Domestic Homicide Review Case 17 – Feedback Letter

Sam Peterson
Service Development Manager (Domestic Abuse & Homicide) Communities Team,
Devon County Council
County Hall,
Topsham Road,
Exeter, Devon

31 October 2022

Dear Sam,

Thank you for submitting the Domestic Homicide Review (DHR) report ‘(Louise)’ for the Devon Community Safety Partnership (CSP) to the Home Office Quality Assurance (QA) Panel. The report was considered at the QA Panel meeting on 28th September. I apologise for the delay in responding to you.

The QA Panel felt the review appears to have sought a range of input from family, friends and the perpetrator’s ex-partners. It is positive to see condolences provided by the author to the family as is the recognition of the perpetrator’s economic abuse of Louise and ex-partners.

The DHR Panel membership is appropriate in relation to the individual case and the required knowledge and expertise. The potential involvement of all appropriate agencies is fully explored, and details given as to why where they are excluded. The overview report brings together all of the elements from overall conclusions taken from the information and analysis contained within the individual management reviews (IMRs) and any other information commissioned from relevant interests. It is clear why the information presented in the review is relevant to the homicide.

There was good use of research in the report, including on the risk of homicide related to non-fatal strangulation and Dr Jane Monckton-Smith’s Intimate Partner Femicide Timelines and there was a good recommendation around Gynaecology Department working with the Health Independent Domestic Violence Advisor (IDVA) to ensure that all staff are confident in asking a direct question about domestic abuse.

The QA Panel felt that there are some aspects of the report which may benefit from further revision, but the Home Office is content that on completion of these changes, the DHR may be published.

Areas for final development:

  • The DHR took almost three years to complete. The three-month delay in changing the chair / report author is noted but there is insufficient
    explanation as to the other delays including the delay in informing the victim’s family.
  • Please consider selecting a pseudonym for the perpetrator as it does not help to contribute to the narrative that domestic abuse perpetrators are nothing more than their abuse.
  • Please further anonymise the report by removing the exact data of death and removing the age and sex of the children.
  • Please clarify if the victim’s family contributed to the terms of reference and / or if they were invited to meet with the panel.
  • The executive summary states that friends of the perpetrator participated in the DHR, but the main report designates them as ex-partners. Given that the perpetrator abused them, it is unlikely they would categorise themselves as his friends.
  • Page 3 appears to be unnecessary given that the information is repeated on the following page. Similarly, Section 1.6 is repeating information included elsewhere in the report.
  • Please clarify whether the victim’s ex-husband gave his permission for his private medical information to be shared. if this is not the case, please consider redacting this.
  • The report would have been easier to read with a genogram at the beginning explaining something about the children Louise had. It was somewhat confusing who the children were, how many she had, etc.
  • The Equality and Diversity section was insufficiently addressed and was not inclusive or reflective of the nine protected characteristics for either Louise (the victim) or the perpetrator.•
  • Acronyms should be given in full on first use –e.g., DVDS (3.1.12), CSC (page 20), PNH (page 21), SW (page 25), SPOC (, – there are a lot of acronyms used which does make the report more challenging for the lay reader.
  • It’s unnecessary, and could compromise anonymity, to name the company that the victim began to host for (page 16).
  • There was a very pertinent section by the victim’s sister on about how she felt the outcome could have been different for her sister if the police had run his name through the database and identified his history of violence. Disappointingly, this was dismissed by the police. The conclusion of the report contained no recommendations at all for the police. It feels the report writer accepted the police explanation, rather than pushing the police to think creatively about possible solutions. It must have been particularly disheartening that the family’s valid suggestions were dismissed.
  • There was significant exploration of the DA training for Home Start volunteers, but no mention of the DA training that the health visitor had, despite the finding that the health visitor didn’t ask many questions about DA despite many indicators. It would have been helpful to know what training she had, if it was sufficient and to see if a recommendation was needed in this area.
  • For future reference, the terms of reference were assessed as being substandard. They should include clear lines of inquiry (i.e. the questions the DHR will seek to answer) and be tailored to the specific circumstances of this case. The analysis should be undertaken against the key lines of inquiry. There is further detail in the statutory guidance.

Once completed the Home Office would be grateful if you could provide us with a digital copy of the revised final version of the report with all finalised attachments and appendices and the weblink to the site where the report will be published. Please ensure this letter is published alongside the report.

Please send the digital copy and weblink to This is for our own records for future analysis to go towards highlighting best practice and to inform public policy.Please also send a digital copy to the Domestic Abuse Commissioner

On behalf of the QA Panel, I would like to thank you, the report chair and author, and other colleagues for the considerable work that you have put into this review.

Yours sincerely,

Lynne Abrams
Chair of the Home Office DHR Quality Assurance Panel