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 identified a volatile relationship with mutual abuse, where the couple's fear of child removal led to non-engagement with services. Key concerns include inconsistent risk assessment, poor information sharing, lack of professiona…
AI-generated summary The review identified shortcomings in multi-agency information sharing, record-keeping, and the effectiveness of multi-agency meetings. It also highlighted a need for enhanced professional training on domestic abuse, including controlling …
AI-generated summary The review identified missed opportunities by agencies to identify and intervene in the victim's domestic abuse, stemming from inadequate information sharing, limited understanding of coercive control, and challenges in engaging the victim…
AI-generated summary Key concerns include agencies' and the victim's failure to recognise coercive control and domestic abuse indicators. The report highlights issues with police recording practices, such as warning markers, and the need for enhanced professio…
AI-generated summary The review identified concerns regarding the continuous assessment of firearms licence holders, particularly for individuals with dementia, and the integration of patient care across agencies. It highlighted deficiencies in information sha…
AI-generated summary The review identified systemic failures in recognising the victim as a male victim of domestic abuse, a lack of professional curiosity across agencies, and poor information sharing. Agencies also struggled to adequately assess and manage r…
AI-generated summary The review highlights the complexities of relationship breakdown in later life, with mismatched expectations and communication issues. It notes the perpetrator's mental distress and the victim's controlling behaviour, alongside a lack of p…
AI-generated summary The report identifies inconsistent risk assessment and management by mental health services, poor inter-agency communication, delays in Mental Health Act assessments, and inadequate police responses to domestic incidents, particularly rega…
AI-generated summary Key concerns include the perpetrator's extensive use of coercive control, economic, financial, and sexual abuse, compounded by the victim's immigration status and the perpetrator's manipulation of their children. Agency responses were hamp…
AI-generated summary The review identifies systemic failures in inter-agency information sharing and communication, particularly concerning domestic abuse risk assessment and mental health crisis response. It highlights missed opportunities to engage the victi…
AI-generated summary The review identified missed opportunities for agencies to intervene, including non-compliant police practice and a lack of routine enquiry for domestic abuse. It highlights the need for improved multi-agency information sharing, training …
AI-generated summary The review identified inconsistent police response and victim care, including failures to fully implement domestic abuse policies and keep victims informed. It also highlighted insufficient attention to child safeguarding, missed opportuni…
AI-generated summary The review identifies systemic failures in multi-agency understanding and application of adult safeguarding, domestic abuse, and mental capacity legislation, particularly concerning a vulnerable victim with a learning disability. It highli…
AI-generated summary This DHR identifies a lack of agency involvement and missed opportunities to recognise high-risk behaviours, including coercive control, stalking, and the victim's fear, which were not identified by family, friends, or professionals. It al…
AI-generated summary The review highlights missed opportunities by agencies to identify and intervene in domestic abuse, particularly regarding the victim's minimisation of violence and third-party reluctance to report. It also notes inconsistencies in police …
AI-generated summary The review identifies that agencies focused on the perpetrator's mental health and vulnerability, leading to missed opportunities for earlier criminal justice intervention for escalating harassment. There was a lack of suitable services fo…
AI-generated summary The report highlights a lack of formal multi-agency coordination for adults with capacity making unwise decisions, gaps in police safeguarding referrals, and insufficient awareness of 'cuckooing' and prescription drug misuse. It also point…
AI-generated summary The review identified concerns regarding the management and transfer of the perpetrator's severe mental illness records, leading to a lack of monitoring. It also highlighted missed opportunities by health services to identify potential dom…
AI-generated summary The review identified underlying relationship tensions, mental health issues, and financial pressures, but a lack of reported domestic abuse. Concerns were raised regarding missed opportunities to recognise the perpetrator's pattern of sel…
AI-generated summary The review identifies concerns regarding inconsistent domestic abuse risk assessments, failure to correctly identify the nature of the relationship, and inadequate information sharing between agencies. These issues led to missed opportunit…
AI-generated summary The review identified insufficient attention to the emotional and practical support needs of the perpetrator as a carer, particularly as the victim's dementia progressed and after the victim's move to residential care. There were missed op…
AI-generated summary The review identified a lack of joined-up agency working, inadequate risk assessment, and missed opportunities in mental health care for the perpetrator, particularly concerning potential child criminal exploitation and familial violence. …
AI-generated summary The review found no specific agency failings or missed opportunities for intervention. However, it identified dangerous cultural narratives around whirlwind romances and male control as contributing factors to the homicide.
AI-generated summary The review identifies systemic failures in agencies' ability to recognise domestic violence indicators, particularly when co-occurring with substance misuse and pregnancy. It highlights gaps in multi-agency communication, record-keeping, a…
AI-generated summary The review highlights significant failures in inter-agency coordination and information sharing, leading to an uncoordinated response to the victim's complex needs, including mental health, substance misuse, and domestic abuse. Professiona…
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.