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 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…
AI-generated summary The DHR found no evidence of domestic violence or abuse, concluding the deaths were neither predictable nor preventable. Key themes included the perpetrator's mental health and financial stressors, and the GP practice's lack of a domestic …
AI-generated summary The review identified systemic issues including inconsistent and incomplete risk assessments, fragmented information sharing across and within agencies, and challenges in the victim's engagement due to distrust of services. It also highlig…
AI-generated summary The review identified missed opportunities by General Practices and hospitals to identify and respond to the victim's domestic abuse and mental health needs. Concerns include GPs inappropriately discussing relationships with both partners …
AI-generated summary The report identifies concerns regarding the police response to domestic abuse incidents, including failures in arrest decisions, risk assessment, and supervision. It also highlights issues with medical practitioners' handling of disclosur…
AI-generated summary The DHR concluded that the homicide could not have been predicted or prevented by agencies involved. However, it identified learning points concerning family care dynamics, record-keeping, timely agency DHR involvement, and oversight of co…
AI-generated summary The review identifies systemic issues including inadequate inter-agency information sharing, inconsistent risk assessments, and procedural gaps in managing high-risk domestic abuse cases. Specific concerns relate to managing perpetrators w…
AI-generated summary The review identified a lack of professional curiosity and missed opportunities for routine enquiry about domestic abuse. Agencies struggled with coordinated multi-agency support for individuals with complex needs and those engaging in ris…
AI-generated summary The review highlights historical missed opportunities by agencies to intervene in long-standing domestic abuse due to evolving understanding of coercive control and victim reluctance to report. It identifies a need for improved multi-agenc…
AI-generated summary Key concerns include inadequate multi-agency response to domestic abuse, poor information sharing, insufficient consideration of the victim's and perpetrator's complex needs (mental health, substance misuse, self-neglect), and difficulties…
AI-generated summary The report found no prior indicators of domestic abuse or opportunities for professional intervention. However, it highlighted the need for improved accessibility of mental health support for males, particularly from Black, Minority, Ethni…
AI-generated summary The review identified failures in medication management, significant delays in arranging Mental Health Act assessments, poor inter-agency communication during patient transfer, and inadequate family support, exacerbated by language barrier…
AI-generated summary The report identifies concerns regarding inconsistent multi-agency information sharing, insufficient professional curiosity, and inadequate risk assessments for domestic abuse and safeguarding. It highlights missed opportunities to assess …
AI-generated summary The report highlights a lack of multi-agency coordination and professional curiosity in identifying and responding to domestic abuse, substance misuse, and safeguarding risks to children. It notes insufficient information sharing, inadequa…
AI-generated summary The review identified missed opportunities by agencies to identify and respond to domestic abuse, including a lack of professional curiosity, insufficient information sharing, and inadequate assessment of substance misuse. Barriers to repo…
AI-generated summary The review highlights inconsistent agency responses to older victims of domestic abuse, including issues with risk assessment, multi-agency coordination, and understanding of coercive control and perpetrator behaviour. Concerns also exist …
AI-generated summary The report identifies missed opportunities by multiple agencies to identify and manage the perpetrator's escalating risks, including drug misuse, mental health concerns, and violent behaviour. This was due to ineffective information sharin…
AI-generated summary The review identifies systemic failures in information sharing between criminal justice agencies regarding the perpetrator's extensive history of domestic abuse and high-risk behaviour. Frontline police and domestic abuse services did not …
AI-generated summary The review highlights a lack of agency knowledge regarding the victim's long-term domestic abuse and coercive control by the perpetrator, despite early violence and sustained control. It notes the victim's heightened vulnerability during s…
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.