One minute guide: Domestic homicide reviews

What are Domestic Homicide Reviews

A Domestic Homicide Review (DHR) examines the circumstances surrounding the death of a person aged 16 or older when it has, or is suspected to have, resulted from violence, abuse, or neglect by someone they were related to, had been in an intimate personal relationship with, or was a member of the same household. Additionally, reviews are commissioned in cases where a person has died by suicide, and domestic violence or abuse appears to have been a contributing factor - these are referred to as Fatal Incident Reviews (FIR).

The purposes of DHRs and FIRs are to:

• Identify lessons learned regarding how local practitioners and agencies work to safeguard victims, and determine how agencies will implement these lessons
• Improve intra and inter-agency working to strengthen service responses for all victims of domestic violence and abuse, including their children, with the goal of preventing future

Under the Domestic Violence Crime and Victims Act (2004), Community Safety Partnerships have had a statutory duty to commission DHRs since April 2011. In Leeds, the Community Safety Partnership, Safer Leeds, oversees this responsibility. DHR reports from the past two years, including executive summaries and lessons learned briefings, can be requested through Lessons learned from DHR.

What have we learned from the DHRs and FIRs in Leeds?

Since April 2011, 33 reviews have been commissioned in Leeds, revealing the following demographic features:

• twenty-six victims were women who were killed by their current or former partner
• one DHR involved a male victim who was killed by their partner
• two FIRs involved male victims, while another two involved female victims. Additionally, one Joint Safeguarding Adults Review was commissioned in a case of neglect
• two children were killed alongside their mother, and the youngest victim, at just 17 years old, was herself a child
• fourteen DHR reviews involved perpetrators with mental health issues
• seven cases identified substance misuse (alcohol and drugs) as a factor affecting both the victim and perpetrator
• in ten of the reviews, victims were aged over 50 years or over
• twenty-six cases involved victims and perpetrators of White British ethnicity, six involved individuals of Asian ethnicity, and one case involved a victim of Black British African-Caribbean ethnicity

The following issues were identified from DHRs and FIRs:

• some risk assessments underestimated the significance of coercive and controlling behaviour; a recognised ‘high risk’ indicator of potential homicide
• there is a need to enhance how agencies and services engage with vulnerable and isolated individuals and communities, such as migrant communities, in a culturally sensitive
• while improvements have been made, further progress is needed in identifying domestic violence and abuse, responding to disclosures, and effectively recording and flagging information within
• services and interventions for abusive men remain
• agencies must improve information sharing and better connect service users who are in abusive
• many agencies focus on presenting issues like substance misuse, without addressing domestic violence and abuse when it is present and known

Learning from DHRs is integrated into all key areas of workforce development, service improvement and commissioning activity.

How Leeds responded to lessons from DHRs and FIRs

Learning and recommendations from DHRs and FIRs have informed several developments in Leeds over the past 14 years and have contributed to the domestic abuse breakthrough priorities. These include:

Routine enquiry

A proactive approach in which practitioners ask all women seen alone whether they are experiencing domestic abuse. This method is implemented in various settings and has proven effective in promoting the early identification of domestic abuse.

Improved understanding of coercive control

The longer someone experiences coercive and controlling behaviour, and the more intense it is, the higher the risk, especially when the victim tries to leave the relationship. To the perpetrator, this act of leaving is often seen as a reclaiming of control, which can escalate the danger.

Improved responses to mental health

DHRs have identified difficulties in accessing mental health services amongst both victims and perpetrators of domestic abuse. Referral procedures into some statutory mental health services have been revised to secure timely responses and offer a range of support and services.

Improved recognition of Adverse Childhood Experiences (ACEs)

Across the partnership, practitioners are becoming more aware that victims may have experienced significant ACEs such as family breakdowns, being care experienced, involvement with the criminal justice system, alcohol or substance misuse, and risks of Child Sexual Exploitation (CSE) or Child Criminal Exploitation (CCE).

Safeguarding Lead GPs

An increasing number of practices have identified Safeguarding Lead GPs, who play a key role in advising colleagues on domestic abuse related issues, conducting risk assessments, and signposting or referring cases to specialist services.

Commissioning activity

DHRs have influenced the way we commission a range of services, including housing and substance misuse support services as well as specialist domestic abuse support.

Equality and diversity

Efforts are underway to ensure that isolated and vulnerable victims can access services and support. This includes training practitioners and commissioning domestic abuse services with the expectation that they demonstrate how they are reaching victims from all communities, including migrant communities, those with substance misuse and mental health issues, and victims from LGBT+ groups.

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