Domestic homicide reviews
The Domestic Violence, Crime and Victims Act 2004 places a duty on Community Safety Partnerships to commission a multi-agency review (often known as a Domestic Homicide Review) in any death of a person aged 16 or over who has, or appears to have, died as a result of violence, abuse or neglect by:
- A person to whom they were related or with whom they had been in an intimate personal relationship, or
- A member of the same household as themselves.
Despite the word ‘homicide’ in the title, these reviews are also conducted in the cases of deaths by suicide where there is domestic abuse in their history which is considered to have contributed to their death.
A review panel, led by an independent chair and consisting of representatives from statutory and voluntary agencies, is commissioned to undertake the review. The panel reviews each agency’s involvement in the case and considers information from the victim’s friends and family where appropriate.
Reviews are conducted to understand where public services may improve their responses to similar situations in the future. They do not consider who is to blame but seek to support the prevention of similar incidents from happening in the future. They do not replace the inquest or any other form of inquiry.
Lessons learned from the reviews help agencies to improve their response to domestic abuse and to work better together to prevent such tragedies from occurring again.
The Home Office has published statutory guidance on how to complete DHRs.
The Home Office has also published a report on common themes identified as lessons to be learned from DHRs.
North East Lincolnshire Community Safety Partnership published reviews can be accessed below.
Domestic Homicide Review into the death of Edie
Edie’s and Ricky’s relationship started about 12 months prior to their tragic deaths. Edie had been a victim of three violent and abusive men prior to this relationship and had young children who were in the care of their grandparent. Edie’s GP referred her to a local counselling service because of the impact of stress on her emotional and psychological health relating to the ongoing prosecution of a previous partner and contact with her children. The referral was declined due to criminal and Family Court proceedings being in progress. On multiple occasions Ricky assaulted Edie and damaged her property and, although arrested, broke his bail conditions to visit Edie and to send threatening text messages. Ricky was remanded to prison on charges relating to theft and criminal damage but the prison was not aware that he had also been charged with assaulting Edie or that there was a history of domestic abuse. Ricky was able to maintain contact with Edie by phone. Ricky died by suicide and, a week later, Edie also died by suicide.
Good practice identified
- The support worker from Women’s Aid continued to make calls to Edie even when Edie declined conversations or didn’t pick up calls when Covid prevented home visits.
- Edie had contact and support from two IDVAs at different times which provided a better opportunity for understanding her circumstances and relationship-building.
- The mental health nurse at the GP provided regular opportunities for Edie to talk about the stressors in her life. The nurse referred Edie to the Blue Door.
- The night shelter provided a safe refuge for Ricky and attempted to signpost him to services.
- The probation officer supervising Ricky made sure Edie was aware of Ricky’s long history of alcohol abuse and the implications for her children.
- A police community support officer was allocated to make regular contact with Edie as a higher-risk victim of domestic abuse.
Key learning points
- Individual DASH risk assessments should be supported by other risk markers and motivation, including controlling behaviour and economic abuse, which may provide clearer evidence of escalation.
- Professionals should be curious about new relationships where there is a previous history of domestic abuse.
- It is not enough for healthcare staff to have an awareness of domestic abuse; healthcare should have integrated pathways with domestic abuse services.
- Separation marks a potential escalation of risk. Remand to prison requires an agreed safety plan with good information passed to the court liaison services about domestic abuse, including victim contact details to be included in prohibited lists.
- Research suggests that men who seek control in their intimate relationships can be dependent on the woman for their sense of identity. Ricky showed this dependency together with a history of depression and threats of self-harm and these should have been seen as significant risk markers for him. Prison health services and GPs should liaise to ensure vulnerability information is shared.
- Professionals should understand the barriers for women in disclosing abuse, escaping abuse and engaging with help. They are robbed of their ability to make choices.
Executive summary (PDF, 820KB)
Overview report (PDF, 970KB)
Local action plan (PDF, 413KB) Please note that the action plan is currently being delivered against and so is subject to change as actions are completed.
Domestic Homicide Review into the death of Suzanne
Suzanne had been in an ‘on and off’ relationship with her partner since she was 16 years old. They had young children together who lived at home with them. It is clear to this review that at the time of her death, Suzanne felt under immense pressure from her home circumstances, exacerbated by the country having moved into the most severe Covid lockdown regulations (lockdown one). A few days before she took her life Suzanne had spoken with her GP, describing suicidal thoughts and disclosing that her partner was prone to becoming verbally abusive after consuming alcohol. The GP made an urgent referral to mental health services, prescribed medication and provided her with details of specialist domestic abuse services. The mental health trust conducted an access assessment the same day. Due to temporary Covid-19 adjustments to service provision, this was completed by telephone rather than face to face. Suzanne was assessed as not being immediately suicidal and was talked through coping strategies. There was the intention of a further call the following day but no evidence on the patient record that this took place. Sadly, Suzanne ended her life before any further contact was made.
Good practice identified
- The GP not only referred Suzanne urgently to mental health service, but also followed up this electronic referral with a telephone call and provided Suzanne with details of support agencies.
- Following the GP’s referral, the single point of access practitioner contacted Suzanne by telephone within one hour.
- Earlier in Suzanne’s life, when she was pregnant, Suzanne was referred to the perinatal mental health Midwife and consented to this.
- During the interactions with Suzanne, she was asked twice by the health visitor if she was experiencing domestic abuse.
- The unintended consequences of the first Covid-19 lockdown have been considered by all organisations involved; they have reflected upon the practices that were put into place at the time and all have made changes to better respond to such cases in the future.
Key learning points
- Suzanne did not recognise herself as a victim of abuse because her partner was not violent towards her. Her family were also of the view that abuse meant ‘physical abuse’.
- Suzanne always minimised her partner’s behaviour and placed the onus upon herself to cope better.
- Staff within some services are unaware of the wider aspects of domestic abuse including controlling behaviour and verbal abuse. Professionals need to try to understand the factors affecting people’s anxiety for what they are – to look for the cause and not just the symptom.
- The severity of the pressures building in Suzanne’s home and the risk of her harming herself were not recognised. The advice given to her was not cognisant of the circumstances at home, particularly given the acute and intensive period of time when lockdown rules were at their tightest.
- The Covid-19 regulations during lockdown one of the pandemic unintentionally contributed to the pressures on Suzanne. She was unable to have a face-to-face mental health assessment which may have provided the opportunity to discuss issues in a more conversational manner with time and space away from the pressures of her home circumstances. In addition, she was required to spend almost all her day at home, in the very circumstances that were causing the pressures.
Local Action Plan (PDF, 367KB)