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
Merton review
CSP: MertonPublished: August 2026Year of death: 2021Extracted: 11 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identifies systemic failures in recognising the links between domestic abuse, mental health issues, and suicide risk, alongside inadequate multi-agency information sharing and risk assessment practices for the victim and their children, particularly across different service areas and during the pandemic.
Home Office classifications
46 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - died by suicide
Victim - substance misuse
Victim - housing issues
Victim - physical disability
Victim - pregnancy
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - panic attacks
Victim - self harm
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
Children - under 18 shared parental responsibility (between victims)
Children - subject to child protection or domestic abuse prior to homicide
Perpetrator - substance misuse
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 mental 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 others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - physical stalking
Aggravating factors - digital stalking
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 - police recommendations
DHR process - social services recommendations
DHR process - school 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 - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
11 recommendations pulled from the report · 9 matched to organisations in the index
Addressed to
Community Safety (Safer Merton) | Safeguarding Adults Board | Safeguarding Children Partnerships
All agencies to implement the recommendations made within their own reports and share action plans and progress with Community Safety (Safer Merton) and other strategic partnerships where appropriate.
Community Safety (Safer Merton) to implement a process to provide assurance to the victim’s family demonstrating learning has taken place as a result of this review: This should be on a six-monthly basis once the Home Office has agreed the report and it has been published. It should continue until the action plan is complete and has demonstrated evidence of impact.
Addressed to
Community Safety (Safer Merton) | Safeguarding Adults Board | Safeguarding Children Partnerships
The 3 strategic partnerships (Community Safety (Safer Merton), Safeguarding Adults Board and Safeguarding Children Partnerships) to work jointly to promote a wider understanding and awareness of the link between adult mental health issues and domestic abuse.
Addressed to
Community Safety (Safer Merton) | Safeguarding Adults Board | Safeguarding Children Partnerships
The 3 strategic partnerships to promote a wider understanding of domestic abuse and the impact on children: This should be evidenced through case file audits to ensure the child’s lived experience is appropriately understood.
Addressed to
Community Safety (Safer Merton) | Safeguarding Adults Board | Safeguarding Children Partnerships
The 3 strategic partnerships to promote a wider understanding of the use and interpretation of risk assessing victims of domestic abuse. All training and learning events must include how risk assessments identify domestic abuse victims when they are a risk to themselves as well as identifying factors such as sexual and reproductive control.
Addressed to
Metropolitan Police | Merton Children’s Social Care | Community Safety (Safer Merton) | Central London Community Healthcare NHS Trust
Operation Encompass: • A review should be undertaken to ensure Operation Encompass is embedded in to all schools. • Consideration should be given as to whether school nurses could be informed as part of an extension of the process.
Addressed to
Merton Adult Social Care | Merton Children’s Social Care | Safeguarding Adults Board | Safeguarding Children Partnerships
Think Family approach: • Note the learning from SAR published March 2023. • Adult social care should consider how to work more closely with the children’s MASH to ensure all relevant information is shared. • A multi-agency, cross partnership audit of cases known to either children’s or adult services should be undertaken to provide assurance that assessments of all family members and lived experiences of children are included.
Addressed to
Community Safety (Safer Merton) | Safeguarding Adults Board | Safeguarding Children Partnerships
The 3 strategic partnerships: • To develop a joint action plan to ensure the learning from both reviews (DHR and SAR) is disseminated widely and agree continued joint working following all case reviews regarding families. This will include seeking assurances from single agency recommendations and action plans. • To consider how to identify complex families and implement a multi-agency approach to review them in order to share all known information and develop risk management plans of intervention and support in order to reduce risk.
Addressed to
Safeguarding Adults Board | Safeguarding Children Partnerships
Cross Boundary working: • A process should be put in place to ensure when a person is in crisis, timely notification is undertaken to appropriate services in and out of hours when the subject’s whereabouts is known. This could be through revision of the newly introduced Multi-Agency Risk Framework.
Marac processes should be reviewed to ensure victims are protected when moving to different areas: • Merton VAWG lead to liaise directly with SafeLives as part of learning from this DHR.