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 found limited agency awareness of the victim's extensive coercive control and economic abuse. Barriers to reporting included the victim's perception that non-physical abuse would not be taken seriously by police, a lack of safet…
AI-generated summary The review identified systemic failures in multi-agency communication, risk assessment, and information sharing, particularly concerning domestic abuse, forced marriage, and honour-based violence. Agencies missed opportunities for early in…
AI-generated summary Agencies failed to identify domestic abuse, including financial exploitation, within the relationship, lacked professional curiosity regarding disclosures of sexual abuse, and did not consistently share information or apply safeguarding pr…
AI-generated summary The review identified significant communication and process failures in mental health service referrals and care transitions, alongside missed opportunities for information sharing and safeguarding adult concerns by police and primary care…
AI-generated summary Agencies failed to recognise domestic abuse when the victim was a parent, leading to missed risk assessments. Health professionals did not adequately triangulate information with family, impacting holistic assessments. Families supporting …
AI-generated summary The review identifies significant long-term, hidden familial domestic and sexual abuse, highlighting the profound barriers to disclosure faced by victims. It also notes missed opportunities by health services to investigate underlying caus…
AI-generated summary The review identifies missed opportunities by agencies to identify and respond to coercive control and domestic abuse, particularly within the Family Court system where the victim was unrepresented. It highlights the enhanced risks at sepa…
AI-generated summary The review identified a lack of agency involvement prior to the death and significant barriers to reporting domestic abuse, particularly for male victims. There was a societal struggle to recognise women as perpetrators and men as victims,…
AI-generated summary The review identified missed opportunities for agencies to enquire about domestic abuse, particularly for BAME women facing additional disclosure barriers. It highlighted the need for increased professional curiosity, targeted support, and…
AI-generated summary The review identified a lack of inter-agency information sharing regarding the perpetrator's history of domestic abuse and missed opportunities to identify the victim's vulnerability to abuse. Gaps in safeguarding processes and the need fo…
AI-generated summary The review identified systemic failures in inter-agency coordination, information sharing, and consistent application of domestic abuse policies. Agencies did not adequately supervise the high-risk perpetrator or respond effectively to the…
AI-generated summary The review found that agencies had no direct knowledge of the victim's domestic abuse, despite family and colleagues holding pieces of information. There were missed opportunities by health professionals to proactively inquire about domest…
AI-generated summary The review identified missed opportunities in risk assessment, information sharing, and multi-agency coordination, particularly regarding child protection and stalking. Agencies struggled with consistent identification of high-risk domesti…
AI-generated summary The review found no overt indicators of domestic abuse were identified by agencies. Key concerns include a lack of a 'Think Family' approach, insufficient support for the victim's daughter and carer, and challenges in healthcare due to lim…
AI-generated summary The review identifies systemic failures in agencies' recognition of the victim's vulnerability and 'mate crime', alongside a lack of professional curiosity and multi-agency information sharing. This led to incidents being treated in isolat…
AI-generated summary The review identifies critical gaps in inter-agency information sharing, particularly between police and mental health services, leading to an incorrect incident grading and delayed emergency response. It also highlights issues with mental…
AI-generated summary The review identifies a limited understanding among professionals of the co-morbidity of problem gambling, mental health issues, and substance misuse. It highlights a lack of professional curiosity in assessments and insufficient holistic …
AI-generated summary The review identifies systemic failures in multi-agency information sharing, risk assessment, and understanding of domestic abuse's impact on children, particularly stepchildren. It highlights missed opportunities to hear the child's voice…
AI-generated summary The review highlights challenges in identifying the primary perpetrator in cases of mutual allegations and significant barriers to the victim's engagement with support services, including mental health issues, financial dependence, and fea…
AI-generated summary The review identified a history of controlling, manipulative, and violent domestic abuse by the perpetrator, exacerbated by his alcohol misuse. The victim faced significant barriers to disclosure, including cultural and religious factors, …
AI-generated summary The review identified significant concerns regarding multi-agency information sharing, the integration of domestic abuse considerations into suicide prevention and mental health services, and the need for greater cultural awareness in supp…
AI-generated summary The report identifies missed opportunities by professionals to recognise and assess domestic abuse, particularly in older people, leading to an inappropriate decision not to conduct a safeguarding enquiry. Failures in mental capacity asses…
AI-generated summary The review identifies systemic issues including victim-blaming, a lack of professional curiosity, and inadequate recognition of the perpetrator's controlling behaviour. It highlights missed opportunities to use legal remedies and address t…
AI-generated summary The review identified concerns regarding the perpetrator's unaddressed alcohol and mental health issues, inconsistent engagement with support services, and missed opportunities by agencies to conduct comprehensive risk assessments, particu…
AI-generated summary The review identifies concerns regarding delayed multi-agency risk assessment, missed opportunities for perpetrator arrest, and a lack of understanding among professionals about coercive control and its impact on the victim's decisions. It…
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.