Recommendations - Domestic Homicides and Suspected Victim Suicides 2021-2022
Recommendation 1 [to the police and partners]: Whilst it is not possible to identify and confirm trends like seasonality within a small two-year dataset, the limited data available so far does indicate the possibility of an elevated risk of suicide amongst domestic abuse victims in the Christmas and New Year period. When carrying out domestic abuse communications campaigns in the Christmas and New Year period, forces and partners consider signposting to suicide prevention services as well as domestic abuse support
Recommendation 2 [to the police]: We recommend that forces routinely review the ‘problem profile’ of their domestic abuse and domestic homicide cases, including identifying cases of adult family violence and intimate partner violence. Within the appropriate local structures for reviewing domestic abuse (e.g., Vulnerability Boards, local domestic abuse partnerships), forces should review what interventions best match their problem profiles, including prevention approaches. The problem profile and matching intervention plans could be included as part of Homicide Prevention Strategies, where those exist locally.
Recommendation 3 [to the Government and police]: Building on the recommendation in our Year 1 report, investigation is still needed into whether the overall number of domestic homicide suspects who were previously being managed by police or probation (e.g., under MAPPA, IOM or DRIVE) is actually as low as reported to this Project. If it is, further discussion may be needed between the police and government about what can be done to strengthen monitoring and disruption of these individuals.
Recommendation 4 [to the police]: Forces should ensure that all potentially dangerous domestic abuse perpetrators who sit outside MAPPA arrangements are identified and managed in line with the College of Policing guidance, ‘Identification, assessment and management of serial or potentially dangerous domestic abuse and stalking perpetrators’.
Recommendation 5 [to DHR Panels]: All professionals involved in DHRs must take personal responsibility to ensure the victim is treated with care, respect and dignity, with their voice and perspective centre stage. This means attention to details such as: checking that their name is spelled correctly (and avoiding replicating others’ errors) and ensuring that only relevant details of the victim’s life are focused on, and that their lifestyle or vulnerabilities are not used to victim-blame, or allowed to overshadow the abuse.
Recommendation 6: [to DHR Chairs / DHR Panels / Government]: Bereaved families should be given the opportunity to contribute to the DHR from the outset, and to ensure that the victim’s voice and perspective are central to the review. The Home Office Statutory Guidance on DHRs clearly sets this expectation, but it seems that this may not always be well implemented in practice. DHR Chairs and Panels should ensure that they are following the Guidance closely in involving families.
Recommendation 7 [to the police and their partners]: The police and partner agencies should be made aware of an elevated risk of both intimate partner homicide and of victim suicide where coercive or controlling behaviour (CCB) is present. Frontline and supervisory officers and safeguarding/vulnerable victim units should consider referrals to suicide prevention interventions in setting safeguarding actions when CCB is identified.
Recommendation 8 [to the police]: There should be a continued push within policing to identify, record and take positive action where coercive or controlling behaviour (CCB) is identified. This might involve forces reviewing their recording rates for CCB as part of their own crime auditing processes.
Recommendation 9 [to the College of Policing]: We recommend that the College of Policing, in consultation with the Home Office and NPCC develop training to directly address the evidential issues experienced in domestic abuse cases where suicide and/or coercive or controlling behaviour is identified.
Recommendation 10 [to this Project]: We recommend that this Project, in Year 3, conduct further work to understand the profile and implications of caring relationships in domestic homicides (both suspect to victim, and victim to suspect).
Recommendation 11 [to the police and their partners]: The police and partner agencies should consider ways to improve data sharing across compatible systems to facilitate communication and coordination that may help identify domestic abuse and risk within the context of adult family relationships.
Recommendation 12 [to the Government and health agencies]: We recommend that, in developing local and national suicide prevention activities, health agencies should consult domestic abuse specialists to ensure that appropriate measures relating to domestic abuse victims are included. At a local level, Local Health Partnerships should consider the risk of suicide following domestic abuse in their suicide prevention strategies. At a national level, the Department for Health and Social Care should ensure that domestic abuse is reflected in national suicide prevention strategies.
Recommendation 13 [to the National Police Chiefs’ Council]: We recommend that the National Police Chiefs’ Council (NPCC) explore with Coroners whether there is scope for standardising police unexpected death investigations (previously ‘sudden death investigations’). This might include exploring whether unexpected death reports (previously ‘sudden death reports’) could be standardised across force areas, something that forces from our deep dives welcomed.
Recommendation 14 [to the police]: We recommend that initial police enquiries in unexpected deaths or suspected victim suicides should: (1) record all persons present in the household at the time of the death; (2) record any known history of domestic abuse associated with the victim, address or persons present in the household at the time of the death; and (3) contact close associates and others who may have information material to a history of domestic abuse, including family, friends and neighbours. Any relevant information uncovered about domestic abuse could be included in the ‘circumstances of death’ section in the death report to Coroners.
Recommendation 15 [to the police]: When attending the scene of an unexpected death or suspected suicide, police must always apply professional curiosity and an investigative mindset to test the obvious explanation. Attending officers should be alert to any signs or disclosures of a history of domestic abuse, especially of coercive or controlling behaviour. Forces should develop mechanisms to check that learning is captured from key cases and that the College of Policing’s guidelines for Recognising and Responding to Vulnerability-Related Risks (which focus on professional curiosity) are being implemented effectively. Vulnerability-related risks | College of Policing
Recommendation 16 [to the police]: When there is an unexpected death or suspected suicide, reasonable and prompt system checks should be made for any known history of domestic abuse crimes and non-crime incidents by appropriate officers or staff. Where possible, this should be done prior to the attending officer leaving the scene and/or within initial enquiries. Slower-time searches for domestic abuse history should then be conducted to inform the investigation, for instance on call-handling, intelligence, and public protection systems. Considering that domestic abuse is often not reported to police, these slower-time searches should also consult local partners who may have knowledge of an undisclosed history of domestic abuse, including domestic abuse services.
Recommendation 17 [to the police]: In line with forthcoming guidance from the College of Policing on unexpected deaths, a PIP 3 Senior Investigating Officer (SIO) (minimum detective inspector or police staff equivalent) should be appointed to provide oversight of all unexpected death investigations. This should include providing advice and direction to the officer in the case, reviewing investigations and conclusions. Oversight review should consider any evidence of domestic abuse history.
Recommendation 18 [to the police]: We recommend that police officers should be made aware of the possibility of domestic abuse perpetrators attempting to manipulate the narrative and processes after a death, especially where they are next of kin.
Recommendation 19 [to the police]: We recommend that police forces not already using Real Time Suicide Surveillance (RTSS) systems to share information on suspected and attempted suicides and domestic abuse histories should consider implementing them. Forces already using an RTSS system should consider adding domestic abuse agencies’ data to that system and should review how information from domestic abuse partners can best be used to inform suicide prevention activities.
Recommendation 20 [to the CPS]: We recommend that the CPS include guidance on prosecuting the domestic abuse perpetrator posthumously for controlling or coercive behaviour in cases of suspected victim suicide in its forthcoming refresh of Legal Guidance on Controlling or Coercive Behaviour in an Intimate or Family Relationship. Controlling or Coercive Behaviour in an Intimate or Family Relationship | The Crown Prosecution Service (cps.gov.uk) We further recommend that the CPS review its guidance on Unlawful Act Manslaughter in relation to suspected victim suicides following domestic abuse. Homicide: Murder and Manslaughter | The Crown Prosecution Service (cps.gov.uk)
Recommendation 21 [to the College of Policing]: At present, guidance for police on responding to unexpected deaths and suspected victim suicides where there has been domestic abuse sits across several different documents. We therefore suggest that all the recommendations in this report on responding to unexpected deaths and suspected victim suicides should be considered for inclusion in the appropriate sections of these key policing guidance documents:
- The College of Policing Practical Advice on dealing with sudden and unexpected death Dealing-with-sudden-unexpected-death-(COP)-v1.0.pdf (college.police.uk)
- The College of Policing APP on Initial Investigation Investigation process | College of Policing
- The College of Policing APP on Mental Health which includes a section on Suicide and Bereavement Response Suicide and bereavement response | College of Policing
- The College of Policing APP on Domestic Abuse Domestic abuse | College of Policing
- The Major Crime Investigation Manual 2021 Major-Crime-Investigation-Manual-Nov-2021.pdf (college.police.uk)
- The (forthcoming) College of Policing guidance on Unexpected Deaths
Recommendation 22 [to the College of Policing]: We recommend that the College of Policing should propose to the Domestic Abuse Matters Board that any key learning in this report which is not already in the Domestic Abuse Matters police training programme should be included in the next programme refresh.
Recommendation 22 [to the College of Policing]: We recommend that the College of Policing should propose to the Domestic Abuse Matters Board that any key learning in this report which is not already in the Domestic Abuse Matters police training programme should be included in the next programme refresh.
Recommendation 23 [to this Project]: We recommend that this Project co-ordinate a learning event for police on suicide following domestic abuse to share promising practice from forces, including on initial enquiries in unexpected deaths with a history of domestic abuse, on Real Time Suicide Surveillance, and on pursuing posthumous prosecutions.
Recommendation 24 [to the Home Office]: We recommend the Home Office proceed as quickly as possible to publish their forthcoming refresh of the DHR guidance. This re-issued guidance should reflect the learning on suspected victim suicides presented throughout this report.
Recommendation 25: [to this Project] We recommend that this Project continue to develop and report on suspected victim suicides following domestic abuse in Year 3. The Project should continue to consult with AAFDA and bereaved families to inform this work