The Home Office has published a report that summarises information from domestic homicide reviews (DHR) from October 2019 to 2020. The reviews are multi-agency reviews that are commissioned by community safety partnerships. They look into the deaths of adults that may have resulted from violence, abuse or neglect by a related person, someone they were intimate with or a member of the same family.

The intention behind the report is to make key information available in order to share learning. A domestic homicide review (DHR) is carried out to establish lessons that need to be learned. Those lessons can ve shared across agencies to improve their responses by developing a coordinated approach to ensure abuse is identified and responded to at the earliest opportunity.

The report
The report is structured in order to provide:
• Information on location, age and gender of victims and perpetrators.
• Characteristics of victims and perpetrators, including vulnerabilities, mental health and previous history of abuse/offending.
• Themes highlighting areas for improvement.
• Recommendations.
• Contributions from, and support for, families in the review process.
• Common reasons for the Home Office Quality Assurance Panel requiring reviews to be resubmitted.

• Victims – 61% of victims had a vulnerability, 34% had one vulnerability, and 27% had more than one.
• Vulnerabilities – 34% of vulnerabilities were mental-health, 28% were an issue with alcohol misuse, and 22% were illicit drug use.
• Mental health – 26% of those with a mental health vulnerability had depression, 16% had suicidal thoughts, and 14% had attempted suicide.
• Recurrence – 36% of victims had been targeted previously, usually by a previous partner.
• Aggravating factors – in 64% of the reviewed cases, aggravating factors were identified, the most prevalent being coercive control.
• Perpetrators – 71% of perpetrators were identified as having a vulnerability, the most common being alcohol or drug misuse and mental ill-health.
• Vulnerabilities – 31% of the vulnerabilities were mental health issues, 23% of these related to depression and 21% were suicidal thoughts.
• History – 60% of perpetrators had a previous offending history, 75% of these had abused previous partners, and 33% had abused family members; a small proportion had abused both previous partners and family members.
• Verdicts – 62 perpetrators were sentenced for murder and 25 for manslaughter; 13 individuals were deemed to have diminished responsibility or were unfit to plead.

There has been a fall in the number of victims of domestic homicide, from 152 in 2009/10 to 114 in 2019/20. In 83% of cases, the death took place at the victim’s own home, with 4% occurring at the perpetrator’s address. Other places of death included hospitals, open spaces and roads.

Location – the location of reviews is likely to be influenced by differing population sizes as the highest numbers are in London and the South East. There were 116 reviews in England and only 8 in Wales.

Age – the average age of a victim was 41 years old, and for perpetrators, it was 40. There were two victims under the age of 18, and the eldest was 94. The oldest perpetrator was aged 89.

Gender – within the reviews, 80% of victims were female, and the remainder were male; 83% of perpetrators were male.

Ethnicity – 80% of the review victims were white, 8% were Asian, 5% were black, and 7% of other or multiple ethnicities. Of perpetrators, 71% were white, 13% were black, 11% were Asian, and 5% of other or multiple ethnicities.

Relationships – 113 reviews contained detail of the relationship between the victim and perpetrator. For 73% of victims, the perpetrator was a partner or ex-partner; in 9% of the cases, a separation had or was taking place. For the remaining cases, the relationship was described as familial, half where the victim was the parent of the perpetrator and a wide range of others, including grandparents, brother and sister.

Method – 49% of killings were stabbings, 25% were strangulation, 17% were recorded as ‘other’, 8% blunt force trauma and 1% used a firearm. The ‘other’ category included prolonged or sustained assaults and cases where a specific detailed description was provided.

Areas for improvement
• Fifty of the reviewed cases were examined in greater detail, and areas for improvement were identified.
• There is a need for greater contact with victims along with a recognition that sometimes a perpetrator will control a victim’s contact with agencies.
• An improvement is required in risk assessments, mental health assessments and carer assessments. The risk level needs to be correctly identified and account taken of information from other agencies.
• Multi-agency engagement needs to be improved with the recording and sharing of information.
• In some cases, support for a victim was not identified, in others, a need for support was identified, but no plan was out in place for it to be provided. Referrals must be made when appropriate.
• Training needs to be updated and accessible.
• There were some occasions when action was taken that was not in line with existing policy, and some agencies did not have a domestic abuse policy at all.

DHRs should make specific recommendations and identify actions to be taken to improve responses. The agency to have the responsibility to implement the recommendations should also be specified. The agency most likely to be identified is stated to be ‘partnerships’; these tend to be community safety partnerships and domestic abuse boards. This is closely followed by health organisations such as hospitals, mental health services and GPs, followed by the police.

The recommendations indicate the type of action needed ranging from awareness-raising, policy and practice through to reviews and training. The most frequent recommendation (in 28% of reviews) was to review existing practice, followed by awareness-raising.

Quality Assurance
The Home Office Quality Assurance panel provides feedback in two ways; a letter approving the DHR for publication with suggestions for minor amendments or detailed feedback for further amendments and analysis before the DHR is of a suitable standard.

The most significant reasons for a request to resubmit a DHR were:
• the DHR did not follow the report template in the Statutory Guidance;
• insufficient probing or depth of analysis;
• grammatical and typographical errors;
• additional anonymisation required;
• insufficient information about the author’s experience, background and independence provided; and/or
• a lack of evidence or research to back up statements.


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