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: 2021 Extracted: 31 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 multi-agency coordination, professional curiosity, and understanding of complex vulnerabilities including substance misuse, exploitation, mental health, and homelessness. It highlighted the impact of unconscious bias and inadequate risk assessments in supporting the victim.

Home Office classifications

43 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - issued life sentence
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - alcohol misuse
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - family attended dhr panel
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • 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

31 recommendations pulled from the report · 14 matched to organisations in the index

Recommendation 1

Addressed to Safer Somerset Partnership | agencies involved in this DHR

That the Safer Somerset Partnership seek assurance from agencies involved in this review that a) develop practitioners’ professional curiosity skills (drug and alcohol services, mental health, specialist domestic abuse services and housing) and b) Improving knowledge in case supervision for line managers covered in training and encouraged through supervision and other means available.

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

Recommendation 2a

Addressed to Somerset Safeguarding Adults Board

Somerset Safeguarding Adults Board to relaunch the guidance “What to do if it is not safeguarding” and to seek assurance that professionals within partner agencies have knowledge of and understand how to implement the guidance. ( Completed and now rebranded as Mult Agency Risk Management, MARM February 2024)

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

Recommendation 3

Addressed to Agencies involved in this DHR

That all agencies who contributed to this DHR, review their “Did Not attend” Policy ( or equivalent) to ensure that they work in partnership with other agencies especially in cases where someone is known to have multiple complex needs and also may be experiencing a barrier to engagement due to their location e.g. rural v town – particularly to include reference to dynamics of domestic abuse and impact that has on engagement for a survivor.

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

Recommendation 4

Addressed to All agencies involved in this DHR

Using this DHR as a case study, agencies involved in this review include guidance/training for professionals on the following subject matter; unconscious bias relating to substance misuse/victim blaming and to ensure that this includes guidance to support managers to be able to challenge and support professional through supervision.

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

Recommendation 5

Addressed to Somerset Council (Housing)

Somerset Council (Housing) to ensure that all agencies who have a duty to refer if a service user who may be homeless or threatened with homelessness understand their duty and are provided with guidance on the required process to make a referral.

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

Recommendation 6

Addressed to Somerset Council-Housing

Somerset Council (Housing) to ensure that when a new Information Technology system is introduced that within the procurement process there is a requirement that data relating to individuals is retained for seven years and that access can be made by the housing service to seek historic information on a client if required.

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

Recommendation 7

Addressed to Somerset Council Community Safety Team

Somerset Council Community Safety Team to develop guidance (7-minute briefing) for agencies on appropriate language when describing a victim of domestic abuse or sexual exploitation and agencies to ensure that professionals across the Safer Somerset Partnership agencies are provided with the guidance.

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

Recommendation 8

Addressed to Somerset Council Community Safety Team

Somerset Council Community Safety Team to ensure that the impact of economic abuse is included within its training modules and to ensure that cuckooing and organised crime are included as being relevant to domestic abuse.

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

Recommendation 8.2.1.1

Addressed to Avon and Somerset Constabulary

Head of Victim Care, Safeguarding & Vulnerability to continue activity with relevant colleagues across the force to support understanding of the complexity of vulnerability and multiple disadvantages, particularly in relation to victims who may present as suspects of crime.

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

Recommendation 8.2.1.2

Addressed to Avon and Somerset Constabulary

LSU to bolster their directory of support services and referral pathways for all victims- Completed January 2023

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

Recommendation 8.2.2.1

Addressed to Somerset Adult Social Care

To ensure ASC staff consider the impacts of substance misuse when undertaking Care Act Assessments and how this may impact on an individual’s care and support needs, and decision making.

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

Recommendation 8.2.2.2

Addressed to Somerset Adult Social Care

SCC Adult Safeguarding Staff are supported to understand research and practice guidance of working with people who have addictions, to support their decision making.

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

Recommendation 8.2.3.1

Addressed to NHS Somerset Integrated Care Board

When a person has made a disclosure of domestic abuse, even if well known, practitioners could use the opportunity to explore further and complete a DASH form/signpost to SIDAS.

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

Recommendation 8.2.3.2

Addressed to NHS Somerset Integrated Care Board

If a person has contact with a GP service about their mental wellbeing, substance and/or alcohol misuse and/or pain that does not appear to have a clear medical cause, that GP practices should include a clinical enquiry about Domestic Abuse in the consultation.

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

Recommendation 8.2.4.1

Addressed to Probation Service

The New Probation Office Service performance measures states that all Initial Sentence Plans need to be completed within 15 working days of a Person on Probation’s initial appointment. This is being implemented by the new probation service and is monitored and Probation Service locally are reaching their targets now.

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

Recommendation 8.2.4.2

Addressed to Probation Service

Enforcement policy needs to be adhered to, for all failed appointments a formal warning should be issued providing the Person on Probation an opportunity to provide evidence for their failure to attend. This is being monitored by the new probation service and incremental improvements are being achieved.

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

Recommendation 8.2.4.3

Addressed to Probation Service

Home visits to be completed on a regular basis given the chaotic nature of the victim’s lifestyle a home visit should have been completed. Home visits provide a valuable window into the person on probations circumstances and lifestyle. By seeing someone in their own environment, it enables staff to verify their self-report of their circumstances including who they are living with, identifying any issues with the property or the local area and understanding the impact of the person on probation’s role in their family, household and community. This can aid a comprehensive assessment of risk, needs and safeguarding concerns in relation to children, vulnerable adults, and partners in cases of domestic abuse. The New Probation Service has the following home visit schedule which must be adhered to following the commencement of supervision. Within 10 working days for any person on probation subject to National Security Division oversight. Within 15 days of the start of supervision for individuals who are a high risk of serious harm. Within 15 working days to all Registered Sex Offenders – regardless of level of risk, within 15 working days for all individuals convicted of/or identified as having been involved in Child Sexual Exploitation, within 6 weeks of the start of supervision for individuals who are a medium risk of serious harm, within 12 weeks of the start of supervision for individuals who are a low risk of serious harm. Whenever the victim moved a home visit should have been completed. This is now being implemented in the new probation service – the above are the new expectations for the future;

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

Recommendation 8.2.4.5

Addressed to Probation Service

Referral should have been made to CYPS, the OM only accepted the word of the victim for what was going on with regards to her two children, liaison should have been made with CYPS and clearly recorded. NEW SAFEGUARDING POLICY IN PLACE NATIONALLY which is being followed

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

Recommendation 8.2.4.7

Addressed to Probation Service

Probation Service are currently considering nationally a resource for Domestic Abuse checks and providing more resources for this service in conjunction with the Police. This will be by the provision of additional administrative staff, related to police provision for this specific task. Recommendation to be updated and finalised when the full details of this National Response are available.

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

Recommendation 8.2.4.8

Addressed to Probation Service

Regular Police checks to be made on the addresses of Service Users to establish is any issues. It is worth noting that the Probation Service now receives regular arrest and Domestic Violence information concerning Service users, in 2017/2018 this procedure was not in place.

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

Recommendation 8.2.5.1

Addressed to Somerset Drug and Alcohol Service

Further training to staff around identifying, escalating, managing safeguarding concerns/risks, and sharing safeguarding concerns with relevant external agencies

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

Recommendation 8.2.5.3

Addressed to Somerset Drug and Alcohol Service

Staff refresher around domestic abuse processes inc. managing disclosures, DASH, safeguarding referrals

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

Recommendation 8.2.6.1

Addressed to Somerset Public Health Service

Public Health Nursing adopt the Health Visitor centralised triaging and duty system to improve adherence to the Pre-birth SOP.

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

Recommendation 8.2.6.2

Addressed to Somerset Public Health Service

Children Social Care to notify other agencies/service when someone/family of concern moves into the area.

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

Recommendation 8.2.7.1

Addressed to Somerset Integrated Domestic Abuse Service | Somerset Drug and Alcohol Service

SIDAS and SDAS to review how they work collaboratively and if improvements can be made to better support victims of domestic abuse.

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

Recommendation 9

Addressed to Safer Somerset Partnership

SSP to continue to review and audit the updated MARAC procedures in Somerset, to ensure that MARAC referrals are discussed at a MARAC and decisions are recorded.

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

Recommendation 10

Addressed to Somerset Council Community Safety Team

Somerset Council Community Safety Team to ensure that within its training module that children are included as being relevant to domestic abuse. Update- this recommendation has been implemented.

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

Recommendation 11

Addressed to Home Office | other government departments

Safer Somerset Partnership to request that the Home Office in partnership with other government departments identify how agencies can embed trauma informed practices within their professional practice. This to include social workers, health practitioners, police and probation.

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