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 Agencies failed to adopt a coordinated, problem-solving approach to persistent domestic abuse, often dealing with incidents in isolation. Flawed risk assessments, ineffective MARAC processes, and poor information sharing meant the victim's…
AI-generated summary The review identifies systemic failures in identifying and responding to intra-familial domestic abuse, particularly concerning adult-to-parent violence. It highlights inadequate support for the perpetrator's ADHD, poor transition to adult…
AI-generated summary The review identified systemic failures in multi-agency risk management, particularly regarding the intersection of domestic abuse, substance misuse, homelessness, and trauma. There was a lack of adequate mental health support, suicide pre…
AI-generated summary The review identified concerns regarding agencies' under-assessment of the victim's risk, inconsistent information sharing, and delays in referrals. It also highlighted a failure to fully consider the cumulative impact of domestic abuse on…
AI-generated summary The review identified under-resourced IDVA services, fragmented information sharing across agencies and with external parties, and MARAC capacity issues. Missed opportunities in the criminal justice process and a lack of clear post-MARAC c…
AI-generated summary Concerns include GP practices' inadequate monitoring of prescribed medication and follow-up for dependent patients, alongside missed opportunities to offer support to carers disclosing mental health issues. The report also highlights the s…
AI-generated summary This DHR identifies significant barriers for non-English speaking migrant communities, including the victim's household, in accessing local services. Key concerns include low engagement with healthcare, cultural distrust of authorities, hi…
AI-generated summary The review identifies concerns regarding inadequate inter-agency coordination, inconsistent information sharing, and insufficient use of risk assessment tools. It also highlights gaps in professional training on domestic abuse and a need f…
AI-generated summary The review identifies concerns regarding the perpetrator's use of a false identity and coercive control tactics, which agencies were unaware of due to no direct contact with the couple. It highlights missed opportunities for routine domest…
AI-generated summary The review identifies concerns regarding the serial perpetrator's history of violence and missed opportunities for multi-agency intervention. It highlights the victim's vulnerability due to childhood difficulties and inadequate support, al…
AI-generated summary The review identified a lack of agency awareness of domestic abuse, particularly economic abuse and its link to debt, and the need for trauma-informed responses to victims with alcohol misuse. It also noted historic shortcomings in child s…
AI-generated summary The review identifies concerns regarding inter-agency communication and joint working between Police and Adult Social Care in safeguarding investigations, particularly in cases involving non-intimate household members. It highlights issues…
AI-generated summary The review identified significant deficits in mental health care, including inadequate risk assessment focused solely on the perpetrator's self-harm risk, poor record-keeping, and lack of continuity of care. There was a failure to recognis…
AI-generated summary Agencies failed to share information effectively, leading to incomplete risk assessments and missed opportunities to intervene in domestic violence and manage the perpetrator's risks. There were also deficiencies in supervision and adheren…
AI-generated summary The review identified concerns regarding the police's assessment of malicious communication and witness intimidation complaints, and the GP practice's provision of domestic violence and abuse (DVA) information and continuity of patient car…
AI-generated summary The report identifies systemic failures in health agencies to identify domestic abuse due to insufficient training, inadequate policies, and the perpetrator's presence during consultations. It also highlights inadequate information sharing…
AI-generated summary The review found that the victim, despite a history as a perpetrator, was not consistently identified as a victim of domestic abuse, especially as relationship dynamics evolved. Agencies missed opportunities for comprehensive risk assessme…
AI-generated summary The DHR found the homicide was unexpected, with no prior history of domestic abuse known to agencies or family. The perpetrator was later diagnosed with undiagnosed behavioural variant frontotemporal dementia. Key concerns include the diff…
AI-generated summary The report identifies systemic failures in identifying long-term domestic abuse, gross neglect, and isolation of the victim, exacerbated by hoarding and missed opportunities by agencies to intervene and provide support.
AI-generated summary The review identifies systemic challenges in providing consistent mental health support, particularly for individuals requiring regular medication, and highlights gaps in information sharing across healthcare and criminal justice systems. …
AI-generated summary The report identifies concerns regarding inadequate multi-agency information sharing and integrated risk assessment, particularly concerning the impact of parental mental health on children and the needs of young carers. It also highlights…
AI-generated summary Agencies repeatedly missed opportunities to identify and respond to domestic abuse, often treating the victim's substance misuse and mental health issues in isolation. Misconceptions about how victims present and a lack of integrated, trau…
AI-generated summary The review identifies limited agency contact, unrecognised coercive control, and missed opportunities for professional curiosity regarding relationship difficulties and mental health. Concerns include inconsistencies in firearms licensing …
AI-generated summary The review identifies that strong cultural and generational influences within the Tamil community suppressed reporting of domestic abuse. It also highlights a misperception among professionals regarding the heightened risk of domestic abus…
AI-generated summary The review highlights challenges in victim disclosure of domestic abuse to professionals and the need for improved professional understanding of disclosure barriers and risk factors, particularly around separation. It also identifies a gap…
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.