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: Somerset
Published: July 2026
Year of death: 2023
Extracted: 10 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 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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 20.10 | 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. | Somerset Drug and Alcohol Service |
| 20.11 | 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. | South Western Ambulance Service NHS Foundation Trust |
| 20.2 | 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. | Somerset Council Public Health | Safer Somerset Partnership | Gloucestershire Community Safety Partnership |
| 20.3 | 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 |
| 20.4 | 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. | Safer Somerset Partnership |
| 20.5 | 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. | Children Social Care |
| 20.6 | 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. | Children Social Care |
| 20.7 | 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. | Children Social Care |
| 20.8 | 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 Council Public Health |
| 20.9 | Officers at Somerset Council Housing to improve around professional curiosity and signposting for support around mental health and bereavement. | Somerset Council Housing |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||