Research and analysis

Quantitative analysis of domestic homicide reviews: October 2022 to September 2023 (accessible)

Updated 31 October 2024

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This publication is available at https://www.gov.uk/government/publications/key-findings-from-analysis-of-domestic-homicide-reviews/quantitative-analysis-of-domestic-homicide-reviews-october-2022-to-september-2023-accessible

Prepared for the Home Office by Analytics Cambridge and QE Assessments Ltd

Responsible author:

Richard Potter, Independent Researcher, BSc (Hons), MPhil, Dip. Management, fellow of Royal Statistical Society at AnalyticsCambridge

Contact: info@analyticscambridge.co.uk

Reviewed by:

Simon Kerss, MA, BA (Hons.), PA Dip. Honorary Fellow (The International Policing and Public Protection Research Institute)

Gaynor Mears OBE, MA, BA (Hons), AASW, Dip. SW

1. Executive Summary

Statistics from Domestic Homicide Reviews

This report summarises information from Domestic Homicide Reviews (DHRs) which went before the Home Office Quality Assurance Panel for the 12 months between September 2022 and October 2023. DHRs are multi-agency reviews into the deaths of adults which may have resulted from violence, abuse, or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship. Reviews also take place where a victim took their own life (died by suicide) where there is a known history of domestic abuse.

This report provides information about victims whose relationship with the perpetrators was familial, intimate partner, or who died by suicide.

Overview

  • This report summaries information from 153 Reviews. In these reviews there were 158 victims of which 51% (80) were in, or had been in an intimate partnership. Thirty-one per cent (49) of the victims are those who died by suicide, and 18% (29) had a familial relationship with the perpetrators.

  • Relating the deaths to adults living in regions, the North West of England had the highest rate and London the lowest.

  • Number of victims related to the number of adults indicates there is a greater risk of being a victim in a predominantly rural area.

  • The average age of familial abuse victims (56 years old) was higher than intimate partner victims (48 years old) and victims who died by suicide (40 years old).

  • Seventy-six per cent of victims were female (and 24% male). Where the victim was or had been an intimate partner the proportion of female victims was 83%, and where the victim was familial the proportion was 55%.

  • The proportion of victims and perpetrators in different ethnic groups was similar for both victims and perpetrators and also similar to the overall population.

  • Ninety-one per cent of victims had their nationality as British, similar to the population overall.

  • Children (under 18) stayed in 41% (of 39) households where the victim died by suicide. Children were staying in 29% (of 52) households of an intimate partner victim. There were no children aged under 18 in households of familial victims.

Victims

  • Vulnerabilities had been identified for 96% (of 49) victims who died by suicide, 65% (of 80) intimate partner victims, and 52% (of 29) familial victims. Mental health was the most common vulnerability (34% of 228 overall), followed by problem alcohol use (24%).

  • Mental health issues were identified for 96% (of 49) victims who died by suicide, 54% (of 80) intimate partner victims, and 31% (of 29) familial victims. Of the mental health issues depression was the most frequent.

  • Thirty-one per cent (of 29) familial victims was or had been a carer. None had received a carer’s assessment.

  • Half (50% of 36) of victims who died by suicide had been the target of an abuser before. For intimate partner victims this was suicide, 27% (of 59), and for familial victims 11% (of 19).

  • Thirty-four per cent (of 138) victims had been referred to a Multi-Agency Risk Assessment Conference (MARAC). This ranged from 65% (of 31) victims who died by suicide, 29% (of 79) intimate partner victims, and 14% (of 28) familial victims.

  • Eighty-two per cent (of 44) victims who died by suicide experienced aggravating factors. Sixty-two per cent (of 63) intimate partner victims also experienced these, as did 40% (of 20) of familial victims. Of the aggravating factors 51% (of 154 identified) were coercive control, with financial abuse being the second largest (29%).

Perpetrators

  • Familial perpetrators were more likely to experience vulnerabilities (93% of 28) than intimate partner perpetrators (70% of 70). The three most common vulnerabilities were mental ill-health (37% of 151), illicit drug use (28%), and problem alcohol use (26%).

  • The most common mental health issues were depression (19% of 184), and low mood or anxiety and suicidal thoughts (16% for each).

  • Forty-six per cent of perpetrators had previously abused family members or partners: 63% (of 24) familial perpetrators and 38% (of 52) intimate partners.

  • The police were aware of 42% (of 86) perpetrators as abusers. Fourteen per cent were known to children’s social services and 14% also to health services.

  • Mental health services managed, supervised or were attended by 65% (of 23) familial perpetrators and 37% (of 35) intimate partner perpetrators.

  • In relation to Court verdicts, murder was the most common (45% of 92). For intimate partner perpetrators murder was 58% of 59 Court verdicts and manslaughter 22%. For familial perpetrators manslaughter was 45% of 33 verdicts and diminished responsibility 33%.

  • For familial perpetrators, for 33% (of 33) it was diminished responsibility and a secure hospital order court verdict.

Family contributions

  • Contributions were made by family and friends in 82% of the 153 Domestic Homicide Reviews.

2. Introduction

1. This report is from information from Domestic Homicide Reviews (DHRs) which were subject to the Home Office quality assurance process[footnote 1] for the twelve months from October 2022 to the end of September 2023[footnote 2] (referred to as 2022/23). It follows previous reports for years 2019/20[footnote 3] and 2020/21[footnote 4] .

2. The aim is to provide analysis from the DHRs examined in the quality assurance process. This report looks at domestic homicides which involved intimate partner relationships, those where the relationships were familial, and those where the victim died by suicide. There were four DHRs where the relationship between the victim and perpetrators does not fall into these categories e.g. “living in same household as a lodger”. These DHRs have not been included[footnote 5] ; the analysis is from 153 DHRs.

3. Home Office statutory guidance (2016) states[footnote 6] that a Domestic Homicide Review is a multi-agency review, commissioned by a Community Safety Partnership, into the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse, or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship, or a member of the same household. Reviews should also take place where a victim took their own life (suicide) and the circumstances give rise to concern[footnote 7]. The purpose of a DHR is to:

  • Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations can 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 national and local policies.

  • Prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co- ordinated multi-agency approach to ensure that abuse is identified and responded to effectively at the earliest opportunity.

  • Contribute to a better understanding of the nature of domestic violence and abuse; and

  • Highlight good practice.

4. A Domestic Homicide Review does not replace the criminal or coroners’ processes

Structure

5. The report starts with information from the Office for National Statistics on trends in domestic homicide. It then follows with information from the management information reports (MIRs) which are submitted to the Home Office alongside DHRs[footnote 8]. The data in MIRs has been edited if information from the DHRs indicates this is needed.

6. The MIRs are structured to give:

a) The location, age, sex, ethnicity and nationality of victims and perpetrators;

b) Characteristics or experience of victims in terms of their vulnerability, mental health, and whether they had been the target of an abuser before;

c) Characteristics or experience of perpetrators, including vulnerabilities and mental health, any previous offending history, and details of criminal charges; and

d) Contributions from and support for families in the DHR process.

Background of COVID

7. The DHRs are those which were reviewed between October 2022 to the end of September 2023. The deaths in 96 of the 153 Reviews took place within the period of COVID lockdowns and restrictions (from March 2020 to the end of December 2021[footnote 9]).

8. There are references to COVID in 91% (of 150) Reviews. These cover a range of impacts. The following are examples of impacts on the victims(s):

  • “She struggled during Covid with the loss of social networks and activities”;

  • “The true impact of COVID on XXX has been difficult to determine in terms of her being socially isolated at a time in her life when she needed continuous help and support. Her friend described how the isolation from her family and the inability to socialise had a huge impact on her mental wellbeing and susceptibility to being a victim of abuse”;

  • “The Project found that COVID-19 acted as an ‘escalator and intensifier of existing abuse’ in some instances, with victims less able to seek help due to COVID-19 restrictions. It also concluded that COVID-19 had not ‘caused’ domestic homicide, but it had been ‘weaponised’ by some abusers, as both a new tool of control over victims and – in some cases – as an excuse or defence for abuse or homicide of the victim”.

9. Many of the references to COVID relate to how the Review was carried out:

  • “The review has been delayed by the disruption caused by the COVID-19 pandemic. Specifically, the Crown Court trial did not commence until January 2021”

  • “The review was not completed within six months because the Chair and Report Author were not able to meet with XXX’s family until after the Covid-19 lockdown”.

10. Some of the Reviews noted that COVID did not seem to have had an effect: “this review has not found any information which suggests the COVID 19 pandemic was in anyway a factor in this case”.

Interpretations of numbers

11. Information in the management information reports (MIRs) is used to show patterns and differences, but they are not precise. As one example of the difficulty of being certain, in five reviews the date of death is not exact. In four of these the uncertainty is in days, in one the exact month of the death was not known.

12. Not every piece of information asked for in MIRs can be found; answers can be given as “not known”[footnote 10] or left blank. The extent varies between questions. For example, for the 158 victims’ ethnicity is given for 151. For the question ‘any serious or life limiting illness?’ there are 14 marked as “not known”. The bottom rows in tables give the numbers of answers on which percentages in the rows above have been calculated. The percentages are calculated from answers given which are known – they exclude those marked N/K (not known).

13. The answers requested for some questions on the MIRs are Y, N or N/K. Answers for some questions on vulnerability and mental health issues are “please mark ‘X’ for ALL that apply” and these do not ask for N/K. The figures used are from MIRs where vulnerabilities have been identified. These might be different if answers had been asked to indicate where N/K.

14. To help compare figures between the different types of victims, they are given as percentages. A balance is taken between putting the data into more categories against making differences dependent on small numbers. Caution should be applied where differences in percentages are relatively small.

15. The percentages are rounded to the nearest whole number, there are occasions when they do not add to 100%.

16. This chapter begins with national trends in domestic homicides. It then describes information from the Domestic Homicide Reviews on the dates of death and the time between the death and when the Reviews were submitted to the Home Office. This is followed with the number of Reviews in each region. The chapter then provides information on the victims and the perpetrators including their age, sex, and relationships.

17. For context, Figure 1 shows the number of victims of domestic homicide over the 10- year period 2012/13 to 2122/23. There is a fall in the average of 137 for the first three years to 118 for the last three years. Looking at these two periods, the proportion of female victims has fallen from 77% to 65% and the proportion of victims who are male has increased from 23% to 35%. These figures on domestic homicides do not include people who have died by suicide.

Figure 1 Number of domestic homicides in England and Wales: 2011/12 to 2021/22

Source: Office for National Statistics, Homicide in England and Wales: year ending March 2023 - Appendix Tables Table 32 [Accessed 2 March 2024]

Number of victims and perpetrators

18. Within the 153 Reviews here there is information on 158 victims who died - there are two Reviews with two victims and one Review with three victims.

19. To provide information which is helpful to tackle domestic abuse, information in this report is provided firstly where the relationship between the victim and the perpetrator can be described as “familial”, secondly where it can be described as “intimate partner” and thirdly where victims have died by suicide (Table 1).

Table 1 Numbers of victims by relationship

Characteristics of victims associated in DHRs Number of victims Per cent
Intimate partner 80 51%
Died by suicide 49 31%
Familial 29 18%
Total 158  

20. In relation to perpetrators, the information used is from 98 perpetrators. The definition of perpetrator relates to either being found guilty through a trial or where a person considered responsible for the death of the victim then takes their own life or dies by suicide[footnote 11] (of which there are 15).

21. There are eight DHRs which give some information on perpetrators but where there has been no police charge or court sentence e.g. “Coroner’s Inquest Verdict_ Drugs overdose – misadventure”. For these Reviews the information on victims has been included but information on a perpetrator has not been used.

Domestic Homicide Reviews where the victim died by suicide, over time

22. Of the 153 Domestic Homicide Reviews in this report, 31% (49) involved victims who died by suicide. This is a higher proportion than the previous analyses of DHRs reports[footnote 12]. There is an increase in DHRs where victims have died by suicide when the suicide rate for England and Wales has not changed[footnote 13].

Domestic Homicide Reviews: date of death of victim

23. The time between a victim’s death and the completion of the Review is influenced by a range of factors:

  • Length of time of police investigation;

  • Completion of a criminal trial;

  • Coroner’s Inquest;

  • Contact with family members and others to enable them to contribute to the Review;

  • Community Safety Partnership meetings; report sign off and submission to the Home Office; and the

  • Quality assurance process through the Home Office.

24. Reflecting on the time it can take related to the above factors Figure 2 shows the years in which the victims died in the Reviews of October 2022 to September 2023. Taken together, in 101 of the 153 Reviews (two thirds) the victims died in either 2020 or 2021.

Figure 2 Year of death of victims in DHRs

Location of the deaths of victims

25. The victims in Reviews for each region in England and for Wales are shown in Table 2 (and a map of regional boundaries in Figure 3). Comparisons can be made by relating these to the number of people who live in them (using the population in 2021). The North West has the highest rate of victims with 5.6 (per million persons aged 18 or over) and London has the lowest (1.3).

Table 2 Number of Victims by region or nation

Region / Nation Total number of victims Number of victims per (one million) population aged 18 and older
North East 8 3.8
North West 33 5.6
Yorkshire and the Humber 16 3.7
East Midlands 13 3.3
West Midlands 14 3.0
East 19 3.8
London 9 1.3
South East 19 2.6
South West 23 5.0
England 154 3.4
Wales 4 1.6
England and Wales 158 3.3

Note: The number of victims per million persons aged 18 or over is calculated from the 2021 mid-year population estimates from the Office for National Statistics [Accessed 26 August 2024]

Figure 3 Map of regional boundaries in England

Source: Ordnance Survey election maps

26. The relationship to place can also be examined by comparing urban and rural areas. The Department for Environment, Food & Rural Affairs has placed Local Authorities in England into urban to rural categories. Table 3 relates the number of victims to the number of people aged 18 or over using the “Rural Urban Classification 2011 (3-fold)”. Using these three categories, it shows that there is a higher rate of victims in Local Authorities which are predominantly rural.

Table 3 Domestic homicides in urban and rural areas, England

Urban to rural category Number of victims Number of victims per million people aged 18 or over
Predominantly Rural 48 5.0
Urban with Significant Rural 13 2.1
Predominantly Urban 93 3.2
Number of victims on which table based 154  

Notes:

The number of Reviews per million persons aged 18 or over in 2021 is from Office for National Statistics (2024) Estimates of the population for the UK, England, Wales, Scotland, and Northern Ireland , [Accessed 24 August 2024]

The Department for Environment, Food & Rural Affairs classification of Local Authorities in Rural Urban Classification 2011 lookup tables for local authority areas, last updated on: 17 October 2023, [Accessed 17 July 2024]

27. Looking at this in more detail by the type of victim[footnote 14] (Table 4) there is a greater likelihood of domestic homicide in predominantly rural areas where the victim is either familial or intimate partner. For those victims who died by suicide this is the same for both those who lived in predominantly rural areas and those who lived in predominantly urban areas.

Table 4 Domestic homicides in urban and rural areas, England, per million people aged 18 or over

Urban to rural category Familial Intimate partner Victims who died by suicide
Predominantly Rural 1.3 2.3 2.3
Urban with Significant Rural n/a n/a n/a
Predominantly Urban 0.5 1.7 2.3
Number of Reviews on which table based 28 78 48

Notes: The victims in Local Authorities in the “urban with significant rural” group have not been included in the table due to the small numbers

28. The place where the victim died is also given as whether it is the victim’s home address. Table 5 shows that, for all victims, close to three quarters of the deaths (74%) occurred at the home address. The proportion was highest for victims who died by suicide (79%) and lowest for intimate partners (70%).

Table 5 Reviews and whether death of victims was at home address

Location Familial Intimate partner Victims who died by suicide Overall
At home address 74% 70% 79% 74%
Not at home address 26% 30% 21% 26%
Total number of Reviews on which table is based 27 76 48 151

Notes: Above are the 151 number of Reviews where information is given, there are two where it is marked N/K. The table does not exactly match all victims as there are three Reviews with more than one victim.

Defining relationships between victims and perpetrators

29. The MIRs give information on the relationship between the victim and perpetrator, and this is available for 109 victims[footnote 15]. These relationships have been classified as either familial or intimate partner. The term “intimate partner” comes from a range of words used such as “husband or wife, boyfriend or girlfriend” as well as the term “intimate partner”. As Table 6 shows, for the group “intimate partner” 80% of (the also 80) relationships could be called current and 20% as former relationships e.g. “former long- term partner” or “ex-partner”.

Table 6 Victims in Domestic Homicide Reviews with relationship with perpetrators

Characteristics of relationships Number of victims Per cent
Familial relationship with perpetrator 29 27%
In or had been in an intimate relationship with perpetrator: 80 73%
of which current relationship 64  
of which former relationship 16  
Total number of victims with a relationship 109  

30. The familial relationships can also be seen as different types. Table 7 shows 21 of the victims (nearly three quarters, 72%) were a parent of the perpetrator. Of these eight were fathers and 13 were mothers. Of the eight victims who were not parents four had a filial relation (i.e. were the son or daughter of the perpetrator) and three were siblings (brother or sister).

Table 7 Types of familial relationship

Type of familial relationship Number of victims Per cent
Parent: 21 72%
of which father 8  
of which mother 13  
Grandparent 1 3%
Filial (e.g. son or daughter) 4 14%
Sibling (e.g. brother or sister) 3 10%
Total number of familial victims 29  

Notes: Of the fathers, one was a step-father.

Age of victims and perpetrators

31. The average age of all victims and perpetrators are similar (47 and 46 years old). There are differences between the different groups (as shown in Table 8). The average age of those who died by suicide is 40 years old, for intimate partner victims 48 years old, and for familial victims 65 years old[footnote 16]. For familial victims the average age is higher than the perpetrators. As shown in Table 7, 21 of the familial victims were parents of the perpetrators.

Table 8 Average age of victims and perpetrators, by type of victim

Type of victim Average age (years):Victims Average age (years): Perpetrators
Familial relationship 56 39
Intimate partner relationship 48 48
Victim who died by suicide 40  

Notes: The number of victims in each category are shown in Table 1. There is one victim who died by suicide where the age was not given.

32. When the numbers of victims and perpetrators are place into age groups, the proportions (percentages) of these are similar (Table 9). The oldest victim was aged 86 and was the father of the perpetrator. The oldest perpetrator was 85 years old and was the husband of the victim.

Table 9 Percentage of victims and perpetrators, by age group

Age Percentage of: Victims Percentage of: Perpetrators
Under 40 43% 43%
40-59 30% 35%
60-79 21% 16%
80 or over 6% 6%
Numbers on which % based 157 98

Sex of victims and perpetrators

33. The overall position with regard to the sex of the victim is that three quarters (76%) were female and one quarter (24%) were male (Table 10). The proportion of female victims are higher for both those who were (or had been) intimate partners of the perpetrators and those who died by suicide. The proportions who were female or male were closer together where the victim had a familial relationship with the perpetrator (55% of the victims were female and 45% of the perpetrators male).

Table 10 Sex of victims, per cent by type of victim

Sex Familial Intimate partner Victims who died by suicide Overall
Female 55% 83% 78% 76%
Male 45% 18% 22% 24%
Numbers on which % based 29 80 49 158

Notes: The percentage of sex where intimate partners adds to 101% as these are 82.5% and 17.5%.

34. The sex of perpetrators is shown in Table 11. Overall, 85% of the perpetrators were male and 15% female. This is not the exact opposite to the sex of victims as there are some domestic homicides where the sex of both the victim and the perpetrator are the same. Where the victims have a familial relationship with the perpetrator there are seven where the father is the victim and a son the perpetrator, there are also three where the victim is the mother and the perpetrator is a daughter.

Table 11 Sex of perpetrators, per cent by type of perpetrator

Sex Familial Intimate partner Overall
Female 14% 16% 15%
Male 86% 84% 85%
Numbers on which % based 28 70 98

Ethnicity

35. The National Institute for Health and Care Excellence sets out that “Domestic violence and abuse occurs across the whole of society, regardless of race, ethnicity, gender, religion, age, class and economic status, or where people live”[footnote 17]. Aspects of these factors are not collected in the MIRs with the Domestic Homicide Reviews. The Office for National Statistics report on Homicide in England and Wales[footnote 18] makes a similar point: “differences in … figures are likely to be related to the ethnicity of the population differing by age, region, and socioeconomic factors which have not been taken into account”.

36. The percentage of victims and perpetrators by different ethnicity are shown in Table 12, as are the proportions of people aged 18 or over as measured in the 2021 Census. The patterns are similar between both perpetrators and victims and between both and the population.

Table 12 Per cent of victims and perpetrators by ethnicity

Ethnicity Per cent of DHR victims Per cent of DHR perpetrators Per cent of population in ethnic groups 2021, aged 18+
Asian / Asian British 6% 7% 9%
Black / African / Caribbean / Black British 1% 4% 4%
Other or multiple ethnic group 2% 3% 5%
White: any other white background 90% 85% 84%
Numbers on which % based 157 95  

Notes: the per cent of the population ages 18 or over from the 2021 Census. Office for National Statistics (2023), Ethnic group by age and sex in England and Wales [Accessed 24th August 2024]

37. The ethnicity of the different types of victim is shown in Table 13. The proportions which are either white or in a different ethnic group are similar for familial and intimate partner victims (89% and 90%). Where victims have died by suicide the proportion who were white is slightly higher (94%).

Table 13 Ethnicity by type of victim

Ethnicity Familial Intimate partner Victims who died by suicide Total
White 90% 89% 94% 90%
Non-white 10% 11% 6% 10%
Numbers on which % based 29 79 49 157

Nationality

38. Table 14 shows the nationality[footnote 19] of the victims: 91% were British. There are 9% of victims whose nationality is not British - the nationality is of 10 different countries. This 9% is 14 victims and of these six victims have the same (non-British) nationality as the perpetrator (as shown in Table 15).

39. The proportion of victims with British nationality (Table 14) is similar to that identified in the 2021 Census: “90.3% of the population … in England and Wales identified with at least one UK national identity)”[footnote 20].

Table 14 Nationality of victim

Nationality Total
British 91%
Non-British 9%
Numbers on which % based 157

Table 15 Comparing nationality of victim and perpetrator

Comparative Nationality Overall
Both British 80%
Both non-British 9%
One British 12%
Numbers on which % based 69

Information on children aged under 18 years

40. Information from the DHRs is given on whether children lived or regularly stayed in the household. This was true in 28% of all the households, but this figure is influenced by the difference between the categories (see Table 16). Where victims died by suicide children lived or regularly stayed in 41% of the households, this was lower (29%) where the victim was in or had been in an intimate partnership with the perpetrator. If the relationship was familial then none had children under 18 living in the household: the most frequent victims in familial DHRs were parents.

Table 16 Children living, or regularly staying, in the household

Familial Intimate partner Victims who died by suicide Overall
Yes 0% 29% 41% 28%
No 100% 71% 59% 72%
Number of Reviews on which % based 19 52 39 110

Notes: This question was asked in the 126 newer MIRs. Of these there were 16 where the answer was marked as N/K or N/A.

41. The question “Were children present when the homicide occurred?” was asked in a new MIR for 126 DHRs. Answers were given for 71 DHRs and children were present in 21% of these. There were also 52 DHRs where the answer was given as not known (N/K) or left blank. If these answers were “No” then the percentage where children were present would be lower at 12%.

42. Information was also asked on the sex of the children present and, of the 57 children where this information was given, 53% were female and 47% were male.

43. The information was given in 33 Reviews to indicate that one child was present at the time of the homicide in 36% of these, two children in 48%, and three or more children in 15% of the DHRs where known.

44. For the 153 DHRs information is given in 82 on “were children subject to Child Protection procedures due to Domestic Abuse prior to the homicide?” For these, 27% indicated that children were subject to Child Protection procedures due to domestic abuse prior to the homicide. The answer was N/K for 71 DHRs and if for these the answer was “No” then the 27% is 15%.

45. The DHRs were also asked to provide information on whether any children were “removed into the Care of the Local Authority”. Information was given for 83 Reviews and in 20% the answer was “Yes”. As with some other questions, for a large number (70) the answer was left blank or given as “N/K”. And if the number of DHRs where the answer was given as Yes this is given as a percentage of all DHRs and the proportion “Yes” becomes 11%.

4. Characteristics of victims

46. This chapter summarises the information on the vulnerabilities and mental health issues identified as experienced by 158 victims. The figures are separated to show differences or similarities between 29 who had a familial relationship with the perpetrator(s), 80 who had or previously had an intimate partner relationship with the perpetrator(s), and 49 who died by suicide.

47. The chapter also looks at whether the victim was a carer or had a life limiting illness. This is followed by whether the victim had been the target of an abuser before and whether they had been referred to a Multi-Agency Risk Assessment Conference (MARAC)[footnote 21]. There is also a summary of aggravating factors that many victims experienced.

Vulnerabilities

48. The DHR forms indicate the vulnerabilities victims may have experienced, in terms of:

  • Illicit Drug Use;

  • Mental ill-health;

  • Physical disability;

  • Pregnancy;

  • Problem alcohol use;

  • Any other vulnerability.

49. The proportions of victims where vulnerabilities have been identified are shown in Table 17 and Figure 4. There are considerable differences between different victims. Where the victims were familial, for 42% no vulnerabilities were identified and for 31% one was noted. The number of vulnerabilities for victims who were intimate partners was higher for those where it was two or more vulnerabilities (35%, compared to 20% for familial victims). The proportion with vulnerabilities is much higher where victims have died by suicide: only 4% have no vulnerability and 68% had two or more identified.

Table 17 Victims and number of vulnerabilities

Number of vulnerabilities Per cent by of victims with number of vulnerabilities: Familial Per cent by of victims with number of vulnerabilities: Intimate partner Per cent by of victims with number of vulnerabilities: Victims who died by suicide All victims
0 48% 35% 4% 28%
1 31% 30% 29% 30%
2 10% 19% 37% 23%
3 or more 10% 16% 31% 20%
Number of victims on which % based 29 80 49 158

Figure 4 Victims and number of vulnerabilities

50. The proportion of different types of vulnerabilities which had been identified (Table 18) shows some difference between the different types of victim. Mental health vulnerability was 41% of the vulnerabilities of victims who died by suicide and 21% of familial victims. Physical disability was highest (29%) of the vulnerabilities of familial victims, and eight per cent of those of victims who died by suicide.

Table 18 Vulnerabilities of victims

Vulnerability Per cent of vulnerabilities by type of victim: Familial Per cent of vulnerabilities by type of victim: Intimate partner Per cent of vulnerabilities by type of victim: Victims who died by suicide Total
Illicit drug use 13% 17% 17% 17%
Mental ill-health 21% 30% 41% 34%
Physical disability 29% 14% 8% 13%
Pregnancy 0% 5% 6% 5%
Problem alcohol use 21% 28% 21% 24%
Other 17% 7% 7% 8%
Number of vulnerabilities on which % based 24 101 103 228

Mental health issues

51. DHRs were asked to indicate mental health issues of victims and the categories to be identified were:

  • Adjustment disorder;

  • Anxiety;

  • Dementia or Alzheimer’s;

  • Depression;

  • Low mood / anxiety;

  • Panic attacks;

  • Psychosis;

  • Post-traumatic stress disorder (PTSD);

  • Self-harm;

  • Suicidal thoughts;

  • Suicide attempts;

  • Other.

52. The number of mental health issues by type of victim are shown (as percentages) in Table 19 and Figure 5. The larger differences are between familial victims and victims who died by suicide. Where victims were familial 69% had no mental health issues identified. For victims who died by suicide four per cent had no mental health issues – they were identified for 96% of these victims. While no familial victims had three or more mental health issues identified, 73% of victims who died by suicide did. Where victims were an intimate partner 46% had no mental health issues.

Table 19 Victims and number of mental health issues

Number of mental health issues Per cent of victims with number of mental health issues: Familial Per cent of victims with number of mental health issues: Intimate partner Per cent of victims with number of mental health issues: Victims who died by suicide Total
0 69% 46% 4% 37%  
1 21% 16% 4% 13%  
2 10% 23% 18% 19%  
3 or more 0% 15% 73% 30%  
Number of victims on which % based 29 80 49 158  
           

Figure 5 Victims and number of mental health issues

53. The mental health issues which were asked to be identified are shown in Table 20. Those most often found for familial victims were depression, low mood / anxiety and anxiety. These three mental health issues are also those found most frequently for intimate partner victims. For victims who died by suicide the three most common mental health issues were suicidal thoughts and suicide attempts. Depression and anxiety follow closely behind.

Table 20 Mental health issues of victims

Mental health issue Per cent of mental health issues by type: Familial Per cent of mental health issues by type: Intimate partner Per cent of mental health issues by type: Victims who died by suicide Total
Anxiety 17% 18% 16% 17%
Dementia or Alzheimer’s 0% 4% 0% 1%
Depression 33% 23% 17% 20%
Low mood / anxiety 25% 21% 9% 14%
Panic attacks 8% 0% 3% 2%
Psychosis 0% 1% 1% 1%
Post-Traumatic Stress Disorder (PTSD) 0% 2% 4% 3%
Self-harm 0% 7% 9% 8%
Suicidal thoughts 0% 12% 19% 16%
Suicide attempts 0% 5% 18% 13%
Other 17% 5% 5% 5%
Total number of mental health issues on which % based 12 98 190 300

Notes: The total number of mental health issues identifies for familial victims is 12. The percentages for each issue are based on this small number, so the 17% of mental health issues labelled as “other” is simply two.

Carer

54. The MIRs were asked to note whether victims were or had been carers and, overall, 12% were or had been carers (Table 21). For the different types of victim, the proportion who were carers was highest for familial victims (31%) and lowest for intimate partner victims (6%). In total there were 19 victims who were or had been carers.

Table 21 Proportions of types of victims who were or had been carers

Was or had been a carer Per cent of victims who were or had been a carer: Familial Per cent of victims who were or had been a carer: Intimate partner Per cent of victims who were or had been a carer: Victims who died by suicide Total
Yes 31% 6% 10% 12%
No 69% 94% 90% 88%
Number of victims on which % based 29 80 48 157

55. None of the victims (in any group) had received a carer’s assessment.

Life limiting illness

56. Information from the DHRs was requested regarding whether the victim(s) experienced a serious or life limiting illness. As Table 22 shows, 13% of all victims experienced a serious or life limiting illness. Similar proportions (17% and 16%) of familial and intimate partner victims who experienced such conditions. The proportion of victims who died by suicide was lower (7%).

Table 22 Did the victim suffer from any serious or life limiting illness?

Life limiting illness? Per cent of victims suffered from a life limiting illness: Familial Per cent of victims suffered from a life limiting illness: Intimate partner Per cent of victims suffered from a life limiting illness: Victims who died by suicide Total
Yes 17% 16% 7% 13%
No 83% 84% 93% 87%
Number of victims on which % based 24 74 46 144

57. The average age of those with a life limiting illness is older (60 years) than those without (40 years old).

Target of abuser before

58. The MIR asked: “Has the victim been a target of an abuser before?”[footnote 22] Of victims who died by suicide, half had been the target of an abuser before (Table 23). For intimate partner victims this was a lower proportion of 27%. For both these types of victims the former abusers were previous partners. The smallest proportion was 11% for familial victims.

Table 23 Victims who had been the target of an abuser before

Target of abuser before? Per cent of victims who had been the target of an abuser before: Familial Per cent of victims who had been the target of an abuser before: Intimate partner Per cent of victims who had been the target of an abuser before: Victims who died by suicide Total
Yes 11% 27% 50% 32%
No 89% 73% 50% 68%
Number of victims on which % based 19 59 36 114

Multi-Agency Risk Assessment Conference

59. Information was available for 138 victims on whether they had been referred to a Multi- Agency Risk Assessment Conference (MARAC) (shown in Table 24). Overall, one third (34%) of victims had been referred to a MARAC. There was variation between the different types of victim: 65% of victims who died by suicide had been referred, 29% of intimate partner abuse, and 14% of familial victims. For victims who died by suicide there were 18 where the information was marked as not known (N/K). If these were assumed to be instances where a referral had not been made the proportion of those who took their own lives who were referred to MARAC is still the highest at 48%.

Table 24 Victims referred to a Multi-Agency Risk Assessment Conference

Referred to MARAC? Familial Intimate partner Victims who died by suicide Total
Yes 14% 29% 65% 34%
No 86% 71% 35% 66%
Number of victims on which % based 28 79 31 138

60. After the question asking whether victims had been referred to a MARAC there is the question “was the case heard at MARAC before the homicide?” (the results are shown in Table 25). The smallest proportion is for familial victims, where for 13% the case was heard at MARAC before the homicide, the highest proportion (65%) is for victims who died by suicide.

Table 25 Was the case heard at MARAC before homicide?

Case heard at MARAC before the homicide Familial Intimate partner Victims who died by suicide Total
Yes 11% 31% 63% 34%
No 89% 69% 37% 66%
Number of victims on which % based 27 68 27 122

Aggravating factors

61. Information from the DHRs includes aggravating factors experienced by victims[footnote 23]. The question asks if any of the following are relevant:

  • Coercive control;

  • Digital stalking;

  • Financial abuse;

  • Forced marriage;

  • Honour-based violence;

  • Immigration issues;

  • Physical stalking.

62. Table 26 below shows that 65% of victims experienced at least one aggravating factor. Nearly a quarter (24%) of victims had one aggravating factor and 30% had two. For 11% of victims there were three of more aggravating factors.

63. The number of aggravating factors varies for different type of victim (Table 26 and Figure 6). There were fewer aggravating factors for familial victims: for 60% none were identified and also none were identified with three or more. Where victims had died by suicide 82% experienced at least one aggravating factor.

Table 26 Aggravating factors experienced by victims

Number of aggravating factors identified Per cent of victims: Familial Per cent of victims: Intimate partner Per cent of victims: Victims who died by suicide Per cent of victims: Total
0 60% 38% 18% 35%
1 15% 21% 34% 24%
2 25% 29% 34% 30%
3 or more 0% 13% 11% 11%
Number of factors on which % are based 20 63 44 127

Notes: The number of victims for which data available is smaller than the total as it is the number of victims where data was made available on Form 1 (0ne of the two form types) and this did not include financial abuse.

Figure 6 Number of aggravating factors experienced by victims

64. There are different types of aggravating factor and Figure 7 and Table 27 show those which occurred most frequently. Coercive controls forms half (51%) of the factors. Financial abuse occurs in 45 Reviews and this forms 29% of the factors. There are 78 instances of coercive control with 43 (55%) found together with financial abuse. In (the other) 45% of the Reviews coercive control was identified and financial abuse was not identified.

Figure 7 Aggravating factors as proportions of total

65. There are differences between the aggravating factors experienced by different types of victim (Table 27). For familial victims slightly over half (54%) of the aggravating factors were coercive control and 38% were financial abuse. Where victims were or had been intimate partners the coercive control (47%) and financial abuse (38%) are slightly less. For intimate partner victims 12% of the aggravating factors are physical stalking and nine per cent are digital stalking – none of these were recorded as experienced by familial victims. Digital and physical stalking are also experienced by victims who died by suicide (5% of the aggravating factors are each of these). Coercive control was 54% of the aggravating factors and 26% were financial abuse of victims who died by suicide.

Table 27 Aggravating factors – by type

Type of aggravating factors Per cent of Reviews where aggravating factor identified: Familial Per cent of Reviews where aggravating factor identified: Intimate partner Per cent of Reviews where aggravating factor identified: Victims who died by suicide Per cent of Reviews where aggravating factor identified: Total
Coercive control 54% 47% 54% 51%
Digital stalking 0% 9% 5% 6%
Financial abuse 38% 30% 26% 29%
Physical stalking 0% 12% 11% 10%
Other 8% 1% 5% 3%
Number of aggravating factors on which % based 13 76 65 154

5. Characteristics of perpetrators

66. This chapter summarises information on 98 perpetrators[footnote 24] from the Domestic Homicide Reviews. There is one Review with two perpetrators.

67. The vulnerabilities and mental health categories considered are the same as those for victims[footnote 25]. The chapter looks at whether the perpetrator was a carer or had a life limiting illness. Information summarised on whether the perpetrator had abused previous partners or family members and whether this was known to agencies is also included. It is followed by a section on Court verdicts and sentences.

Vulnerabilities

68. The number of vulnerabilities for perpetrators either familial or intimate partners are shown in Table 28 and Figure 8. There are differences between the types of perpetrator - with larger proportions of familial perpetrators having more vulnerabilities: 36% of familial perpetrators have had three or more vulnerabilities identified compared to 20% of intimate partner perpetrators. This is also shown by only seven per cent of familial perpetrators where no vulnerabilities were identified compared to 30% of intimate partner perpetrators.

Table 28 Perpetrators and numbers of vulnerabilities

Number of vulnerabilities Per cent of perpetrators with number of vulnerabilities: Familial Per cent of perpetrators with number of vulnerabilities: Intimate partner Total
0 7% 30% 23%
1 25% 27% 27%
2 32% 23% 26%
3 or more 36% 20% 24%
Number of perpetrators 28 70 98

69. Earlier this report (Table 17) examined the vulnerabilities of victims. While overall the proportions of victims and perpetrators with the numbers of vulnerabilities identified are similar; there are large differences between familial victims and familial perpetrators. Forty-eight per cent of familial victims had no vulnerabilities identified while this was only the case for seven per cent of the familial perpetrators. Therefore, while 51% of familial victims did have vulnerabilities identified, they were identified for 93% of familial perpetrators.

Figure 8 Perpetrators and number of vulnerabilities

70. The types of vulnerability identified for perpetrators is shown in Table 29. Mental ill- health was 37% of the total vulnerabilities, 28% was illicit drug use and 26% was problem alcohol use. The largest differences between the types of perpetrator was illicit drug use was identified for 36% of familial abuse perpetrators compared to 23% of intimate partner perpetrators. Problem alcohol use was identified for 19% of familial perpetrators and 31% of intimate partner perpetrators.

Table 29 Vulnerabilities of perpetrators

Type of vulnerability Per cent of vulnerabilities by type and by type of perpetrator: Familial Per cent of vulnerabilities by type and by type of perpetrator: Intimate partner Total
Illicit drug use 36% 23% 28%
Mental ill-health 34% 39% 37%
Physical disability 5% 5% 5%
Problem alcohol use 19% 31% 26%
Other 5% 2% 3%
Number of vulnerabilities on which % based 58 93 151

Mental health issues

71. The MIRs were asked to record the mental health issues of perpetrators (as they were for victims). Table 30 and Figure 9 show the number of mental health issues identified. The number of mental health issues experienced by familial perpetrators was greater than by intimate partner perpetrators. On average a familial perpetrator experienced 2.5 mental health issues compared to 1.6 for a perpetrator who was (or had been) an intimate partner.

72. No mental health issues were identified for one third (33%) of intimate partner perpetrators compared to 14% of familial perpetrators and, also showing this, 46% of familial perpetrators had three or more mental health issues identified while this was the case for 21% of intimate partner perpetrators.

Table 30 Perpetrators and number of mental health issues

Number of mental health issues Per cent by type of perpetrator: Familial Per cent by type of perpetrator: Intimate partner Total
0 14% 33% 28%
1 29% 26% 27%
2 11% 20% 17%
3 or more 46% 21% 29%
Number of perpetrators for which data available 28 70 98

Figure 9 Perpetrators and number of mental health issues

73. When the mental health issues are shown individually (Table 31), half of these are: depression, low mood or anxiety, and suicidal thoughts. Following these anxiety, psychosis, and suicide attempts each account for 11 or 10 per cent of the mental health issues. The remaining six mental health issues (adjustment disorder, Dementia or Alzheimer’s, panic attacks, Post-Traumatic Stress Disorder, Self-harm, and “other”) account in total for the remaining 18%.

74. Looking at the three most common mental health issues, there are similar proportions between familial and intimate partner perpetrators with the exception of low mood or anxiety which is higher within intimate partner perpetrators (18% compared to 13% for those familial). The largest difference between these perpetrators is psychosis which is 19% of the mental health issues identified for familial perpetrators and five per cent of intimate partner abuse perpetrators.

Table 31 Mental health issues of perpetrators

Mental health issue Per cent by type of mental health issue: Familial Per cent by type of mental health issue: Intimate partner Total
Adjustment Disorder 0% 1% 1%
Anxiety 10% 11% 11%
Dementia or Alzheimer’s 0% 3% 2%
Depression 19% 19% 19%
Low mood / anxiety 13% 18% 16%
Panic attacks 0% 1% 1%
Psychosis 19% 5% 10%
Post-Traumatic Stress Disorder (PTSD) 1% 3% 2%
Self-harm 7% 4% 5%
Suicidal thoughts 16% 17% 16%
Suicide attempts 9% 11% 10%
Other 6% 7% 7%
Total number of mental health issues 69 115 184

Carer

75. Fourteen per cent of perpetrators were or had been carers, the percentage was the same for both types of perpetrator (intimate partner and familial). Two of the 10 intimate partner perpetrators who were or had been carers were the only perpetrators who had received a carer’s assessment under the Care Act 2014.

Life limiting illness

76. Overall, 14% of perpetrators suffered from any serious or life limiting illness. This was similar for both familial perpetrators (12%) and those in the intimate partner group (15%).

Had the perpetrator abused previous partner/s or family members?

77. Close to half of the perpetrators (46%) had abused previous partner/s or family members (Table 32). The percentage was higher (63%) for familial perpetrators than those who were or had been intimate partners of the victims (38%)[footnote 26].

78. For the 63% (15) of familial perpetrators abuse of previous partners or family members was recorded. For 12 of these the previous abuse included partners or former partners. There were 20 intimate partner perpetrators who were known to have abused previous partners or family members (forming 38% of the 52 where the information was known); in these cases, most (15) were of partners only.

Table 32 Previous abuse of partner/s or family members by perpetrators

Abuse of previous partner/s or family members Familial Intimate partner Total
Yes 63% 38% 46%
No 38% 62% 54%
Number of perpetrators for which data available 24 52 76

Was the perpetrator known to agencies as an abuser?

79. Forty-five per cent of the perpetrators were known to agencies as an abuser, with this being very similar for both intimate partner and familial perpetrators[footnote 27]. Thirty-one per cent of perpetrators were known by one or two types of agency and 13% of perpetrators were known by three or more.

80. The type or area of agency are shown in Table 33. These percentages are from relatively small numbers. From the table the following remarks are made:

  • The Police are the agency most likely to know the perpetrator was an abuser;

  • For familial perpetrators health agencies are the second most likely to know of previous abuse; and

  • For intimate partner perpetrators the second most likely type of agency are those of children’s social care, with health being the third.

Table 33 Agencies to whom perpetrator was known as an abuser

Agencies where perpetrator was known as an abuser: Familial Per cent by type of victim Per cent by type of victim: Intimate partner Total
Adult Social Care 7% 3% 5%
Children’s Social Services 11% 16% 14%
Domestic Abuse Service 4% 9% 7%
Health 21% 10% 14%
Housing 0% 3% 2%
Police 39% 43% 42%
Probation 14% 9% 10%
Other 4% 7% 6%
Total number of agencies with knowledge 28 58 86

Previous offending history

81. Information regarding whether perpetrators had a previous offending history (Table 34) shows the proportion of familial offenders with previous offending history (58%) was greater than intimate partner perpetrators (38%).

Table 34 Previous offending history of perpetrators

Previous offending history Familial Intimate partner Total
Yes 58% 38% 43%
No 42% 63% 57%
Number of perpetrators for which data available 26 64 90

82. The previous offending history sits alongside whether the perpetrator was being supervised or managed by a range of services at the time of the death of the victim (there are differences in the length of time from the previous offence and the type of offence e.g. drink driving). There are differences between the type of perpetrator; 68% of those familial perpetrators being managed or supervised by services, and 36% for intimate partner perpetrators (Table 35).

Table 35 Was perpetrator being managed or supervised?

Managed of supervised Familial Intimate partner Total
Yes 68% 36% 45%
No 32% 64% 55%
Number of perpetrators for which data available 28 70 98

83. The services by which the perpetrators were managed or supervised are shown in Table 36. For both types of perpetrator mental health services are a common factor, though the proportion is greater (65%) for familial perpetrators than those intimate partner perpetrators (37%). Probation is engaged with the second highest proportion for both types of perpetrator; the differences here are that Probation managed 31% of the services for intimate partner perpetrators and 17% of those for familial perpetrators. Drug and alcohol services are the third most common and, as with those for Probation the proportions are greater for intimate partner perpetrators (20%) than for those familial perpetrators (13%).

Table 36 Services perpetrator managed by, supervised or attending

Perpetrator managed or supervised by or attending a service Per cent by type of perpetrator: Familial Per cent by type of perpetrator: Intimate partner Total
Attend Perpetrator Programme 4% 3% 3%
Drug and Alcohol 13% 20% 17%
Multi-agency public protection arrangements (MAPPA) 0% 9% 5%
Mental Health 65% 37% 48%
National Probation 17% 31% 26%
Total services 23 35 58

Method of killing

84. Where the method of killing has been noted, stabbing with a knife is related to close to half (47%) of the victims’ deaths (Table 37). For familial victims the second most common (23%) is blunt force trauma. Where the perpetrators were or had been intimate partners of the victims the second most common method of killing (22%) was strangulation.

Table 37 Method of killing

Method of killing Per cent by type of perpetrator: Familial Per cent by type of perpetrator: Intimate partner Total
Blunt Force trauma 23% 12% 15%
Fire Arm 3% 7% 6%
Stabbing with a knife 52% 45% 47%
Strangulation 6% 22% 17%
Other 16% 15% 14%
Number of deaths for which data available 31 74 105

Notes: the number of deaths here is larger than the number of victims (of familial or intimate partner perpetrators as there are instances where more than one method of killing has been given).

Court verdict and sentence

85. Information recording Court verdicts is given in Table 38. Where the perpetrators were or had been intimate partners of the victims murder was the most common verdict (58%) with manslaughter being the second (22%). Where the perpetrators had a familial relationship with the victim manslaughter was the most common verdict (45%) and the second was diminished responsibility (33%) with murder being the third most frequent verdict (21%).

Table 38 Court verdicts

Court verdict Per cent by type of perpetrator: Familial Per cent by type of perpetrator: Intimate partner Total
Diminished responsibility 33% 15% 22%
Manslaughter 45% 22% 30%
Murder 21% 58% 45%
Other 0% 5% 3%
Number of court verdicts for which data available 33 59 92

Homicide followed by perpetrator suicide

86. Fifteen of the perpetrators took their own lives after the murder of the victim. Of these 14 were intimate partner perpetrators. The average age (of all) was 57 years old. Six were aged over 65 years old).

6. Family contributions and support through the Domestic Homicide Reviews process

88. The Multi-Agency Statutory Guidance for Domestic Homicide Reviews (2016)[footnote 28] sets out the importance of contributions and engagement with family, friends, work colleagues, neighbours, and the wider community. The management information report (MRI) requested with the DHRs included questions to record family contributions to the review process.

Did the family contribute to the DHR?

89. Family (and friends) contributions were made in 82% of all the 158 DHRs. The proportion who contributed where the relationship between the victim and perpetrator had been familial was slightly lower at 74%.

90. An example from a DHR is given below of engagement with families.

The review panel considered which family members, friends, and members of the community should be consulted and involved in the review process. XXX’s family all lived in Poland and following advice and guidance from AAFDA (Advocacy After Fatal Domestic Abuse) the independent chair wrote to them providing information about the review and inviting them to contribute. All correspondence was translated into Polish, including the AAFDA leaflet to include in the correspondence. However, the family declined to engage stating they would find the process too painful. The panel were also made aware of friends XXX worked with. Four were written to and one of these decided to contribute. The information provided by this friend was invaluable in providing context and gaining some understanding of the relationship between XXX and YYY in the last months of her life. The Panel were extremely grateful to her and recognise how difficult this was for her.

Were the family consulted about the terms of reference?

91. In 73% of the DHRs the family were consulted about the terms of reference for the Review. As with the family contributions, it was a smaller percentage (59%) for familial DHRs.

Did the family have the support of an expert specialist advocate?

92. The information requested from the DHRs asked whether the family had the support of an expert specialist advocate. In 54% of the of the DHRs an offer had been made. Of the 156 DHRs where information was given the 64% was: 49% where an offer was made and taken up and 15% where an offer was made but not taken up.

93. The proportion taken up was lower (35%) where the DHRs were reviewing where the victims had died by suicide.

Did the family receive the draft report to comment on?

94. Families were sent draft reports on which to comment for 74% of the DHRs, and this was similar for all three types of DHR.

Did the family attend the DHR panel?

95. Families attended DHR panels in 14% of the Reviews. This varied between 22% of the familial DHRs to 9% where the victim died by suicide.

Appendix 1. Questions in Management Information Reports

Guidance or definition given with some questions are placed at the end of the Appendix. The form uses the following abbreviations:

CSP Community Safety Partnership
DHR Domestic Homicide Review
PTSD Post-Traumatic Stress Disorder
MAPPA Multi-Agency Public Protection Arrangements
MARAC Multi-Agency Risk Assessment Conference

PLEASE MARK EACH BOX: IF QUESTION IS NOT APPLICABLE PLEASE STATE: N/A IF ANSWER IS NOT KNOWN PLEASE STATE THIS OR PUT: N/K

Name of Community Safety Partnership

Local Authority

Police Force Area

Date of death

Location of death

Is location victim’s home address? (Y, N or N/K)

Review Panel Chair

Review Author

Date Home Office notified of DHR

Local DHR Reference

Date report completed by author

Date signed off by CSP Board

Date submitted to Home Office by CSP Board

Home Office Reference Number given for report

1. Victim/s

Victim 1 Victim 2 Victim 3
Sex of victim/s      
Age at time of death      
Relationship to perpetrator      
Ethnicity      
Nationality      
Is or was the victim a Carer? (Y, N or N/K)      
If Yes, had they had a Carer’s Assessment under the Care Act? (Y, N or N/K)      

Vulnerabilities. Please mark (e.g. X) for ALL that apply

Victim 1 Victim 2 Victim 3
Illicit Drug Use      
Mental Ill-Health      
Physical Disability      
Pregnancy      
Problem Alcohol Use      
Other - Please state      

Mental health Issue/s identified in the DHR. Please mark ‘X’ for ALL that apply

Victim 1 Victim 2 Victim 3
Adjustment Disorder      
Anxiety      
Dementia or Alzheimer’s disease      
Depression      
Low mood / anxiety      
Panic attacks      
Psychosis      
PTSD      
Self-harm      
Suicidal thoughts      
Suicide attempt/s      
Not specified (please state)      
Any serious or life limiting illness? (Y, N or N/K)      
If Yes please describe      
Has the victim been a target of an abuser before? (Y, N or N/K)      
if Yes please state by whom?      

2. Perpetrator/s

Perpetrator 1 Perpetrator 2
Sex of perpetrator    
Age at time of death    
Relationship to victim/s    
Ethnicity    
Nationality    
Is or was the perpetrator a Carer? (Y, N or N/K) If YES state for whom they were a carer?    
If Yes, had they had a Carer’s Assessment under the Care Act? (Y, N or N/K)    

Vulnerabilities. Please mark (e.g. X) for ALL that apply

Perpetrator 1 Perpetrator 2
Illicit Drug Use    
Mental Ill-Health    
Physical Disability    
Problem Alcohol Use    
Other - Please state    

Mental health Issue/s identified in the DHR. Please mark ‘X’ for ALL that apply

Perpetrator 1 Perpetrator 2
Adjustment Disorder    
Anxiety    
Dementia or Alzheimer’s disease    
Depression    
Low mood / anxiety    
Panic attacks    
Psychosis    
PTSD    
Self-harm    
Suicidal thoughts    
Suicide attempt/s    
Not specified (please state)    
Any serious or life limiting illness? (Y, N or N/K)    
If Yes please describe    
Had the perpetrator abused previous partner/s or family member before? (Y, N or N/K)    
If Yes please state who the victim was    
Was the perpetrator known to agencies as an abuser? (Y, N or N/K)    
If Yes please state which agencies    
Has the perpetrator any previous offending history? (Y, N or N/K)    
If Yes please state offences committed    

Was the perpetrator being managed or supervised by, or attending any of the following? Please mark (e.g. X) for ALL that apply

Perpetrator 1 Perpetrator 2
Attending or had attended a Perpetrator Programme    
Drug and Alcohol Services    
MAPPA    
Mental Health Services    
National Probation    

3. Crime details, MARAC and Outcome of Trial

Y, N, N/K
Had the victim been referred to MARAC? (Y, N or N/K)  
Was the case heard at MARAC before the homicide? (Y, N or N/K)  

Method of killing. If relevant please state weapon used

Y, N, N/K
Blunt Force trauma  
Fire Arm  
Stabbing Knife  
Strangulation  
Other, please state  
Cause of death - results from Post-Mortem  

Details of Court verdict. Please mark (e.g. X) for ALL that apply

Y, N, N/K
Murder  
Manslaughter  
Diminished responsibility  
Unfit to Plead  
Not Guilty  
Details of sentence/s AND sentence tariff/s  

4. Details, if reviewing suicide or murder / suicide

Y or N
Is DHR reviewing a murder and suicide? (Y or N)    

If DHR is reviewing a death by suicide, please answer the following about the Person who took their life by Suicide
Sex and Age of deceased    
Method of suicide    
Is the suicide by the perpetrator who is responsible for the victim’s homicide? (Y, N, N/K)    

5. Aggravating factors

Aggravating factors in DHR. Please mark (e.g. X) for ALL that apply

Coercive control  
Digital Stalking  
Forced Marriage  
Honour Based Violence  
Financial Abuse  
Immigration issues (V if relevant for victim and / or P if relevant for perpetrator)  
Physical stalking  

6. Details of children if relevant (0-18yrs)

Child/Children’s details
Were there any children living, or regularly staying in the household? (Y, N or N/K)  
Were children present when the homicide occurred?  
If YES, please give sex of child/ren  
If YES, please give age of child/ren  
Were children subject to Child Protection procedures due to Domestic Abuse prior to the homicide? (Y, N or N/K)  
Any children removed into Care of Local Authority? (Y, N or N/K)  

7. Family contribution and support though DHR process

Y, N or N/K
Did the family contribute to the DHR? (Y, N or N/K)
If answer is N, please comment  
Were the family consulted about the terms of reference? (Y, N or N/K)  
If answer is N, please comment  
Did the family have the support of an expert specialist advocate? (Y, N or N/K)  
If answer is Y, please specify  
Did the family receive the draft report to comment on? (Y, N or N/K)  
If answer is N, please comment  
Did the family attend the DHR panel? (Y, N or N/K)  
If answer is N, please comment  

For Ethnicity (Office for National Statistics)

White

1. English/Welsh/Scottish/Northern Irish/British

2. Irish

3. Gypsy or Irish Traveller

4. Any other White background, please describe

Mixed/Multiple ethnic groups

5. White and Black Caribbean

6. White and Black African

7. White and Asian

8. Any other Mixed/Multiple ethnic background, please describe

Asian/Asian British

9. Indian

10. Pakistani

11. Bangladeshi

12. Chinese

13. Any other Asian background, please describe

Black/ African/Caribbean/Black British

14. African

15. Caribbean

16. Any other Black/African/Caribbean background, please describe

Other ethnic group

17. Arab

18. Any other ethnic group, please describe

Notes given in the form, next to relevant questions

  • Ethnicity: please use codes / descriptions given at foot of the form.

  • Carer: the definition of a carer in this context refers to an adult or young person who is caring for someone due to their health and social care needs. This includes mental health as well as physical health support, which would entitle the carer to a Carer’s Assessment under the Care Act 2014. The Children and Families Act 2014 also includes duties for the assessment of young carers and parent carers of children under 18.

  • Physical disability: a person is considered to have a disability if they have a long- standing illness, disability or impairment which causes difficulty with day-to-day activities (Equality Act 2010).

  • Life-limiting illness is a term used to describe an incurable condition that will shorten a person’s life, though they may continue to live active lives for many years. There is a wide range of life-limiting illnesses, including heart failure, lung disease, neurological conditions, such as Parkinson’s and Multiple Sclerosis, and cancer that is no longer responding to treatment intended to cure. stclarehospice.org.uk/what-does-that-mean/

  • Details of sentence/s AND sentence tariff/s: i.e. Guilty of Murder, Manslaughter, or Manslaughter Diminished Responsibility etc, then the sentence tariff i.e. minimum 25yrs, Hospital Order with Restriction etc.

Glossary

Acronyms Full description
CSP Community Safety Partnership
DA Partnership Domestic Abuse Partnership
DHR Domestic Homicide Review
DNA Did not attend
HMICFRS His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services
MARAC Multi-Agency Risk Assessment Conference
MIR Management Information Report
N/A Not applicable
N/K Not known
ONS Office for National Statistics
PTSD Post-Traumatic Stress Disorder

  1. Home Office (no date) Criteria for considering Domestic Homicide Review reports https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/207602/cri teria-DHR-web-v2.pdf [Accessed 25th July 2024] ↩

  2. References in this report to 2022/23 refer to these twelve months - October 2022 to the end of September 2023 ↩

  3. Potter, R. (2022), Key findings from analysis of domestic homicide reviews, https://www.gov.uk/government/publications/key-findings-from-analysis-of-domestic-homicide-reviews/key- findings-from-analysis-of-domestic-homicide-reviews [Accessed 25th July 2024] ↩

  4. Potter, R. (2022), Domestic homicide reviews, quantitative analysis of domestic homicide reviews October 2020 - September 2021, https://www.gov.uk/government/publications/key-findings-from-analysis-of- domestic-homicide-reviews [Accessed 25th July 2024] ↩

  5. Information on two people who were second perpetrators in two DHRs has also been excluded. Their relationships with the victims were described as “Friend of ex-husband” and “Known to each other”. The information on the other perpetrators in these two “intimate partner” DHRs is carried through this report. ↩

  6. Home Office (2016) Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, from paragraph 13, page 7 and paragraph 18, page 8. Source: https://www.gov.uk/government/publications/revised-statutory-guidance-for-the-conduct-of-domestic- homicide-reviews [Accessed 25th July 2024] ↩

  7. The term “Domestic Homicide” is used in this report to include victims who have died by suicide. ↩

  8. Appendix 1 shows the Management Information Report. ↩

  9. As given by the Institute for Government (2022) Timeline of UK government coronavirus lockdowns and restrictions, https://www.instituteforgovernment.org.uk/data-visualisation/timeline-coronavirus-lockdowns [Accessed 12th August 2024] ↩

  10. In the forms some questions are asked to indicate Y, N or N/K. ↩

  11. With refence to victims who died by suicide the Guidance states : “18. Where a victim took their own life (suicide) and the circumstances give rise to concern, for example it emerges that there was coercive controlling behaviour in the relationship, a review should be undertaken, even if a suspect is not charged with an offence or they are tried and acquitted. Reviews are not about who is culpable” Home Office (2016, page 8) Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews https://assets.publishing.service.gov.uk/media/5a80be88e5274a2e87dbb923/DHR-Statutory-Guidance- 161206.pdf [Accessed 24th July 2024] ↩

  12. Referenced in footnotes 3 and 4 ↩

  13. “In 2022, there were 5,642 suicides registered in England and Wales (10.7 deaths per 100,000 people); this is consistent with 2021 (5,583 deaths; 10.7 per 100,000).” (Office for National Statistics, 2022, Suicides in England and Wales: 2021 registrations, page 2 Office for National Statistics (2023) Suicides in England and Wales: 2022 registrations: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesi ntheunitedkingdom/2022registrations [Accessed 7th March 2024] ↩

  14. The next section gives more information on the categories into which the DHRS were place. ↩

  15. Information on relationship with a perpetrator (in a homicide) is not given where the victim has died by suicide. ↩

  16. The average ages here for familial and intimate partner victims are means. The average of familial victims is given by median as there were two victims aged under 10. ↩

  17. Department of Health (2013) Guidance for health professionals on domestic violence Department of Health (2013) https://www.gov.uk/government/publications/guidance-for-health-professionals-on-domestic- violence [Accessed 13th August 2024] ↩

  18. Office for National Statistics (ONS), released 9 February 2023 (page 20), Homicide in England and Wales: year ending March 2023, https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/homicideinenglandandwale s/yearendingmarch2023 [Accessed 25th July 2024] ↩

  19. The question in the MIR does not give an exact definition of nationality. ↩

  20. Office for National Statistics (2020) National identity, England and Wales: Census 2021, https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/bulletins/nationalidentityengl andandwales/census2021#national-identities-in-england-and-wales [Accessed 11th August 2024] ↩

  21. A locally held meeting where statutory and voluntary agency representatives share information about people at high risk of harm due to domestic abuse. Any agency can refer an adult or child they believe to be at high risk of harm. The aim of the meeting is to produce a co-ordinated action plan to increase an adult or child’s safety, health and well-being. Agencies that attend vary, but are likely to include the police, probation, health and housing services (available through HMICFRS (2023) Multi-agency risk assessment conference (MARAC) https://hmicfrs.justiceinspectorates.gov.uk/glossary/multi-agency-risk-assessment-conference/ [Accessed 5th August 2024]. ↩

  22. This question is whether the victim has been abused before the current perpetrator and therefore has experienced abuse from more than one perpetrator. ↩

  23. The information here is for 90 victims from the newer forms where financial abuse was an option for an answer. ↩

  24. Information on perpetrators is not used from four DHRs where the perpetrators were either not charged or found not guilty. ↩

  25. With the exception that the vulnerability of pregnancy is not asked for. ↩

  26. Both these percentages exclude the answers given as Not Known (N/K). If it was assumed that where N/K was indicated then the answer was N, the percentages for “Yes” became lower. For family members it changed to 54% and for intimate partner perpetrators it became 29%. ↩

  27. With the similarity being that 44% of familial perpetrators were known to agencies as an abuser and 45% of intimate partner perpetrators. ↩

  28. Home Office (2016) Domestic homicide reviews: statutory guidance https://www.gov.uk/government/publications/revised-statutory-guidance-for-the-conduct-of-domestic- homicide-reviews [Accessed 13th August 2024] ↩

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