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.
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AI-generated summary The review identifies systemic failures in multi-agency domestic violence risk assessment and management, including missed opportunities to consider the perpetrator's history and the victim's homelessness. Inconsistent application of proce…
AI-generated summary The review identifies missed opportunities by agencies to fully explore reported domestic abuse, volatility, and acrimony in the relationship between the victim and the perpetrator, leading to potentially weaker risk assessments. It also h…
AI-generated summary The review identifies inconsistent domestic abuse classification by police, failures in inter-agency information sharing and safeguarding alerts, and issues with MARAC processes. It also highlights limited intervention for the victim's alc…
AI-generated summary The review identified inconsistent risk assessment and management, poor inter-agency information sharing, and a failure to adequately safeguard the victim and her child from escalating domestic abuse, compounded by the victim's disengageme…
AI-generated summary The report identifies themes of missed opportunities by agencies to recognise the victim's vulnerability and the exploitation she experienced. Key concerns include a lack of professional curiosity, insufficient multi-agency information sha…
AI-generated summary The review highlights significant gaps in inter-agency information sharing, particularly between police/MARAC and health services, impacting risk assessment and coordinated support for the victim. Challenges in victim engagement due to co-…
AI-generated summary The review found no agency could have predicted or prevented the homicide, with no specific learning identified regarding agency actions. However, it noted potential coercive and controlling behaviours in the relationship and identified ad…
AI-generated summary The review identifies systemic failures in multi-agency responses to domestic abuse involving young people, including delayed interventions, inadequate risk assessment for coercive control, and challenges in balancing adolescent autonomy w…
AI-generated summary The review highlights missed opportunities by agencies to proactively assess and support an elderly carer struggling with his wife's dementia, despite family concerns and his refusal of direct assistance. This led to a lack of safeguarding…
AI-generated summary The DHR identified a lack of professional curiosity by health agencies regarding the victim's relationship, substance misuse, and mental health, leading to missed opportunities to identify coercive control and address medication management…
AI-generated summary The review identifies significant failures in hospital discharge planning, inter-agency communication, and referral processes, leading to inadequate support for the victim and increased stress for the perpetrator. Concerns were also raised…
AI-generated summary The review identified concerns regarding the victim's vulnerability due to drug use, mental health, and sex work, alongside challenges in agency engagement due to a chaotic lifestyle. It highlighted issues in recognising domestic abuse in …
AI-generated summary The review identified missed opportunities to recognise the victim as a domestic abuse victim, a lack of routine enquiry about domestic abuse by health and social care, and insufficient multi-agency information sharing and assessment for c…
AI-generated summary The report identifies systemic failures in risk assessment, inter-agency information sharing, and tailored support for a vulnerable adult in an alcohol-fuelled, co-dependent relationship. Agencies underestimated the risk due to unclear rel…
AI-generated summary The review identified systemic failures in multi-agency information sharing, risk assessment, and management of domestic abuse, particularly concerning the victim's vulnerability and fluctuating capacity. Agencies often failed to recognise…
AI-generated summary The review identified failures in multi-agency communication and holistic assessment of the couple's interdependent care needs, particularly for self-funders. Gaps in medication management, carer support, and domestic abuse policies were a…
AI-generated summary Agencies, particularly GPs, missed opportunities to identify domestic abuse indicators and assess risk due to lack of specific policies, training, and cultural awareness. Friends and employers also lacked knowledge on how to respond to dis…
AI-generated summary The review identified missed opportunities by West Yorkshire Police to link domestic incidents and make adult safeguarding referrals in Leeds. In Tower Hamlets, agencies lacked awareness of escalating domestic abuse prior to the homicide. …
AI-generated summary The review identifies systemic failures in inter-agency information sharing and risk assessment, leading to an incomplete understanding of the perpetrator's risk and the victim's vulnerability. This resulted in poor case management and bai…
AI-generated summary The review identifies missed opportunities by health professionals to explore the perpetrator's disclosures of childhood abuse and a lack of consistent identification of his learning difficulties, alongside issues with recording domestic a…
AI-generated summary The review identified missed opportunities by health agencies to recognise and respond to long-term domestic abuse, a lack of professional curiosity, and the victim's isolation and fear, which hindered her from seeking support. It also not…
AI-generated summary The review identified shortcomings in Adult Social Care assessment processes, particularly regarding carer suitability and risk assessment, and noted a lack of comprehensive monitoring of the victim's alcohol abstinence and support needs p…
AI-generated summary The review identified significant failures in inter-agency information sharing and risk assessment regarding the perpetrator's violent and sexually assaultive behaviour. Agencies minimised the seriousness of incidents, missing opportunitie…
AI-generated summary Multiple agencies missed opportunities to identify and respond to domestic abuse, including failures in risk assessment, separate interviewing of parties, and information sharing regarding the perpetrator's history. There was also insuffic…
AI-generated summary The report identifies systemic failures in inter-agency information sharing, risk assessment, and recognition of domestic abuse and child sexual exploitation, leading to missed opportunities to intervene and protect the victim and her fami…
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.