sentence end date, good practice would be that there should still be a MAPPA meeting so that all agencies are aware of potential risks in the community even if there are limited mechanisms in place to manage risks. | National Probation Service (NPS) |
| J | For staff to be professionally curious at all patient interactions. This will be done via training, the NCHC Safeguarding newsletter and Safeguarding Group Meeting will have a focus on Professional Curiosity. Re-circulate the Professional Curiosity Document of 2020 on an annual basis. There is also further support via phone calls, emails and TEAMs calls. | Norfolk Community Health and Care NHS Trust (NCHC) |
| K | Staff to be aware of the DA Champions role, how to access them and how to become a Champion. Guidance will be updated on the NCHC Safeguarding intranet page, this will include what champion is, what training and support is given and how the Champions are accessed. We aim to have a DA Champion in every locality by end of 2023. This will be communicated in Safeguarding newsletter and Group meeting, via DA lead and at Governance meetings. Registered staff to attend 3 yearly level 3 Safeguarding training day. As well as other subjects the training includes DA, professional curiosity, and the thematic framework. Training content is updated by Safeguarding team. Dates of training are advertised on Safeguarding intranet page, in newsletter and at Governance meetings, and take place approximately 3 times per month. | Norfolk Community Health and Care NHS Trust (NCHC) |
| L | Norfolk Professional Standards Department produces a ‘Learning Times’ magazine of learning points such as this one. This learning point has been recommended for inclusion and circulation to all officers in the next edition. In this case the domestic abuse concern features on compact and a review of the missing circumstances and/or risk assessment by the supervisor before authorising closure of the missing person record could have led to a better understanding of the need for the victim to be spoken with alone to address that concern. That aspect will be incorporated into the summary of the learning for the proposed magazine item. | Norfolk Constabulary |
| M | The Missing Person Force Policy Document section on completing ‘safe and well’ checks is recommended for amendment to include the following wording; “where abuse or exploitation are considered to be a possible factor, extensive efforts should be made to speak with the person alone”. | Norfolk Constabulary |
| N | Remind colleagues and partners of opportunity to request general access visits from the tenancy management team and when they might do so. | Norwich City Council |
| O | Update tenancy information to ask tenants to update the council of any additional support needs they have, as this occurs. | Norwich City Council |
| P | Remind colleagues to capture on information management system any new information on vulnerabilities or support needs of customers. | Norwich City Council |
| Q | To improve communication and process between the criminal justice system and the general medical services in Norfolk at the point of release from prison including registration at a new practice, timely transfer of medical records and communication regarding ongoing physical and psychological needs as well as repeat medication. | Norwich GP |
| R | Norfolk and Waveney primary care services require access to bespoke domestic abuse training which includes an awareness of domestic abuse, how to recognise and respond effectively. | Norwich GP |
| S | A domestic abuse gap analysis on training and content in Norfolk and Waveney to ensure a consistent system wide appropriate response. | Norwich GP |
| T | Ensure primary care services have access to distinct guidance on the identification and response to domestic abuse. | Norwich GP |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||