Learning from Domestic Homicide Reviews: Briefing No. 3

Supported but not safe


This briefing is relevant to individuals who help support vulnerable adults and shares learning from the violent deaths of three women in Devon. All three women were victims of domestic abuse and died in supported housing. The oldest (aged 59) was murdered in 2014 by her son, who was receiving treatment for drug misuse. The youngest (aged 23), took her own life in 2016 while police were investigating her report of past violence by a former partner. The third (aged 32) was murdered in 2018 by her current partner.

Domestic abuse in supported housing

The women lived in supported housing due to their mental or physical health needs. A mental health crisis for the youngest soon after arrival in Devon led to complex engagement with emergency and support services until her death a year later. The two other women both had long term involvement with health, care or housing services but avoided contact due, in the weeks before they were killed.

The 32 year-old and her partner lived in separate supported housing projects with staff on site. Both were receiving community mental health treatment following inpatient stays. During their 6-month relationship she often stayed at his previous placement, where live-in care had been withdrawn due to his aggression. Only after eviction by the housing provider was he found a new placement.

The oldest and youngest women lived in one-bedroom flats with floating housing support. The older one’s son lived with her, concealed from the housing provider, for months before her death. The younger had moved on from a staffed hostel shortly before her community mental health support was disrupted by a vacancy. The housing and care providers included national charities and local independent businesses. Staff were concerned about the victims but unsure how to recognise and respond to domestic abuse.


Residents in specialist housing for vulnerable adults may experience or perpetrate domestic abuse, or be affected by past trauma from it. Abuse may be a factor in disengagement with services. Frontline staff and managers should be alert to this risk and know where to get advice.

…tangled with other problems

The three women had complex life situations, as did the killers, who had both served prison sentences for violence. Misuse of drugs was involved.

A wide range of agencies – at least 11 in each case –provided services to meet identified needs. Staff generally showed compassion and commitment and interventions had some positive impact: for example, emergency responses to self-harm and constructive steps taken with housing support. In the 2018 case, help had been given before the relationship started which had improved the woman’s safety and reduced the risk of the man harming others, but protective factors were eroded as the relationship progressed.

Lack of co-ordination hindered the effectiveness of agencies’ efforts. Some did not seek relevant information or misunderstood others’ roles. For example, a service treating the son’s heroin misuse knew he lived with his mother and called himself her carer but did not recognise her vulnerability to financial exploitation. The housing worker supporting the woman who took her own life had no named mental health contact to consult. At the time of the 2018 death, the two housing providers had no contact with each other. Mental health staff had not alerted the man’s provider to the risk he posed to the woman.


Adults affected by substance misuse and/or mental health problems may also be victims or perpetrators of domestic abuse, perhaps in a relationship with another vulnerable adult. This compounds their problems. To help vulnerable people, taking account of their relationships, staff need to understand how their own contribution fits with that of others, and be aware of triggers that escalate dangerous behaviour.

Collaboration to manage risks is vital

The multi-agency frameworks available to manage risks were not used appropriately. Front line staff working with both victims and perpetrators were unsure of which were relevant or how to refer. Agency expectations, and staff skills in working in a multi-agency context, are as important as formal process. Systems for sharing information were not always effective, so staff sometimes struggled to find out what other agencies were doing. While staff shortages were a contributing factor, joint working can enable better support for vulnerable people despite scarce resources. Communication with relatives was also an issue. Some found it hard to get their concerns heard, or were not informed when they should have been (e.g. of detention under the Mental Health Act).

While sharing information about adults depends on their consent or capacity to decide, it is permitted under various multi-agency frameworks in order to avoid serious harm. Adult safeguarding is a key one, which might have protected the oldest woman, despite her previous reluctance to accept intervention, had any agency triggered it. The youngest woman, a suspected victim of a serious sexual offence, moved home without clarity on how agencies supporting her would work together. Better co-ordination could have helped her feel supported through her mental distress.

Prior to the 2018 killing, mental health staff recognised the risk of domestic abuse and this was discussed at multi-disciplinary internal meetings of those working with the couple. The woman’s housing provider was involved, but the man’s was not, and no advice was sought from the internal safeguarding team, police or domestic abuse agencies. The cross-agency tool for domestic abuse risk assessment, known as a DASH form, was not used at any point.


Multi-agency frameworks such as Safeguarding and MARAC are important in protecting
vulnerable adults: identifying how collaboration can reduce risk; clarifying powers to
share information; adding expertise and recording agreed plans. Front line staff and
their managers need to know when and how to trigger them. Clarity for relatives on how
they can express concerns is also important.

There should be an answer to the question posed by a friend of one of the women: “Who
was looking out for her? Making sure all these agencies coordinated?”

A PDF of this page is available here – Briefing No.3 Supported but not safe