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
Leicester review
CSP: Leicester
Published: June 2026
Year of death: 2020
Extracted: 51 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 inter-agency communication and cooperation, leading to missed opportunities in risk assessment and support for the victim, who faced multiple vulnerabilities including homelessness, mental health issues, and language barriers. It also highlighted challenges in responding to domestic abuse related suicide.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| Accommodation Concer | Individual assessments for all clients – not as couples/family groups | Accommodation Concern |
| Accommodation Concer | Domestic Abuse policy and training to be implemented and accessed by all staff | Accommodation Concern |
| Accommodation Concer | Language Line to be used with everyone where English is not a first language. | Accommodation Concern |
| Accommodation Concer | Training records to be reviewed in supervision and non-attendance followed up | Accommodation Concern |
| Accommodation Concer | Dash Training to be sourced and implemented | Accommodation Concern |
| East Midlands Ambula | Training around perpetrators of domestic abuse will be included when the next review of the EMAS safeguarding training takes place. Perpetrators will also be included in the EMAS Domestic Abuse policy at its next review. | East Midlands Ambulance Service |
| Leicester Homelessne | All Domestic Abuse cases whether in refuge or not will not be closed until the team leader for that officer has agreed that the casework is complete and in the instances of “lost contact” that there are recorded and documented records demonstrating that all attempts to contact the applicant and the refuge in which they reside have been exhausted. | Leicester Homelessness Prevention & Support |
| Leicester Homelessne | All presentations where domestic abuse is the reason for the approach will receive a DASH assessment regardless of whether they are currently in refuge or not. | Leicester Homelessness Prevention & Support |
| Leicester Homelessne | Create a factsheet for housing staff outlining the entitlements for foreign nationals and with details of where to obtain further information for inclusion on the council intranet. | Leicester Homelessness Prevention & Support |
| Leicestershire Polic | Leicestershire Police officers to be reminded, where there is a requirement for a PPN, it is the duty of the attending officer to ensure that submission. | Leicestershire Police |
| Multi-agency - 1 | All health agencies to review their domestic abuse training content to ensure that information on identifying and responding to perpetrators is included. ‘Health agencies’ should be broadly interpreted to cover drug and alcohol services and voluntary sector mental health services. | All health agencies |
| Multi-agency - 2 | All domestic abuse, health and social care staff undertaking frontline work to complete mental health and suicide prevention training. This should include a focus understanding both risks and protective factors with additional support put in place for those at high risk. | All domestic abuse, health and social care agencies |
| Multi-agency - 3 | All mental health staff undertaking frontline work to complete specific domestic abuse training, rather than it being subsumed under general safeguarding training | All mental health agencies |
| Multi-agency - 4 | All Northants MARAC victims to be signposted to specialist domestic abuse informed counselling | Northants MARAC |
| Multi-agency - 5 | All participating agencies to provide reassurance to their respective CSP that language needs of service users are considered and to explore the potential for simple messages (e.g., ‘we need to speak to you – please call this number’) are translated into locally spoken languages for use on business cards or as text messages. | All participating agencies |
| Multi-agency - 6 | All participating agencies to review their DNA policy to include a more flexible application for service users with multiple vulnerabilities, to consider checking contact details are accurate at each successful contact and to attempt more assertive outreach on the third attempt before closing a case. | All participating agencies |
| Multi-agency - 7 | All participating agencies to receive training on economic abuse and understand how to provide better support. For example, ensuring that all staff are aware of the option of applying for a no-fixed-abode bank account such as through services like HSBC’s no fixed abode bank accounts for people experiencing homelessness. | All participating agencies |
| Multi-agency - 8 | CSP to produce a briefing note for distribution to all participating agencies outlining the differences between: alcohol dependent, alcoholic and someone with alcohol issues; the difference between a retraction and a withdrawal statement. | Community Safety Partnership (CSP) |
| National - 1 | The Home Office to consider clearer parameters in its next iteration of the statutory guidance for undertaking DHRs in the context of suicides. | Home Office |
| National - 2 | The Home Office to satisfy itself that UKBA’s responses to requests for information by DHRs are robust and accurate. | Home Office |
| National - 3 | The Home Office to commission research into the links between mental health, domestic abuse and suicide and the experiences of marginalised communities. The methodology chosen should allow for the experiences of those from different cultures to be separated out. Upon completion, guidance for professionals should be developed and widely distributed. | Home Office |
| Northampton General | That relevant staff at NGH receive training related to professional curiosity, respectful uncertainty, and professional courage to enable and empower them to formulate judgements that translate into effective actions for those receiving care and services from the organisation. | Northampton General Hospital |
| Northampton General | Any domestic abuse training delivered should take an intersectional approach, it should include information on the dynamics of domestic abuse, how to appropriately identify, support and risk assess victims, survivors, and perpetrators. This stand-alone training must be mandatory considering the requirements of the Serious Crime Act 2015, and implications to anyone over the age of 16 (Children Act 1989/2004) | Northampton General Hospital |
| Northampton General | For any training to be effective it needs to be complimented with an organisation wide domestic abuse policy which responds to the needs of staff as well as patients experiencing domestic abuse and should include clear and established referral pathways. This should be separate from the adult safeguarding policy within the organisation. | Northampton General Hospital |
| Northampton General | There must be consistent and comprehensive record keeping as this is crucial in ensuring appropriate continuity of care across health disciplines and organisations and an integrated response for victims and survivors of domestic abuse. Record keeping should be included in internal audits to ensure compliance with the domestic abuse policy. | Northampton General Hospital |
| Northampton General | Undertake a root and branch review of the safeguarding service, the safeguarding governance and accountability arrangements across NGH and safeguarding organisational culture to ensure compliance with all statutory legislative, national and local policy arrangements | Northampton General Hospital |
| Northampton Hope Cen | Seek to attend the Part 4 Domestic Abuse Partnership Board | Northampton Hope Centre |
| Northampton ICB - 1 | Explore a more focused response to domestic abuse through the development of domestic abuse specific training and policies and explore the potential for implementing IRIS or similar. | Northampton ICB |
| Northamptonshire Pol | Northamptonshire Police to remind investigating officers and supervising officers of the need to ensure a holistic approach to evidence gathering and preparation when submitting files to the CPS for advice on charging for Breach of Bail. | Northamptonshire Police |
| Northamptonshire Pol | Northamptonshire Police to encourage supervising officers to appeal CPS charging decisions where further evidence could be gathered to strengthen a case against an individual who has breached bail. | Northamptonshire Police |
| Northamptonshire Pol | Northants to work with Voice to develop a protocol with respect to welfare checks. | Northamptonshire Police |
| North Northants Home | Check details of corporate contract for interpretation services in terms of services provided and ability to access translators immediately via a variety of methods. Ensure that staff at all levels have easy and quick access to interpretation services when dealing with a customer whose first language is not English. This is to ensure that appointments are able to be undertaken then and there, and there is no need to send the customer away to return at a later date. Establish the services provided by the new corporate contracted interpretation provider for NNC and disseminate information to all frontline Housing staff. | North Northants Homelessness |
| North Northants Home | Ensure that staff have a good understanding of risk assessments, and the ability to competently complete DASH assessment. Explore the possibility for a domestic abuse ‘specialist’ within the team. Ensure a skills audit of Housing Options staff is completed and a training programme devised in response to findings. | North Northants Homelessness |
| North Northants Home | Ensure that staff are reminded of the importance of always adding contemporaneous and detailed notes of all customer interactions and enquiries / actions. | North Northants Homelessness |
| North Northants Home | Create a factsheet for housing staff outlining the entitlements for foreign nationals and with details of where to obtain further information for inclusion on the council intranet. | North Northants Homelessness |
| Probation - 1 | Address checks to be completed with the Police using information sharing protocols in place within 24 hours of a change of address being provided. | Probation Service |
| Probation - 2 | Quicker information sharing between Police and Probation when requests are made. | Probation Service |
| Probation - 3 | All subsequent failures to engage with a probation sentence following sentence/release or breach action to result in further immediate breach action – unless reasons are clearly recorded and reviewed with a Senior Probation Officer as to why this is not appropriate. | Probation Service |
| Probation - 4 | Where the whereabouts of a domestic abuse perpetrator are unknown and there is no allocated Victim Liaison Officer the Probation Practitioner, to liaise with the Police in the absence of any other identified professionals or personal contact of identified victims to ascertain their safety or any concerns. | Probation Service |
| Probation - 5 | For all foreign national cases or where there is information that the person on Probation reports to have spent a period of time overseas attempts to be made to gain information regarding previous convictions. | Probation Service |
| Probation - 6 | Probation to produce a learning document for training purposes using this Review as a case study | Probation Service |
| Sunflower Centre - 1 | It is recommended that a MARAC-to-MARAC referral is always held between different areas when the victim has moved from one to another, regardless of the last time the victim was discussed at MARAC. To ensure all the information surrounding the victim is passed over. | Sunflower Centre |
| Sunflower Centre - 2 | More outreach attempts could have been made or attempts to proactively engage with homeless support organisations who might have been able to assist. | Sunflower Centre |
| Sunflower Centre - 3 | The outcomes and benefits of the Complex Needs IDVA post to be thoroughly evaluated to demonstrate the impact. With the hope of achieving more sustainable funding in the future to support complex cases. | Sunflower Centre |
| Sunflower Centre - 4 | A timescale should be agreed for when and how to escalate a lack of contact from Northamptonshire police when visits need to be undertaken to victims or upon waiting for actions to be updated. IDVAs should be more proactive in questioning the reasoning why a joint visit cannot be undertaken. | Sunflower Centre |
| Sunflower Centre - 5 | Further methods of communication should be sought when engaging with non-English speaking victims, including translating text messages and written materials. | Sunflower Centre |
| WALL - 1 | Review of Suicide Protocol after each suicide or at least annually. | Women’s Aid Leicestershire Ltd (WALL) |
| WALL - 2 | Staff refresher training on suicide prevention annually | Women’s Aid Leicestershire Ltd (WALL) |
| WALL - 3 | Regular mental health safety planning training for all staff. | Women’s Aid Leicestershire Ltd (WALL) |
| WALL - 4 | Welfare calls to be made to refuge residents before 12 noon each morning. | Women’s Aid Leicestershire Ltd (WALL) |
| WALL - 5 | Posters to be displayed on support available, with crisis numbers and other useful contacts. | Women’s Aid Leicestershire Ltd (WALL) |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||