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 report highlights fragmented agency responses, missed opportunities to identify and address domestic abuse and mental health issues, and inconsistent information sharing, particularly concerning the victim's disclosures and the specifi…
AI-generated summary The DHR highlights a lack of understanding and recognition of Child to Parent Abuse (CPA), failures in adopting a "Whole Family" approach, and challenges in accessing mental health services for the perpetrator. It also notes victim blaming…
AI-generated summary Systemic failings in inter-agency information sharing, risk assessment, and mental health care coordination, particularly post-absolute discharge, contributed to the homicide. Key concerns include insufficient family engagement, unverified…
AI-generated summary The report identifies systemic failures in identifying and responding to domestic abuse in older people, particularly those in rural isolation. It highlights the impact of coercive control, digital exclusion, and inconsistent agency respon…
AI-generated summary The review identified a lack of consistent identification and understanding of domestic abuse, particularly between the victim and the perpetrator, and inadequate multi-agency coordination for complex cases. Deficiencies in police risk ass…
AI-generated summary The review identified systemic failures in inter-agency information sharing, risk assessment, and consistent engagement with the perpetrator, despite her extensive history of violence and alcohol issues. Opportunities to utilise the Domest…
AI-generated summary The review identifies systemic failures in inter-agency information sharing, risk assessment, and understanding of domestic violence dynamics, particularly regarding the perpetrator's history and the victim's safety during separation. It a…
AI-generated summary The review identified a lack of apparent domestic abuse history or significant agency involvement prior to the victim's death, yet several MARAC risk factors were present. This led to recommendations for GP practices to enhance understandi…
AI-generated summary The review highlights the perpetrator's history of violence and substance misuse, which was not adequately addressed by agencies. It also identifies the victim's non-reporting of abuse and a broader public reluctance to report witnessed or…
AI-generated summary Agencies missed opportunities to explore the victim's relationship and living arrangements, particularly regarding domestic abuse and transient family situations. Assumptions based on ethnicity and cultural background hindered proper inqui…
AI-generated summary The review identified flawed risk assessments, poor inter-agency information sharing, and a lack of understanding of domestic violence dynamics, including coercive control. Professionals failed to adequately assess the perpetrator's risks …
AI-generated summary The review identified a failure by professionals to recognise coercive and controlling behaviour as a significant risk factor, alongside insufficient multi-agency information sharing regarding the perpetrator's history of violence and ment…
AI-generated summary The review identified systemic failures in multi-agency safeguarding responses, including inadequate professional oversight in Adult Social Care, poor inter-agency communication, and a lack of awareness regarding the perpetrator's deterior…
AI-generated summary The review identified concerns regarding agencies' inconsistent perception of the victim's vulnerability, over-reliance on bail conditions in risk assessments, and insufficient attention to the victim's stated fears. It also highlighted is…
AI-generated summary The review identified inadequate multi-agency assessment and response to the victim's needs as an adolescent, particularly regarding domestic abuse in peer relationships. Concerns include underestimation of risks posed by the perpetrator, …
AI-generated summary The DHR found no evidence of domestic abuse or agency failings in the specific case. Key learning points relate to improving carer's assessments to identify domestic abuse challenges in older couples and increasing professional awareness o…
AI-generated summary The review highlighted challenges in assessing the perpetrator's deteriorating mental health due to his ability to mask symptoms and the undervaluation of family concerns. It also identified a need for improved processes in mental health a…
AI-generated summary The review identified concerns regarding the clarity of urgent referral protocols between health services, missed opportunities for safeguarding referrals by CAFCASS and schools concerning child abuse, and a lack of clear strategic leaders…
AI-generated summary The review identified challenges in multi-agency responses to domestic abuse, parental mental health issues, and substance misuse, particularly regarding consistent risk assessment, MARAC referrals, and victim engagement. Concerns were rai…
AI-generated summary The review identifies a lack of agency awareness and formal support mechanisms for employees experiencing domestic abuse. The victim confided in colleagues about escalating violence, but a lack of established policy and staff understanding…
AI-generated summary The DHR panel found no identifiable lessons for agencies, concluding that the homicide was neither predictable nor preventable due to a lack of prior agency contact or information regarding domestic abuse in the relationship.
AI-generated summary The review identifies systemic failures in multi-agency risk assessment and information sharing, especially concerning separation and child contact. It highlights insufficient professional training on perpetrator management, coercive contr…
AI-generated summary The review highlights a lack of joined-up agency activity and missed safeguarding opportunities, particularly regarding information sharing about the perpetrator's history of violence and the victim's vulnerabilities, including isolation, …
AI-generated summary The review identified a lack of agency contact with the victim and perpetrator in the area where the homicide occurred. It highlighted the presence of coercive and controlling behaviour by the perpetrator, which escalated rapidly, and the …
AI-generated summary The review identified systemic failures in multi-agency partnership, information sharing, and risk identification for domestic abuse. Agencies lacked awareness of coercive control, struggled to support the victim with complex needs, and di…
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.