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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

42 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 - depression
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Victim - immigration involvement
  • Perpetrator - housing issues
  • 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 health 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 - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police 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 - community safety partnership recommendations
  • DHR process - identification of risk 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 - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

51 recommendations pulled from the report · 20 matched to organisations in the index

Recommendation East Midlands Ambula

Addressed to East Midlands Ambulance Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Leicester Homelessne

Addressed to Leicester Homelessness Prevention & Support

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Leicester Homelessne

Addressed to Leicester Homelessness Prevention & Support

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Leicester Homelessne

Addressed to Leicester Homelessness Prevention & Support

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 1

Addressed to All health agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 2

Addressed to All domestic abuse, health and social care agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 3

Addressed to All mental health agencies

All mental health staff undertaking frontline work to complete specific domestic abuse training, rather than it being subsumed under general safeguarding training

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 5

Addressed to All participating agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 6

Addressed to All participating agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 7

Addressed to All participating agencies

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Multi-agency - 8

Addressed to Community Safety Partnership (CSP)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation National - 1

Addressed to Home Office

The Home Office to consider clearer parameters in its next iteration of the statutory guidance for undertaking DHRs in the context of suicides.

Verified wording from the published review · Original review (PDF) ↗

Recommendation National - 3

Addressed to Home Office

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation North Northants Home

Addressed to North Northants Homelessness

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation North Northants Home

Addressed to North Northants Homelessness

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation North Northants Home

Addressed to North Northants Homelessness

Ensure that staff are reminded of the importance of always adding contemporaneous and detailed notes of all customer interactions and enquiries / actions.

Verified wording from the published review · Original review (PDF) ↗

Recommendation North Northants Home

Addressed to North Northants Homelessness

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton General

Addressed to Northampton General Hospital

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton General

Addressed to Northampton General Hospital

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)

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton General

Addressed to Northampton General Hospital

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton General

Addressed to Northampton General Hospital

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton General

Addressed to Northampton General Hospital

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northampton ICB - 1

Addressed to Northampton ICB

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northamptonshire Pol

Addressed to Northamptonshire Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Northamptonshire Pol

Addressed to Northamptonshire Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Probation - 1

Addressed to Probation Service

Address checks to be completed with the Police using information sharing protocols in place within 24 hours of a change of address being provided.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Probation - 3

Addressed to Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Probation - 4

Addressed to Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Probation - 5

Addressed to Probation Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Sunflower Centre - 1

Addressed to Sunflower Centre

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Sunflower Centre - 3

Addressed to Sunflower Centre

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation Sunflower Centre - 4

Addressed to Sunflower Centre

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation WALL - 5

Addressed to Women’s Aid Leicestershire Ltd (WALL)

Posters to be displayed on support available, with crisis numbers and other useful contacts.

Verified wording from the published review · Original review (PDF) ↗