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

Buckinghamshire review

CSP: Buckinghamshire Published: August 2026 Year of death: 2020 Extracted: 25 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 identifies concerns regarding limited agency engagement with the victim during the abusive relationship, particularly police response to a domestic abuse incident. It highlights the interplay of the victim's trauma, mental health, and isolation with the perpetrator's coercive control and extensive history of abuse, which hindered effective intervention and support.

Home Office classifications

44 tags

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

  • Victim - died by suicide
  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - depression
  • Victim - suicidal thoughts
  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - self harm
  • 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 others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - known to workplace (employer) as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service 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

25 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1

Source reference: paragraph 167

Addressed to Thames Valley Police

TVP to further explore and develop the use of proactive PNC markers for Domestic Abuse High Risk perpetrators and/or subjects who have a domestic abuse history suitable for disclosure under DVDS (Clare’s Law).

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

Recommendation 2

Source reference: paragraph 168

Addressed to Thames Valley Police

In light of resourcing challenges within DAIU leading to the lack of ownership or supervisory oversight in relation to medium risk domestic abuse risk management occurrences (RMOs), TVP need to identify which resources will be responsible for medium risk domestic abuse RMO ownership and management. Once these resources have been identified, an audit of these types of RMO should be undertaken in six months to ensure ownership and supervisory reviews are taking place.

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

Recommendation 3

Source reference: paragraph 169

Addressed to Thames Valley Police

TVP to give clear direction about whether a Niche RMO should continue to be created by the MASH for cases of medium risk domestic abuse.

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

Recommendation 4

Source reference: paragraph 170

Addressed to Thames Valley Police

TVP to determine whether enhanced victim safety planning will be provided for medium risk domestic abuse, and who will undertake this provision.

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

Recommendation 5

Source reference: paragraph 171

Addressed to Thames Valley Police

TVP to ensure operational guidance in relation to blocking perpetrators of stalking should be reviewed to ensure it is in line with national guidance and takes account of recommendations from local and national DHRs.

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

Recommendation 6

Source reference: paragraph 172

Addressed to Thames Valley Police

TVP to ensure operational guidance reflects the fact that separation or planned separation signifies an escalation in domestic abuse risk.

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

Recommendation 7

Source reference: paragraph 173

Addressed to Thames Valley Police

TVP to review operational guidance and ensure it reflects good practice around timeliness of recording contact with domestic abuse victims in the occurrence enquiry log and all other relevant systems.

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

Recommendation 8

Source reference: paragraph 174

Addressed to Thames Valley Police

TVP officers/staff to be reminded that where a relevant domestic abuse history is identified, the Clare’s Law disclosure application process can be police instigated, even if this is not requested by the person at risk or other interested party.

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

Recommendation 9

Source reference: paragraph 175

Addressed to Buckinghamshire Domestic Abuse Partnership Board

Buckinghamshire Domestic Abuse Partnership (BucksDAP) to review and improve the current response and support available to those affected by domestic abuse in rural communities, ensuring they receive the support they need to overcome the challenges they face.

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

Recommendation 10

Source reference: paragraph 176

Addressed to Buckinghamshire Domestic Abuse Partnership Board

BucksDAP to improve the response and support available to people with itinerant lifestyles.

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

Recommendation 11

Source reference: paragraph 177

Addressed to Buckinghamshire Domestic Abuse Partnership Board

BucksDAP and relevant providers should work to ensure awareness and clarity about domestic abuse referral pathways amongst frontline services.

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

Recommendation 12

Source reference: paragraph 178

Addressed to Buckinghamshire Domestic Abuse Partnership Board

BucksDAP and relevant providers should work to reduce barriers and maximise accessibility to specialist domestic abuse services.

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

Recommendation 13

Source reference: paragraph 179

Addressed to Buckinghamshire Council | Buckinghamshire Domestic Abuse Partnership Board

Buckinghamshire Council, BucksDAP and specialist domestic abuse advice and support services should ensure these services are promoted and available for friends and family members of victims and survivors.

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

Recommendation 14

Source reference: paragraph 180

Addressed to Review Chair

Awareness should be raised at a national level about concerns regarding the potential for gaps in responding effectively to victims and survivors of domestic abuse where thresholds for statutory intervention are not met.

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

Recommendation 15

Source reference: paragraph 181

Addressed to Safer Buckinghamshire Board members

All safeguarding settings to review and ensure there is an effective response to domestic abuse where the statutory threshold is not met.

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

Recommendation 16

Source reference: paragraph 182

Addressed to Safer Buckinghamshire Board members

All provider agencies should demonstrate how their audit processes identify the activity relating to asking service users about domestic abuse, mental health and suicidality, and how these meet relevant practice guidelines. They should ensure that any training reflects this requirement.

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

Recommendation 17

Source reference: paragraph 183

Addressed to Safer Buckinghamshire Board members

All provider agencies should review their training requirements to ensure this includes opportunities for staff to attend mental health first aid and suicide prevention first aid training.

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

Recommendation 18

Source reference: paragraph 184

Addressed to South Central Ambulance Service

SCAS should ensure that current safeguarding training emphasises: • The consideration, awareness and identification of domestic abuse and appropriate responses, • The need for professional curiosity around domestic abuse and what this looks like,  • The need for professional consideration of the extrinsic factors which may impact on safeguarding, • The importance of information sharing and the need for staff to make safeguarding referrals in line with local and national policy.

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

Recommendation 19

Source reference: paragraph 185

Addressed to Buckinghamshire Council, Public Health Team

Ensure the Making Every Contact Count approach and training includes reference to mental health and suicide.

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

Recommendation 20

Source reference: paragraph 186

Addressed to Buckinghamshire Council, Public Health Team

Review the multi-agency suicide prevention action plan to ensure it aligns with the new national Suicide Prevention strategy for England 2023 – 2028 and incorporates recommendations from DSRs locally and nationally.

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

Recommendation 21

Source reference: paragraph 187

Addressed to Buckinghamshire Council, Public Health Team

Ensure there is an annual deep dive on DSRs as part of the multi-agency suicide prevention meeting and that specialist domestic abuse services are represented.

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

Recommendation 22

Source reference: paragraph 188

Addressed to Buckinghamshire Council, Public Health Team

Review and implement actions to improve quality of, and identify potential efficiencies for, local data to monitor suicide in Buckinghamshire: Real Time Surveillance System (RTSS) work with Buckinghamshire Oxfordshire and Berkshire West Integrated Care Board (BOB ICB) and Thames Valley colleagues to further develop the regional RTSS in line with national good practice. Monitor and contribute to the new early warning National Near to Real Time Suspected Suicide Surveillance System (NRTSSS) providing updates to the Buckinghamshire multi-agency suicide prevention group on a quarterly basis for review.

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

Recommendation 23

Source reference: paragraph 189

Addressed to Oxford University Hospitals | Milton Keynes University Hospital

OUH and MKUH should ensure maternity staff follow the NICE Antenatal Guidance (2021) in relation to domestic abuse.

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

Recommendation 24

Source reference: paragraph 190

Addressed to Buckinghamshire Adult Social Care | Buckinghamshire Children’s Social Care | Milton Keynes Adult Social Care | Milton Keynes Children’s Social Care | Bedfordshire Adult Social Care | Bedfordshire Children’s Social Care

Adult and Children’s Social Care should ensure routine questions about domestic abuse are asked and recorded.

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

Recommendation 25

Source reference: paragraph 191

Addressed to Buckinghamshire Adult Social Care | Buckinghamshire Children’s Social Care | Milton Keynes Adult Social Care | Milton Keynes Children’s Social Care | Bedfordshire Adult Social Care | Bedfordshire Children’s Social Care

Domestic abuse knowledge should be refreshed with all Social Care staff every 3 years.

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