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 identifies concerns regarding mental health services' compliance with care planning guidance, particularly the lack of holistic risk assessments for violence and substance misuse, insufficient family involvement, and inadequate …
AI-generated summary The review identified concerns regarding inadequate information sharing between primary and secondary mental health services, and within secondary care, about the perpetrator's history of severe depression and stated risk to the victim. Th…
AI-generated summary The review identified limited agency involvement with the victim prior to the homicide. Key concerns include gaps in post-death agency notification processes, challenges in information sharing and engagement from immigration services in DH…
AI-generated summary Merseyside Police failed to follow domestic abuse policy, missing opportunities for risk assessment, information gathering, and referrals for the victim. The report also highlights that separation can magnify risk and that emotional/verbal…
AI-generated summary The review identifies that the victim made informal disclosures of coercive control to friends and colleagues, but these were not formally reported to agencies, limiting risk assessment opportunities. A lack of understanding of coercive co…
AI-generated summary The report identifies concerns regarding agencies' recognition and assessment of domestic abuse, particularly psychological and coercive control, and its impact on the victim's mental health. Gaps in inter-agency communication, risk escala…
AI-generated summary The review identified missed opportunities to assess the perpetrator's role as a carer, particularly given his own mental health issues and the victim's increasing dependency. Concerns were also raised about the detail in GP records, medic…
AI-generated summary The report highlights a lack of a recognised risk assessment tool for suicidal ideation in general practice, which could have supported the GP's clinical decision-making regarding the perpetrator's mental state. No evidence of domestic abu…
AI-generated summary The report identifies concerns with multi-agency information sharing, particularly between civilian and military services, and between health and specialist DVA services. Missed opportunities for intervention were noted given the victim's …
AI-generated summary The review identified systemic failures in multi-agency information sharing and risk assessment, leading to missed opportunities to recognise and respond to domestic abuse against the victim. Cultural stereotyping and poor adherence to pro…
AI-generated summary The review identifies systemic failures in information sharing, risk assessment, and inter-agency coordination regarding the perpetrator's history of violence, mental health needs, and accommodation. Gaps in planning for release from custo…
AI-generated summary The review identified systemic issues in multi-agency information sharing and risk assessment, particularly concerning the perpetrator's history of violence. Gaps in policy application, victim engagement, and consistent police response to …
AI-generated summary The review found limited statutory agency contact with the victim and perpetrator regarding domestic abuse. The abuse, characterised by coercive control, remained largely hidden from services, despite being observed by friends and family. …
AI-generated summary The review highlights how the victim's perceived strength and minimisation of abuse, coupled with financial and social barriers, prevented disclosure. It also notes challenges in third-party reporting, inconsistent professional screening f…
AI-generated summary Agencies failed to identify the victim as a domestic abuse victim or the perpetrator as an abuser, despite indicators of conflict and abusive behaviour within the household. There were issues with multi-agency information sharing, coordina…
AI-generated summary The review identified systemic issues in multi-agency information sharing, risk assessment, and a lack of holistic understanding of the victim's complex needs, including domestic abuse, mental health, and substance use. Concerns also arose…
AI-generated summary The review identified missed opportunities by health services to recognise and respond to domestic abuse, particularly involving older individuals and a female perpetrator. There was a lack of professional curiosity, and age and gender bia…
AI-generated summary The review identified systemic failures in identifying and responding to domestic abuse, particularly for foreign-born victims, due to language barriers, cultural factors, and a lack of integrated multi-agency information sharing. It also …
AI-generated summary The review found that the case, primarily involving the perpetrator's mental health issues, did not exhibit typical domestic violence characteristics. It concluded that the DHR process was disproportionate and costly, yielding no new lesso…
AI-generated summary The review identified missed opportunities by health services to assess the perpetrator's substance misuse and mental health crisis, and to inquire about the victim's safety. There was also a lack of routine inquiry into domestic abuse and…
AI-generated summary The review identified gaps in inter-agency information sharing regarding the perpetrator's history of violence and a lack of monitoring for victims signposted to support services. It also highlighted the need to review police risk assessme…
AI-generated summary The review highlights systemic failures in multi-agency communication, cultural awareness, and routine domestic abuse inquiries for migrant families. It identifies missed opportunities for early intervention due to the victim's isolation a…
AI-generated summary The report identifies missed opportunities to identify domestic abuse due to cultural barriers and interpreter use, inadequate information sharing between agencies, and a lack of professional curiosity regarding the perpetrator's drug misu…
AI-generated summary The report identifies systemic failures in inter-agency information sharing, risk assessment, and professional curiosity across police, health, social care, and education. Key concerns include treating domestic abuse incidents in isolation…
AI-generated summary The review identified inconsistent use of risk assessment tools and application across agencies, leading to missed opportunities for high-risk referrals to MARAC and IDVA. There were also failures to escalate concerns and apply 'near miss'…
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.