Guidance

Conducting a domestic homicide review: online learning

Domestic homicide review online learning for frontline practitioners.

• From: Home Office
• Published: 28 March 2013

This course is for frontline practitioners who will be taking part in domestic homicide reviews.

Course content

There are 2 modules:

• Module 1: introduction to the domestic homicide review process
• Module 2: the chairperson’s responsibilities and the overview report

Module 2 only needs to be completed by the review panel chairperson, although this information may also be of use to other practitioners involved in the review process.

Objectives of the course

By the end of the course you should be able to:

• fully understand the domestic homicide review processes
• understand your individual role and responsibilities within the review process
• understand the importance of sharing best practice and lessons learned locally
• demonstrate your knowledge of the review process

Those that undertake the chairperson modules should be able to:

• demonstrate a knowledge of the role and responsibilities of the chairperson when conducting a domestic homicide review
• understand the process of producing the overview report and its subsequent publication in line with the statutory guidance
• understand issues relating to disclosure and criminal proceedings

The course is based on the multi-agency statutory guidance for the conduct of domestic homicide reviews, which was established under Section 9 (3) of the Domestic Violence, Crime and Victims Act 2004.

Start the course

Module 1: introduction to the domestic homicide review process

When a domestic homicide happens, the police should inform in writing the relevant community safety partnership (CSP) of the incident. The CSP has overall responsibility for setting up reviews.

The chapters below will take you through the process of setting up a review panel.

Background to domestic homicide

Domestic violence includes physical, psychological, sexual, financial and emotional abuse involving partners, ex-partners, other relatives or household members. In 2009 to 2010, the British Crime Survey showed that domestic violence accounted for 14% of all violent incidents and affects both men and women.

Domestic violence is frequently repeated by the perpetrator and the violence can escalate over time.

A domestic attack that results in the death of the victim is often not a first attack and is likely to have been preceded by psychological and emotional abuse. Many people and agencies may have known of previous attacks – neighbours may have heard violence, a GP may have examined injuries, the police may have been called, there may have been previous prosecutions or injunctions.

This can sometimes make serious injury and homicide in domestic violence cases preventable with early intervention. Local agencies should have adequate policies and procedures in place to instruct staff on how to intervene in domestic violence cases. There should also be an emphasis on the need for specialist support for victims and their children as well as services for families, friends and others who may be affected by the homicide.

About domestic homicide reviews

The basis for the domestic homicide review process is to ensure agencies are responding appropriately to victims of domestic violence by offering and putting in place suitable support mechanisms, procedures, resources and interventions with an aim to avoid future incidents of domestic homicide and violence.

The review will also assess whether agencies have sufficient procedures and protocols in place, which were understood and followed by their staff and where there may be a need to improve these procedures.

A domestic homicide review should be carried out to:

• establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims.
• identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result.
• apply these lessons to service responses including changes to policies and procedures as appropriate.
• prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.

Domestic homicide reviews are not inquiries into how the victim died or into who is to blame - that is a matter for coroners and criminal courts to determine. Domestic homicide reviews are also not a part of any disciplinary enquiry or process. Where information emerges in the course of a review suggesting that disciplinary action should be taken, the agency concerned will follow its own internal disciplinary procedures separately to the domestic homicide review process.

Setting up a review: the role of community safety partnerships (CSPs)

When a domestic homicide happens, the police should inform the relevant community safety partnership (CSP) in writing of the incident. The CSP then has the overall responsibility for setting up a review. CSPs are ideally placed to initiate a domestic homicide review and review panel due to their multi-agency design and locations across England and Wales.

Deciding which CSP is responsible

Where partner agencies of more than one local authority area have known about or had contact with the victim, the local authority area where the victim was resident should take responsibility for carrying out any review.

If the victim was of no fixed address before the incident took place, lead responsibility will lie with the area that they were last known to have lived or frequented as a first option, and then considered on a case-by-case basis.

Any professional or agency may refer such a case to the CSP in writing if it is believed that there are important lessons for inter-agency working to be learned from the case.

Deciding whether a review should take place

The chair of the community safety partnership (CSP) is responsible for:

• establishing whether a case is to be subject of a domestic homicide review by applying the definition set out in the guidelines
• the final decision on whether a review should be conducted. This decision should be taken in consultation with local partners with an understanding of the dynamics of domestic violence

Confirmation of a decision to review, as well as a decision not to review a homicide, should be sent in writing to the Home Office domestic homicide review enquiries inbox: DHRENQUIRIES@homeoffice.gov.uk

As stated at Section 9 (2) of the Act, the Secretary of State may in a particular homicide direct a specified person or body within subsection (4) to establish, or to participate in, a domestic homicide review. Such a direction is likely to be made where a person or body has declined involvement in a domestic homicide review. In such circumstances, the Home Office quality assurance group will liaise with the relevant person or body to ensure action is taken as directed. When victims of domestic homicide are aged between 16 and 18, a child serious case review (SCR) should take precedent over a domestic homicide review.

However, it is vital that any elements of domestic violence relating to the homicide are addressed fully and the SCR includes representatives with a thorough understanding of domestic violence.

Circumstances of particular concern

The following factors are some examples of the types of situations preceding homicide which will be of interest to review teams when conducting a domestic homicide review:

• there was evidence of a risk of serious harm to the victim that was not recognised or identified by the agencies in contact with the victim or the perpetrator, and was not shared with others or it was not acted upon in accordance with their recognised best professional practice.
• any of the agencies or professionals involved consider that their concerns were not taken sufficiently seriously or not acted on appropriately by the other parties involved.
• the homicide indicates that there have been failings in one or more aspects of the local operation of formal domestic violence procedures or other procedures for safeguarding adults, including homicides where it is believed that there was no contact with any agency.
• the victim was being managed by, or should have been referred to a multi-agency risk assessment conference (MARAC).
• the homicide appears to have implications or reputational issues for a range of agencies and professionals.
• the homicide suggests that national or local procedures or protocols may need to change or are not adequately understood or followed.
• the perpetrator holds a position of trust or authority e.g. police officer, social worker, health professional, and therefore the homicide is likely to have a significant impact on public confidence.
• the victim had no known contact with any agencies. For example, could more be done in the local area to raise awareness of services available to victims of domestic violence?

Setting up a panel to conduct the review

When the community safety partnership (CSP) agrees the criteria for a domestic homicide review are met and should be undertaken, they will use local contacts and request that a review panel is set up.

The review panel can either have a fixed, standing membership or can be tailored for the purposes of a particular domestic homicide review. It should include individuals from both statutory and voluntary agencies.

The voluntary sector may have valuable information on the victim or perpetrator and the importance of having agencies to represent the victim. Independent domestic violence advisers (IDVAs) and specialist domestic violence services are key representatives to include on the review panel.

Many CSP areas will already have established local forums that deal with domestic violence and hold a wealth of knowledge in understanding its complexities. Practitioners from these forums should also be invited to join the review panel. Where appropriate, the CSP may wish to refer the DHR for action to such a forum to lead on and manage the review, for example a domestic violence forum.

Members of agencies who have responsibilities for completing individual management reviews can also be members of the review panel, but the panel should not be made up solely of these people.

The review panel should bear in mind all equality and diversity issues at all times; age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation may all have a bearing on how the review is explained and conducted and the outcomes disseminated to local communities.

Relevant agencies

The persons and bodies that have a duty to establish or participate in a domestic homicide review if directed to do so by the Secretary of State include (for England and Wales):

• chief officers of police for police areas in England and Wales
• local authorities
• local probation boards established under Section 4 of the Criminal Justice and Court Services Act 2000 (c 43)
• strategic health authorities established under [Section 13 of the National Health Service Act 2006]
• primary care trusts established under [Section 18] of that Act
• providers of probation services
• local health boards established under [Section 11 of the National Health Service (Wales) Act 2006]
• NHS trusts established under [Section 25 of the National Health Service Act 2006 or Section 18 of the National Health Service (Wales) Act 2006

There are other agencies that may have a key role to play in the review process but are not named in legislation, for example, representatives from the Crown Prosecution Service (CPS), housing associations and social landlords, the HM prison service. Involvement with other agenices will need to be decided on a case-by-case basis and should be agreed by the review panel.

Appointing a chair for the review panel

The review panel should appoint an independent chair of the panel who is responsible for managing and co-ordinating the review process and for producing the final overview report based on individual management reviews and any other evidence the review panel decides is relevant.

The review panel chair should, where possible, be an experienced individual who is not directly associated with any of the agencies involved in the review.

Some areas may wish to develop a regional agreement where experienced individuals from neighbouring areas are exchanged or loaned to the review panel to help share good practice and promote the sharing of new information and learning.

Skills and expertise needed to chair a review

When appointing a chair, consideration should be given to the skills and expertise required to effectively chair a review.

The following are guidelines to what is needed:

• relevant knowledge of domestic violence issues including ‘honour’-based violence, research, guidance and legislation relating to adults and children, including the Equality Act 2010
• an understanding of the role and context of the main agencies likely to be involved in the review
• managerial expertise
• good investigative, interviewing and communication skills
• an understanding of the discipline regimes within participating agencies
• the completion of this e-learning training package on domestic homicide reviews, including the additional modules on chairing reviews and producing overview reports

Timescales for conducting a domestic homicide review

In all cases, where lessons can be drawn out they should be acted upon as quickly as possible without necessarily waiting for the review to be completed.

The decision to hold a review should be taken by the chair of the community safety partnership (CSP) within 1 month of a case coming to their attention. The terms of reference for the review should also be drafted and agreed within this timescale.

Individual agencies should quickly secure case records and begin to draw up a chronology of involvement with the victim, perpetrator and their families.

The overview report should be completed within a further 6 months of the date of the decision to proceed unless another timescale is formally agreed with the relevant CSP.

Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it becomes clear that the timescales can’t be met (perhaps because of judicial proceedings), the review panel should notify the CSP to renegotiate the timescale for completion.

If the CSP believes that the delay to completion of the review is unreasonable they should refer the issue to the quality assurance group for further advice.

Involvement of friends, family and other support networks in the review

In domestic violence homicides, members of informal support networks, such as friends, family members and colleagues may have detailed knowledge about the victim’s experiences.

The review panel should carefully consider the potential benefits gained by including such individuals from both the victim and perpetrator’s networks in the review process. Members of these support networks should be given every opportunity to contribute unless there are exceptional circumstances, for example, where there are suspicions of ‘honour’-based violence.

Benefits of involving family, friends and colleagues

The benefits include assisting the family with the healing process which links in with the objectives of the new National Homicide Service - supporting victims for as long as they need after homicide. For example, a review may allow them to disclose information in private, which may not be published. A family would not be able to achieve this in an inquest, which is in the public domain.

Other benefits are:

• helping families satisfy the often-expressed need to contribute to the prevention of other domestic homicides
• obtaining relevant information held by family members, friends and colleagues which is not recorded in official records
• revealing different perspectives of the case, enabling agencies to improve service design and processes
• allowing the review panel to get a more complete view of the victim’s life and see the homicide through the eyes of the victim and those left behind - this approach can help the panel understand the decisions and choices the victim made

Considerations

The review panel should be aware of the potential sensitivities and need for confidentiality when meeting with members of informal support networks during the review and all such meetings should be recorded.

Consideration should also be given at an early stage to working with family liaison officers and senior investigating officers involved in any related police investigation to identify any existing advocates and the position of the family in relation to coming to terms with the homicide.

The review panel should also access other networks that victims may have disclosed to, for example, employers, health professionals or their local voluntary and community sector (VCS) agencies.

There are information leaflets explaining the domestic homicide review process to family, friends and support networks of the victim.

• Domestic homicide review: leaflet for family
• Domestic homicide review: leaflet for friends
• Domestic homicide review: leaflet for employers and colleagues

Involving friends, family and other supports in the review: actions

When meeting with friends, family members and others the panel should:

• communicate through a designated advocate who has, where possible, an existing working relationship with the family eg a voluntary and community sector (VCS) representative.
• make a decision regarding the timing of contact with the family based on information from the advocate and taking account of other ongoing processes ie post mortems, criminal investigations.
• ensure initial contact is made in person and deliver the relevant information letter and leaflet.
• ensure regular engagement and updates on progress through the advocate, including the timeline expected for publication.
• explain clearly how the information disclosed will be used and whether this information will be published.
• explain how their information has assisted the review and how it may help other domestic violence victims.
• a completed version of the review should be given to the family before a final review is sent to the Home Office. This allows other findings and recommendations to be considered, and makes it possible to record any areas of disagreement.
• maintain reasonable contact with the family, even if they decline involvement in the review process. It will be important to communicate through the designated advocate when the review is completed and when the review has been assessed and is ready for publication. They should also be informed about the potential consequences of publication ie media attention and renewed interest in the homicide.

Ongoing risk

The review panel should also be mindful that the perpetrator or members of the perpetrator’s family might in some cases pose an ongoing risk of violence to the victim’s family or friends.

If the review panel is concerned that there may be a risk of imminent physical harm to any known individual, they should contact the police immediately so that steps can be taken to secure protection.

Particular consideration should be given to reviews where ‘honour’-based violence is suspected. Extra caution will need to be taken around confidentiality in relation to agency members and interpreters where there are possible links with the family, who may be the perpetrators.

Extra caution will also be required when considering the level of participation from family members and should be carefully considered in consultation with a practitioner with expertise in this area, for example, a specialist black and minority ethnic (BME) women’s organisation.

Individual management reviews (IMR)

The aim of the individual management review (IMR) is to:

• allow agencies to look openly and critically at individual and organisational practice and the context within which people were working to see whether the homicide indicates that changes could and should be made
• identify how those changes will be brought about
• identify examples of good practice within agencies

Each agency should secure its records relating to the case and draw up a chronology of their involvement with the victim, perpetrator or their families. Each agency should then carry out an IMR of its involvement with the victim or perpetrator.

Professionals outside of the IMR process (eg GPs) should contribute reports of their involvement with the victim or perpetrator to the chair of the review panel. Those conducting IMRs should not have been directly involved with the victim, the perpetrator or either of their families and should not have been the immediate line manager of any staff involved in the IMR.

IMR reports should be quality assured by the senior manager in the organisation who has commissioned the report. This senior manager will be responsible for ensuring that any recommendations from both the IMR and, where appropriate, the overview report are acted on appropriately.

Review panel action on receiving an overview report

On completion of the overview report the review panel should:

• ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the overview report
• ensure that the overview report is of a high standard and is written in line with the guidance

Overview report action plan

The review panel should make sure that relevant recommendations in the overview report are put into an action plan, which is agreed at senior level by each of the participating organisations.

The action plan should set out who will do what, by when, with what intended outcome. The action plan should set out how improvements in practice and systems will be monitored and reviewed.

Once agreed, the review panel should provide a copy of the overview report, executive summary and the action plan to the chair of the CSP.

Community safety partnership (CSP) action on receiving the overview report

The community safety partnerships (CSP) should:

1. Agree the content of the overview report, executive summary and action plan, ensuring that the documents are fully anonymised apart from including the names of the review panel chair and members.
2. Make arrangements to provide feedback and debriefing to staff, family members and the media as appropriate.
3. Provide a copy of the overview report, the executive summary and the action plan to the Home Office quality assurance group. This should be via email to DHREnquiries@homeoffice.gov.uk

The document should not be published until clearance has been received from the Home Office quality assurance group. On receiving clearance from the Home Office quality assurance group, the CSP should:

1. Provide a copy of the overview report, executive summary and action plan to the senior manager of each participating agency.
2. Publish an electronic copy of the overview report and executive summary on the local CSP web page.
3. Monitor the implementation of the specific, measurable, achievable, realistic and timely (SMART) action plan.
4. Formally conclude the review when the action plan has been implemented and include an audit process.

Learning lessons and good practice

Domestic homicide reviews are an important source of information to inform national and local policy and practice. All agencies involved have a responsibility to identify and share common themes and trends across review reports, and act on any lessons identified to improve practice.

It is important to draw out key findings of domestic homicide reviews and their implications for policy and practice.

The following may assist in achieving maximum benefit from the review process:

• as far as possible, the review should be conducted in such a way that the process is seen as a learning exercise and not as a way of apportioning blame.
• consider what type and level of information needs to be disseminated, how and to whom, in the light of the review. Be prepared to communicate both examples of good practice and areas where change is required.
• subsequent learning should be spread to the local multi-agency risk assessment conference (MARAC) and the local domestic violence forum or similar, the local safeguarding children board and commissioners of services.
• include the learning into local and regional training programmes.
• the community safety partnership (CSP) will put in place a means of monitoring and auditing the actions against recommendations and intended outcomes.
• set up a culture of learning lessons by having a standing agenda item for domestic homicide reviews on the meetings of community safety partnerships and domestic violence forums or similar groups.

Quality assurance

Quality assurance for completed domestic homicide reviews rests with an expert group made up of statutory and voluntary agencies and managed by the Home Office.

All completed overview reports, executive summaries and action plans should be sent to the Home Office. They will be assessed against the guidance by an exert group. The group meet on a quarterly basis to assess report standards as well as identifying good and poor practice and training needs.

Send reports to: DHREnquiries@homeoffice.gov.uk

Where reviews are assessed as inadequate, a summary of findings is sent to the community safety partnership (CSP) chair who is responsible for ensuring the areas of concern are revisited and amended by the review panel.

The Home Office quality assurance group is also responsible for:

• disseminating lessons learned at a national level and effective practice
• identifying serious failings and common themes
• communicating with the media to raise awareness of the positive work of the statutory and voluntary agencies with domestic violence victims and perpetrators so that attention is not focused disproportionately on tragedies
• communicating and liaising with other government departments to ensure appropriate engagement from all relevant agencies
• providing central storage for DHRs to allow for clear auditing of review documentation and quick retrieval if required
• requesting updates from local areas on actions taken following a review
• reviewing decisions by CSPs not to undertake a DHR
• recommending national training needs and working across government to ensure existing training is highlighted
• recommending service needs to commissioners

You’ve now completed module 1.

Module 2 only needs to be completed by the review panel chairperson, although this information may also be useful to other practitioners involved in the review process.

Please send your comments and suggestions to DHRenquiries@homeoffice.gov.uk

Module 2: chair person’s responsibilities and the overview report

The chair and review panel should consider in each case the scope of the review process and draw up clear terms of reference.

Relevant issues to consider are outlined in the multi-agency statutory guidelines for conducting domestic homicide reviews.

We welcome your feedback on this online learning tool, please send your comments and suggestions to DHRenquiries@homeoffice.gov.uk

Determining the scope of a review

The chair and review panel should consider in each case the scope of the review process and draw up clear terms of reference. Relevant issues to consider are outlined in the multi-agency statutory guidelines for conducting domestic homicide reviews.

The review panel chair is responsible for ensuring contact is made with the chair of any parallel review process (such as a child or adult serious case review or mental health investigation) to consider combining the reviews.

In some cases that do not meet the criteria for a full domestic homicide review but give rise to concern, it may be valuable to conduct a single agency individual management review or a smaller-scale audit. For example, where there are lessons to be learnt about the way staff worked within one agency rather than about how agencies worked together.

The review panel chair should make the final decision on the suitability of the terms of reference for each review.

Timescales for domestic homicide reviews when there are legal or criminal proceedings

Where possible, the overview report should be completed within 6 months of the date of the decision to go ahead with a domestic homicide review, unless an alternative timescale is formally agreed with the community safety partnership (CSP).

Sometimes the complexity of a case does not become apparent until the review is in progress. As soon as it emerges that a review cannot be completed within the timescales above, the review panel should notify the CSP to renegotiate the timescale for completion.

In some cases, mental health investigations, criminal investigations or other legal proceedings may be carried out after death. The chair of the review panel should discuss with the relevant criminal justice and other agencies (eg HM coroner, SIO, independent police complaints commission), at an early stage, how the review process should take account of such proceedings.

It may be necessary to agree that the review will be pended until after the outcome of any criminal proceedings. But this should not mean that learning that comes out of the homicide should not be taken forward. It is essential that necessary learning is not delayed to prevent the same mistakes being replicated in other cases.

Individual management reviews

The chair of the review panel should write to the senior manager in each of the participating agencies to commission the individual management reviews (IMRs) which will form part of the overview report.

The aim of the individual management reviews (IMRs) is to:

• allow agencies to look openly and critically at individual and organisational practice and the context within which people were working to see whether the case indicates that changes could and should be made
• identify how those changes will be brought about
• identify examples of good practice within agencies

Once it is known that a homicide is being considered for review, each agency should carry out an IMR of its involvement with the victim or perpetrator.

The IMR should begin as soon as a decision is taken to proceed with a review and once the terms of reference have been set, and sooner if a case gives cause for concern within the individual agency. Independent professionals (including GPs) should contribute reports of their involvement with the victim or perpetrator.

Those conducting IMRs should not have been directly involved with the victim, the perpetrator or either of their families and should not have been the immediate line manager of any staff involved in the IMR.

The IMR reports should be quality assured by the senior manager in the organisation who has commissioned the report. This senior manager will be responsible for ensuring that any recommendations from both the IMR and, where appropriate, the overview report are acted on appropriately.

On completion of each IMR report, there should be a process of feedback and debriefing for the staff involved in the case, in advance of completion of the overview report. There should also be a follow-up feedback session with these staff members once the overview report has been completed and prior to its publication. The management of these sessions are the responsibility of the senior manager in the relevant organisation.

The overview report

The overview report should bring together and draw conclusions from the information and analysis contained in the individual management reviews (IMRs) and reports or information commissioned.

Overview reports should be produced according to the outline format and template (see appendices 3 and 4) and as with IMRs, the precise format depends on the features of the homicide. The review panel will need to bear in mind the importance of keeping personal details anonymous within the final report and executive summary.

The overview report should also make recommendations for future action and include an executive summary. It is crucial the chair has access to all relevant documentation and, where necessary, individual professionals to enable them to effectively undertake their review functions.

The findings of the review should be regarded as ‘Restricted’ until the agreed date of publication. Prior to this, information should be made available only to participating professionals and their line mangers who have a pre-declared interest in the review. It may also be appropriate to share these findings with family members as directed by the chair, taking into account ongoing criminal proceedings.

As part of the terms of reference, the chair should appoint a lead to take responsibility for debriefing family members, or for responding to media interest about the case, in liaison with contributing agencies and professionals.

Publication of the overview report

In all cases, the overview report and executive summary should be suitably anonymised and made publicly available. Individual management reviews (IMRs) should not be made publicly available.

The key purpose for undertaking domestic homicide reviews is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence. In order for these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future.

The aim in publishing overview reports is to restore public confidence and improve transparency of the processes in place, across all agencies, to protect victims.

All overview reports and executive summaries should be published unless there are compelling reasons relating to the welfare of any children or other persons directly concerned in the case for this not to happen.

The publication of the documents needs to be timed in accordance with the conclusion of any related court proceedings.
The content of the overview report and executive summary needs to be suitably anonymised in order to protect the identity of the victim, perpetrator, relevant family members, staff and others and to comply with the Data Protection Act 1998. This means preparing overview reports in a form suitable for publication, or redacting them suitably before publication.

Where information is sought using the Freedom of Information Act (FOIA), it is important to refer to sections 30 and 31, which identify key exemptions.

Where appropriate, thought should also be given to translating the executive summary into different languages and other formats, such as Braille or British sign language.

Publication of overview reports and supporting documents will take place following agreement from the quality assurance group at the Home Office and will be published on the local community safety partnership (CSP) web page and Home Office web page.

Disclosure and criminal proceedings

Disclosure is one of the most important issues in the criminal justice system and the application of proper and fair disclosure is a vital part of a fair criminal justice system.

All disclosure issues must be discussed with the police senior investigating officer, the Crown Prosecution Service (CPS) and the HM coroner’s representative as appropriate.

There may be cases where the investigator believes that a third party (for example, a local authority or social care) has material or information which might be relevant to the prosecution case. In such cases, if the material or information might reasonably be considered capable of undermining the prosecution case or of assisting the case for the accused, prosecutors are asked to take steps they regard as appropriate to obtain it, this may include applying for a witness summons causing a representative of the ‘third party’ to produce the material to the Court.

Dependent on the case, material gathered in the course of a DHR may be capable of assisting the defence case and would almost certainly be material that the defence would seek to gain access to. If a DHR is being conducted parallel to a criminal investigation the disclosure officer will be obliged to inform the Prosecutor and any interviews with other agency staff, documents, case conferences etc may all be disclosed.

Suggested process

In all cases of domestic homicide, even when the suspect subsequently commits suicide, a criminal investigation will be commenced.

Once an investigation has begun, the relevant community safety partnership (CSP) should be told in order that they may consider commissioning a domestic homicide review.

Where the evidence suggests that the suspect has committed suicide the case will be referred to the coroner and a file will be prepared. In these circumstances it is appropriate for a review to be conducted without delay and the overview report and supporting documents should be submitted to the coroner to help inform the inquest.
In cases where the suspect is arrested and charged, the commissioning of the overview report should be held until the conclusion of the criminal case but agencies and interested parties should be told of the requirement and should secure any records relating to the case against loss and interference.

In these circumstances, the review panel should ensure records are reviewed and a chronology drawn up to identify any immediate lessons. These should be brought to the attention of the relevant agency or agencies for action, secured for the overview report and forwarded to the disclosure officer for the criminal case.

Following the criminal proceedings the review should be commenced without delay.


Further information about disclosure can be found from the Crown Prosecution Service (CPS)

Lessons learned and effective practice

Domestic homicide reviews are a vital source of information to inform national and local policy and practice. All agencies involved have a responsibility to identify and disseminate common themes and trends across review reports, and act on any lessons identified to improve practice and safeguard victims.

It is vital that the review panel draws out key findings of the reviews and their implications for policy and practice. The following may help in achieving maximum benefit from the review process:

• the review should be conducted in such a way that the process is seen as a learning exercise and not as a way of apportioning blame.
• consider what type and level of information needs to be disseminated, how and to whom, in the light of the review. Be prepared to communicate both examples of good practice and areas where change is required.
• subsequent learning should be disseminated to the local multi-agency risk assessment conference (MARAC), any local domestic violence forums or similar, the local safeguarding children board and commissioners of services.
• incorporate the learning into local and regional training programmes.
• the community safety partnership (CSP) should put in place a means of monitoring and auditing the actions against recommendations and intended outcomes.
• establish a culture of learning lessons by having a standing agenda item for domestic homicide reviews on the meetings of CSPs and domestic violence forums or similar groups.

You have now completed module 2, the online learning course is now complete.

Published 28 March 2013