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 identified the perpetrator's manipulative, controlling, and coercive behaviour towards the victim, alongside instances of violence from both parties. It highlights a need for improved professional curiosity and better support me…
AI-generated summary The report highlights systemic failures in NPS risk management, including delayed recall of the perpetrator despite escalating risk, and critical communication shortcomings between the NPS and Metropolitan Police regarding the perpetrator'…
AI-generated summary The review identifies concerns regarding probation service practices, timely access to perpetrator programmes, mental health assessment for victims of domestic abuse, and inter-agency cooperation with DHRs.
AI-generated summary The review identified inconsistent use of DASH risk assessments and MARAC referrals, a lack of professional curiosity, and poor multi-agency information sharing. Challenges in supporting individuals with co-occurring mental health, substan…
AI-generated summary The report identifies concerns regarding the perpetrator's coercive control, manipulation, and drug use, leading to the victim's isolation, financial exploitation, and the prioritisation of his needs. It also notes missed opportunities by …
AI-generated summary The review identified inconsistent risk assessment, particularly regarding perpetrator suicide threats and stalking, and inadequate information sharing between agencies. Failures in police response to the victim's calls and breaches of bai…
AI-generated summary The review highlights challenges in assessing and managing the perpetrator's declining mental health, drug addiction, and history of domestic abuse, which included coercive control. Agencies struggled with information sharing and fully rec…
AI-generated summary The report highlights inconsistent follow-up on domestic violence disclosures, particularly when the perpetrator was also a victim with complex needs (mental health, alcohol misuse). Agencies often failed to consistently record perpetrator…
AI-generated summary The review identifies concerns regarding Greater Manchester Police's risk assessment processes, particularly the underestimation of the perpetrator's violent history and threats, leading to insufficient information sharing and delayed arre…
AI-generated summary The review concluded that the victim's death was not predictable or preventable, but identified learning points. These include the need for improved inter-agency information sharing, enhanced safeguarding training for GPs on mental health …
AI-generated summary The review highlights systemic failures in inter-agency information sharing, particularly between police forces, leading to missed opportunities for intervention regarding the perpetrator's drug misuse and domestic abuse history. Inadequat…
AI-generated summary The review identifies critical failures in police call handling and incident response for domestic abuse, alongside systemic issues in inter-agency information sharing, DHR process coordination, and public/professional awareness of domesti…
AI-generated summary The review identified a lack of comprehensive risk assessment and poor multi-agency information sharing regarding the perpetrator's escalating violent behaviour. Interventions were often insular, focusing on containment rather than address…
AI-generated summary The review identified missed opportunities by general practice to holistically assess and follow up on the perpetrator's gambling addiction and the victim's disclosed 'worries at home'. Concerns also arose regarding undocumented police che…
AI-generated summary The review identifies concerns regarding fragmented communication and information sharing between health services concerning the perpetrator's serious mental illness and medication adherence. It also highlights insufficient proactive suppo…
AI-generated summary The report identifies missed opportunities for statutory agencies to engage with the perpetrator, communication weaknesses between health agencies, and flawed police risk assessments. It also highlights the need for improved national intel…
AI-generated summary The review identified systemic failures in police adherence to domestic abuse policies, intelligence sharing, and inter-agency communication. There were also missed opportunities by health and education services to identify and respond to …
AI-generated summary Agencies consistently failed to recognise the high-risk indicators of domestic abuse, coercive control, and stalking over 40 years, leading to a lack of robust intervention and support for the victim. There was also a lack of consistent in…
AI-generated summary The review highlights systemic failures in multi-agency working, particularly regarding Adult Social Care's response to domestic abuse referrals and safeguarding concerns. It notes a lack of consistent risk assessment, inadequate informati…
AI-generated summary The report highlights challenges in identifying domestic abuse, particularly coercive control, when the victim does not self-identify, and the perpetrator conceals mental health issues. It also points to the need for better awareness campa…
AI-generated summary The review identified lessons regarding the need for improved risk assessments, professional curiosity, and information sharing across agencies, particularly concerning vulnerable individuals with substance misuse issues and chaotic lifest…
AI-generated summary The review identified a lack of inter-agency information sharing, insufficient understanding of the victim's complex family dynamics and vulnerabilities, and missed opportunities to identify and respond to coercive control and domestic abu…
AI-generated summary The review identified fragmented multi-agency responses, limited information sharing, and an inadequate understanding of the cumulative impact of stalking and harassment. There were missed opportunities to address the victim's complex need…
AI-generated summary The review identified missed opportunities for proactive intervention and signposting support for the victim following a domestic abuse incident. It highlighted gaps in information sharing between health agencies and social services, and t…
AI-generated summary The review identified a complex history of intergenerational family abuse, substance misuse, and mental health issues, with agencies often failing to holistically explore presenting concerns, conduct adequate follow-up, or engage in multi-…
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.