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 challenges in managing complex cases involving co-occurring domestic abuse, mental health issues, and substance misuse, particularly concerning risk assessment for male victims and inter-agency information sh…
AI-generated summary The review identified concerns regarding the monitoring of the perpetrator's mental health, particularly in relation to repeat prescriptions and communication between mental health services and the GP. It also questioned the suitability of…
AI-generated summary The report identifies systemic failures in multi-agency information sharing, risk assessment, and coordination, particularly regarding the perpetrator's unsupervised release from prison and the victim's obscured status as a domestic violen…
AI-generated summary The review identified missed opportunities by agencies to recognise domestic abuse indicators, explore Adult A's social circumstances, and share information effectively, particularly given Adult A's vulnerabilities related to mental health…
AI-generated summary The review identified systemic failures across police forces and an NHS Trust in consistently applying domestic abuse policies, conducting risk assessments, safeguarding vulnerable adults, and sharing critical information. These shortcomin…
AI-generated summary Agencies failed to consistently recognise and respond to domestic abuse, especially in interfamilial relationships and when alcohol misuse was a factor. Challenges were noted in mental health and alcohol care pathways for intoxicated indiv…
AI-generated summary The report identifies confusion among agencies regarding the assessment of vulnerable adults in the context of domestic abuse, leading to missed opportunities for risk assessment and intervention. It also highlights a lack of information s…
AI-generated summary The review highlights missed opportunities to identify the victim's vulnerability and engage him with domestic violence services, as he was primarily seen as a perpetrator. It also notes inadequate risk assessments, particularly regarding …
AI-generated summary The review identified inadequate mental health assessment and care planning for the perpetrator, poor inter-agency communication and information sharing, and misunderstandings of legal frameworks between police and mental health services. …
AI-generated summary The report highlights the perpetrator's history of violence, alcohol use, and breach of bail conditions as factors that, if identified and acted upon, could have potentially prevented the homicide of the victim.
AI-generated summary The DHR identified concerns regarding the recognition of controlling/coercive behaviour as domestic abuse, the understanding of increased risk during separation, and the routine enquiry for domestic abuse and parental capacity by GPs. It a…
AI-generated summary The review found the homicide was not predictable or preventable. Key concerns relate to the need for general practice to routinely inquire about the impact of anger management issues on families and to embed domestic violence enquiries.
AI-generated summary The review highlights concerns regarding the assessment and management of the perpetrator's emerging psychotic illness, including the prioritisation of face-to-face mental health assessments and communication between primary and secondary …
AI-generated summary The report identifies concerns regarding inconsistent engagement of health services, missed opportunities by police to assess domestic abuse risk and identify children, and a lack of domestic abuse awareness in schools and GP practices. It…
AI-generated summary The review identified missed opportunities for early agency intervention and a lack of coordinated response to domestic abuse, particularly concerning risk assessment, referral processes, and support for male victims and children. It highl…
AI-generated summary The review highlights concerns regarding the adequacy of risk assessment processes for serial domestic violence offenders, delays in information sharing between agencies, and procedural issues in emergency service responses, including scen…
AI-generated summary The report identifies systemic failures in inter-agency information sharing and communication, leading to missed opportunities for intervention in domestic abuse and child safeguarding. Concerns include inadequate firearms licensing proced…
AI-generated summary The review identified systemic failures in multi-agency risk assessment and information sharing, particularly concerning escalating domestic violence, child safeguarding, and the victim's immigration status. Cultural and procedural issues …
AI-generated summary The review identified significant failures in mental health service provision, including inadequate risk assessment, care planning, and Mental Health Act assessments. There was poor multi-agency communication, insufficient recognition of d…
AI-generated summary The review highlights systemic issues including agencies working in silos, inadequate information sharing, and failures to refer children at risk to social services. It also notes how prolonged child contact proceedings and community press…
AI-generated summary The review identifies missed opportunities by professionals to identify coercive control and domestic abuse, particularly when the victim's health was deteriorating. There was a lack of professional curiosity regarding the victim's care ne…
AI-generated summary Agencies missed opportunities to identify and address domestic abuse, including coercive control and stalking, and its impact on children's behaviour. There was a lack of routine enquiry and insufficient awareness among professionals and t…
AI-generated summary The review identifies missed opportunities by agencies to recognise and respond to the perpetrator's acute mental health crisis, exacerbated by selective family disclosures and cultural attitudes towards mental health. It also highlights d…
AI-generated summary The review found no clear agency indications or opportunities to prevent the homicide, noting limited agency contact. It identified missed opportunities for the victim's son's school to address his hearing aid use and for the victim's GP t…
AI-generated summary The review identifies systemic failures across multiple agencies to protect the victim from a serial domestic abuser, including inadequate information sharing, underestimation of risk, and challenges in victim engagement, despite various 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.