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 missed opportunities by GPs to explore wider implications of the perpetrator's mental health and family conflict, including fabricated events, which limited agencies' ability to assess risk. This highlights the need f…
AI-generated summary The review identifies concerns regarding inadequate risk assessment and management in cases of inter-familial domestic violence, particularly for same-gender relationships. It highlights failures in inter-agency information sharing and a l…
AI-generated summary The report highlights systemic failures in information sharing and multi-agency risk assessment, particularly concerning domestic abuse, mental health, and substance misuse. Agencies often lacked a full family picture, leading to missed op…
AI-generated summary The review highlights concerns regarding agencies' ability to identify and manage the victim's significant vulnerabilities, particularly her susceptibility to abusive relationships, after her children were removed from her care. There were…
AI-generated summary The report identifies missed opportunities for multi-agency intervention, superficial responses to complex family needs, and a lack of professional curiosity and information sharing, particularly regarding domestic abuse and alcohol misuse.
AI-generated summary The review found no prior agency contact with the victim or perpetrator, preventing any risk assessment or intervention. Concerns were raised regarding the availability of information on substance misuse support for families and the safegu…
AI-generated summary The review highlights concerns regarding inadequate information sharing with families of mental health patients, impacting their understanding of risk and ability to provide care. It also identifies issues with the completeness of informat…
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…
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.