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 highlights systemic failures in multi-agency coordination, information sharing, and risk management for a vulnerable victim with complex needs. Key concerns include the ineffective response to coercive control and adolescent-to-…
AI-generated summary Agency risk assessments were seriously flawed, consistently underestimating the risk of domestic violence despite escalating incidents, coercion, and threats. There were missed opportunities for multi-agency intervention, appropriate refer…
AI-generated summary Agencies missed opportunities to identify and respond to coercive control and domestic abuse, often attributing the victim's vulnerabilities and missed appointments to her alcohol misuse rather than exploring potential manipulation by the …
AI-generated summary The report highlights systemic failures in monitoring a high-risk perpetrator, including over-reliance on self-reporting, inadequate risk assessments, and a lack of professional curiosity regarding his relationships. It also points to poor…
AI-generated summary The report identifies a lack of trauma-informed practice, insufficient understanding of coercive control and its impact on victims with complex needs (EUPD, substance misuse), and missed opportunities for effective multi-agency collaborati…
AI-generated summary The review identified that agencies primarily focused on the victim's health and social care needs and carer breakdown, often overlooking or inadequately addressing direct allegations of domestic abuse. There was a lack of multi-agency coo…
AI-generated summary The review identifies challenges in identifying and monitoring serial domestic abuse perpetrators with historic records. It highlights missed opportunities across health, housing, and employment sectors to proactively identify and respond …
AI-generated summary Concerns include missed opportunities by healthcare professionals to identify domestic abuse, particularly regarding injuries and the legal context of consensual sexual activity. The report also notes the influence of small community setti…
AI-generated summary The review identified systemic issues in multi-agency information sharing and risk assessment, leading to missed opportunities to identify coercive control and manage the victim's complex needs, including suicide risk. Challenges in victim…
AI-generated summary The review identifies systemic failures in multi-agency risk assessment, information sharing, and professional curiosity regarding domestic abuse and coercive control. It highlights economic abuse and increased risks during separation as c…
AI-generated summary The report identifies insufficient inter-agency coordination and information sharing, particularly regarding mental health risk assessments and transitions of care. Concerns include delays in integrating historic domestic abuse support wit…
AI-generated summary The review identified systemic failures in multi-agency communication, information sharing, and understanding of Adolescent to Parent Violence and Abuse. Concerns include missed opportunities for early intervention, inadequate mental healt…
AI-generated summary The review highlights concerns regarding the perpetrator's escalating jealousy, controlling behaviour, and stalking, which led to the victim's isolation and physical abuse. It also identifies barriers to the victim seeking help and the nee…
AI-generated summary Agencies lacked professional curiosity, failed to conduct holistic assessments, and did not adequately identify or respond to domestic abuse, particularly in the context of an older couple, alcohol misuse, and caring responsibilities. Info…
AI-generated summary The report identifies concerns regarding agencies' assessment and response to escalating domestic abuse risks, including the downgrading of police risk assessments despite indicators of coercive control and strangulation by the perpetrator…
AI-generated summary The review identified concerns regarding staff confidence and consent in information sharing, particularly across local authority boundaries. It also highlighted the need for improved support and recognition for carers and families of vuln…
AI-generated summary The review identifies an escalation of domestic abuse, the victim's fear of statutory intervention hindering disclosure, and a lack of coordinated multi-agency information sharing and response. Professionals missed opportunities to identif…
AI-generated summary The review identified systemic failures in multi-agency responses to domestic abuse, including inadequate risk assessment, poor information sharing, and missed opportunities to intervene with the victim and the perpetrator. Agencies strugg…
AI-generated summary The review identified systemic failures in inter-agency information sharing, risk assessment, and coordination of services for the victim and their children. Concerns include inadequate responses to domestic abuse disclosures, missed oppor…
AI-generated summary The report identifies inadequate understanding and response to domestic abuse by health agencies, inconsistent information sharing, and failure to challenge self-reported substance misuse. Challenges with transient lifestyles and aliases h…
AI-generated summary The review identified concerns regarding intergenerational domestic abuse, the victim's vulnerability, self-harm, and substance misuse. It highlighted a fragmented multi-agency response, poor transition between child and adult services, an…
AI-generated summary The review identified concerns regarding agencies' limited knowledge and inconsistent application of the Domestic Violence Disclosure Scheme, and a failure to fully recognise coercive and controlling behaviour. Information sharing issues a…
AI-generated summary The review identified systemic failures in information sharing regarding the perpetrator's mental health history, leading to inadequate risk assessment and care. There were numerous missed opportunities across multiple agencies to identify…
AI-generated summary The report highlights concerns regarding GP awareness of DHRs, the need for police to consider a dedicated family liaison for the perpetrator's family, and the lack of clarity in mental health referral routes and terminology between primar…
AI-generated summary The review identified systemic failures in multi-agency information sharing, risk assessment, and safety planning for a victim with complex needs, particularly concerning the perpetrator's release from prison after breaching a Domestic Vio…
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.