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
Somerset review
CSP: SomersetPublished: July 2026Year of death: 2023Extracted: 10 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified missed opportunities by agencies for professional curiosity and comprehensive risk assessment, particularly regarding non-fatal strangulation and its delayed medical complications. Challenges in inter-agency communication and flexible service engagement were also noted, alongside the victim's difficulties in reporting abuse and the perpetrator's alcohol-related violence.
Home Office classifications
42 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - housing issues
Victim - neurodiverse condition diagnosis
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Children - under 18 shared parental responsibility (between victims)
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - alcohol misuse
Perpetrator - housing issues
Perpetrator - mental ill health
Perpetrator - neurodiverse condition diagnosis
Perpetrator - anxiety
Perpetrator - self harm
Perpetrator - suicidal thoughts
Perpetrator - serious or life limiting illness
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 probation services as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to friends as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - social services recommendations
DHR process - health 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
10 recommendations pulled from the report · 1 matched to organisations in the index
Addressed to
Somerset Council Public Health | Safer Somerset Partnership | Gloucestershire Community Safety Partnership
Somerset Council Public Health on behalf of Safer Somerset Partnership to liaise with Gloucestershire Community Safety Partnership to develop a multi-agency protocol on how to deal with incidences of non-fatal strangulation.
Safer Somerset Partnership should lead on gaining assurance that all agencies embed learning/training on non-fatal strangulation, as all could have NFS disclosure made to them and need to equally be aware of the domestic abuse safeguarding and medical concerns due to this.
Safer Somerset Partnership to write to the Domestic Abuse Commissioner for England and Wales, Minister with responsibility for Home Office and Minister with responsibility for Department of Health to suggest a high-profile campaign to raise awareness around the risks relating to NFS (primarily from a medical welfare perspective), given that evidence shows the majority of domestic abuse is not reported.
It is recommended that when a disclosure needs to be made to keep a child safe, personnel must clearly evidence who needs to be party to the information in order to act in the best interest of the child.
Staff should be reminded when an assessment is being completed and the potential risk is around a child’s contact with one particular parent, that parent should be included in the assessment to widen the safety net for the child.
Where there are children living in a domestic abuse environment, consideration should be given for referrals to be made to domestic abuse services for Young People.
Somerset Council Public Health to improve public understanding on the course of action to take if a 3rd party witnesses or hears an incidence of domestic abuse occurring to victims who may be male or female.
Somerset Drug and Alcohol Service to consider alternative ways to engage with clients who highlight at referral that they are unable to engage in their standard treatment options; Mon-Fri 09:00 - 17:00.
Addressed to
South Western Ambulance Service NHS Foundation Trust
South Western Ambulance Service to ensure that frontline, patient facing staff are aware of the importance of professional curiosity and the need to look at and understand the holistic picture.