*Trigger warning, this blog focuses on a report which talks about homicide, domestic abuse, and suicide. Please only read if you feel safe to do so.*

For almost 15 years, when an individual has sadly lost their life at the hands of a relative or partner, this has been followed by a process called a Domestic Homicide Review (DHR).

Reviews seek to identify whether anything could have been done differently by the professionals involved before the death to prevent it from happening, and whether additional safeguards can be put in place to minimise the risk to others in similar situations.

A DHR occurs every time someone dies either directly because of domestic abuse (which includes a death caused by the person’s child, provided that child was over 16 at the time) or by suicide, where there is evidence that domestic abuse contributed towards the death.

But Domestic Abuse Commissioner Dame Nicole Jacobs has raised a number of serious concerns about how effective DHRs are, releasing a Learning from Loss report with a number of findings she has labelled as ‘stark and concerning’.

The report looks at all DHRs at a whole, whether the case relates to an intimate partner or familial homicide – but, if the changes proposed by the Commissioner are implemented, they will undoubtedly have an impact in tragic cases where an individual is killed by their child.

Thanks to Dr Amanda Holt’s research, we know there are approximately 19 such deaths (referred to as familial homicides, or more specifically parricide) in England and Wales every year.

The report states:

The findings of the report were that families faced an average of a three-year wait for the conclusion of a review. And even once recommendations had been issued, some were never acted upon or had to be ‘abandoned by local agencies because of a lack of resource or guidance’.

Despite calls from campaigners, implementing action plans has remained a local responsibility and – even where recommendations have been shared with the Home Office or other national bodies – it is unclear if and how they have been actioned. This means there is no collective understanding of how action plans have been completed and what impact this has had on preventing future harm.



Better identification of deaths relating to domestic abuse, and the inclusion from 2016 of domestic-related suicides, means there are more DHRs than ever (an increase of 23% between 2020 and 2023) – but there has been little done to change the process or provide more resources to allow effective management of this rise in review numbers.

Additionally, while one of the aims of the review process is to reduce the number of domestic-related deaths, it is challenging to evidence this – especially due to the inability to establish a causal link between review recommendations and a reduction in deaths or harm.

The Commissioner’s pilot:

The pilot detailed within the report aimed to test the best way for DHRs to be overseen nationally by the Commissioner, considering elements such as resourcing, sharing of best practice, supporting escalation of identified issues, and the co-ordination of reviews locally. Two different models were tested by 20 areas over a 12-month period, with data gathered and analysis undertaken around the implementation of recommendations and completion of actions, as well as further information about the reason behind incomplete or abandoned actions.

A number of improvements were identified as being needed across the core areas of multi-agency working, enhancing assessments, managing information, developing practice, training staff, and policy and process. It has now been recommended that a second 12-month pilot take place to further develop a ‘local and national accountability and oversight mechanism’, alongside the development of bespoke AI-enabled technology to collect, analyse and share the vast amounts of data involved in DHRs. Additionally, the report states more resources should be allocated to the Commissioner’s Office so local areas and the Government can be held to account.

At PEGS, we welcome the effort being put into improving the effectiveness of DHRs, to ensure all recommendations which could reduce future risk are put into place, that best practice is shared, and that actions are put in place nationally where needed. We hope to see the Commissioner’s plans become a reality, leading to more joined-up thinking locally and nationally.

Our thoughts are with all of those impacted by domestic-related homicide, we will always remember the very real people behind the statistics and data.