Find recommendations from statutory reviews of domestic homicides, published in the Home Office DHR Library. Victim and perpetrator names are never displayed on this page.
Newest publication first
AI-generated summary The review identifies concerns regarding inconsistent domestic abuse risk assessments, failure to correctly identify the nature of the relationship, and inadequate information sharing between agencies. These issues led to missed opportunit…
AI-generated summary The review identified insufficient attention to the emotional and practical support needs of the perpetrator as a carer, particularly as the victim's dementia progressed and after the victim's move to residential care. There were missed op…
AI-generated summary The review identified a lack of joined-up agency working, inadequate risk assessment, and missed opportunities in mental health care for the perpetrator, particularly concerning potential child criminal exploitation and familial violence. …
AI-generated summary The review found no specific agency failings or missed opportunities for intervention. However, it identified dangerous cultural narratives around whirlwind romances and male control as contributing factors to the homicide.
AI-generated summary The review identifies systemic failures in agencies' ability to recognise domestic violence indicators, particularly when co-occurring with substance misuse and pregnancy. It highlights gaps in multi-agency communication, record-keeping, a…
AI-generated summary The review highlights significant failures in inter-agency coordination and information sharing, leading to an uncoordinated response to the victim's complex needs, including mental health, substance misuse, and domestic abuse. Professiona…
AI-generated summary The review found limited agency awareness of the victim's extensive coercive control and economic abuse. Barriers to reporting included the victim's perception that non-physical abuse would not be taken seriously by police, a lack of safet…
AI-generated summary The review identified systemic failures in multi-agency communication, risk assessment, and information sharing, particularly concerning domestic abuse, forced marriage, and honour-based violence. Agencies missed opportunities for early in…
AI-generated summary Agencies failed to identify domestic abuse, including financial exploitation, within the relationship, lacked professional curiosity regarding disclosures of sexual abuse, and did not consistently share information or apply safeguarding pr…
AI-generated summary The review identified significant communication and process failures in mental health service referrals and care transitions, alongside missed opportunities for information sharing and safeguarding adult concerns by police and primary care…
AI-generated summary Agencies failed to recognise domestic abuse when the victim was a parent, leading to missed risk assessments. Health professionals did not adequately triangulate information with family, impacting holistic assessments. Families supporting …
AI-generated summary The review identifies significant long-term, hidden familial domestic and sexual abuse, highlighting the profound barriers to disclosure faced by victims. It also notes missed opportunities by health services to investigate underlying caus…
AI-generated summary The review identifies missed opportunities by agencies to identify and respond to coercive control and domestic abuse, particularly within the Family Court system where the victim was unrepresented. It highlights the enhanced risks at sepa…
AI-generated summary The review identified a lack of agency involvement prior to the death and significant barriers to reporting domestic abuse, particularly for male victims. There was a societal struggle to recognise women as perpetrators and men as victims,…
AI-generated summary The review identified missed opportunities for agencies to enquire about domestic abuse, particularly for BAME women facing additional disclosure barriers. It highlighted the need for increased professional curiosity, targeted support, and…
AI-generated summary The review identified a lack of inter-agency information sharing regarding the perpetrator's history of domestic abuse and missed opportunities to identify the victim's vulnerability to abuse. Gaps in safeguarding processes and the need fo…
AI-generated summary The review identified systemic failures in inter-agency coordination, information sharing, and consistent application of domestic abuse policies. Agencies did not adequately supervise the high-risk perpetrator or respond effectively to the…
AI-generated summary The review found that agencies had no direct knowledge of the victim's domestic abuse, despite family and colleagues holding pieces of information. There were missed opportunities by health professionals to proactively inquire about domest…
AI-generated summary The review identified missed opportunities in risk assessment, information sharing, and multi-agency coordination, particularly regarding child protection and stalking. Agencies struggled with consistent identification of high-risk domesti…
AI-generated summary The review found no overt indicators of domestic abuse were identified by agencies. Key concerns include a lack of a 'Think Family' approach, insufficient support for the victim's daughter and carer, and challenges in healthcare due to lim…
AI-generated summary The review identifies systemic failures in agencies' recognition of the victim's vulnerability and 'mate crime', alongside a lack of professional curiosity and multi-agency information sharing. This led to incidents being treated in isolat…
AI-generated summary The review identifies critical gaps in inter-agency information sharing, particularly between police and mental health services, leading to an incorrect incident grading and delayed emergency response. It also highlights issues with mental…
AI-generated summary The review identifies a limited understanding among professionals of the co-morbidity of problem gambling, mental health issues, and substance misuse. It highlights a lack of professional curiosity in assessments and insufficient holistic …
AI-generated summary The review identifies systemic failures in multi-agency information sharing, risk assessment, and understanding of domestic abuse's impact on children, particularly stepchildren. It highlights missed opportunities to hear the child's voice…
AI-generated summary The review highlights challenges in identifying the primary perpetrator in cases of mutual allegations and significant barriers to the victim's engagement with support services, including mental health issues, financial dependence, and fea…
The index holds 692 reviews from the Home Office library. 9 are not yet listed here while recommendation extraction and verification completes. 5,050 of 10,174 verified recommendations are matched to organisations tracked in the index.
These are statutory reviews under section 9 of the Domestic Violence, Crime and Victims Act 2004.