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Abstract

This paper aims to contribute to the prevention of future domestic homicide by analysing 141 domestic homicide reviews (DHRs) in England and Wales. All publicly available DHRs (n = 141) were retrieved from Community Safety Partnership websites in England and Wales in June 2016. Utilising a mixed methods approach, we designed templates to extract quantitative and qualitative data from DHRs. Descriptive statistics were generated by SPSS. 54 DHRs were analysed qualitatively, using N‐Vivo for data management. The findings revealed that perpetrators were aged: 16–82 years; with a mean average age of 41 years. Victims’ ages ranged from 17 to 91 years old; with a mean average age: 45 years. Perpetrators’ mental health was mentioned in 65% of DHRs; 49% of perpetrators had a mental health diagnosis. Healthcare services, in particular, mental health services, were most likely to be involved with perpetrators. ‘Movement’ was identified as a key contextual feature of the 54 DHRs analysed qualitatively and this was found to interact with risk assessment, language barriers and housing problems. In conclusion, domestic violence and abuse risk assessments need to be informed by the knowledge that domestic abuse occurs across the age span. Mental health settings offer an opportunity for intervention to prevent domestic homicide. Domestic Homicide Reviews can provide valuable material for training practitioners.
Health Soc Care Community. 2020;28:485–493. wileyonlinelibrary.com/journal/hsc  
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© 2019 John Wiley & Sons Ltd
1 | INTRODUCTION
Multi‐agency approaches to reviewing and extracting learning
from domestic homicides are now operating in a number of ju
risdictions including the United States, Canada, Australia, New
Zealand, Portugal and England and Wales (Bugeja, Dawson,
McIntyre, & Walsh, 2015). The repor ts produced from these re
views offer an oppor tunit y to identify risk and other contextual
factors for domestic homicide and to critically examine interac
tions between victims, perpetrators and other family members
and a range of agencies and professionals. This study draws on the
largest sample of domestic homicide reviews (DHRs) in England
and Wales analysed to date to identif y a broad set of characteris
tics of vic tims and perpetrators. The findings have the potential to
inform prevention strategies and practice in this field.
In England and Wales, the Homicide Index showed there
were 726 homicides in the year ending March 2018 (Office of
National St atistics, 2019a). Whilst the figures for this period
showed an increase on previous years, the homicide rate for the
year ending March 2018 was broadly similar to the homicide
rate ten years ago (ibid). The Office of National Statistics (ONS)
analysed 432 domestic homicides in England and Wales from
Received:17July2019 
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  Accepted :30Septe mber2019
DOI : 10.1111 /hs c.1 2881
ORIGINAL ARTICLE
Learning from domestic homicide reviews in England and
Wales
KhatidjaChantlerBSc,PhD |RachelRobbinsBA,MA,PhD |VictoriaBakerBA,MA |
NickyStanleyBA,MA,MSc,CQSW
School of Social Work, Care a nd
Community, Univer sity of Central
Lancashire, Connect Centre for International
Research on Interpersonal Violence,
Preston, UK
Correspondence
Khatidja Chantl er, School of S ocial Work ,
Care and Community, Univer sity of Central
Lancashire, Connect Centre for International
Research on Interpersonal Violence, Eden
Building 219, Preston PR1 2HE, Lancashire,
England.
Email: kchantler@uclan.ac.uk
Abstract
This paper aims to contribute to the prevention of future domestic homicide by ana‐
lysing 141 domestic homicide reviews (DHRs) in England and Wales. All publicly avail‐
able DHRs (n = 141) were retrieved from Community Safety Partnership websites in
England and Wales in June 2016. Utilising a mixed methods approach, we designed
templates to extract quantitative and qualitative data from DHRs. Descriptive statis
tics were generated by SPSS. 54 DHRs were analysed qualitatively, using N‐Vivo for
data management. The findings revealed that perpetrators were aged: 16–82 years;
with a mean average age of 41 years. Victims’ ages ranged from 17 to 91 years old;
with a mean average age: 45 years. Perpetrators’ mental health was mentioned in
65% of DHRs; 49% of perpetrators had a mental health diagnosis. Healthcare ser‐
vices, in particular, mental health services, were most likely to be involved with per‐
petrators. ‘Movement’ was identified as a key contextual feature of the 54 DHRs
analysed qualitatively and this was found to interact with risk assessment, language
barriers and housing problems. In conclusion, domestic violence and abuse risk as‐
sessments need to be informed by the knowledge that domestic abuse occurs across
the age span. Mental health settings offer an opportunity for intervention to prevent
domestic homicide. Domestic Homicide Reviews can provide valuable material for
training practitioners.
KEY WORDS
age, domestic homicide, ethnicity, gender, mental health, review
486 
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2013 to 2015. The majority (97%) of domestic homicide victims
were female, killed by a male suspect; with over three‐quarters
(77%) of female domestic homicide victims killed by a partner/
ex‐partner and 23% killed by a family member (ONS, 2016).
Domestic homicide is frequently the culmination of a pattern of
domestic violence and abuse (DVA) over time in intimate part
ner and other familial relationships (Dobash, Dobash, Wilson,
& Daly, 1992). Although a relatively rare event, the devastation
inflicted on surviving family members makes it incumbent to
learn from DHRs.
2 | DOMESTICHOMICIDEREVIEWS
In England and Wales, multi‐agency fora known as Community
Safety Partnerships (CSPs) have responsibilit y at a local level to
produce crime reduction strategies. Section 9 of the Domestic
Violence, Crime and Victims Act 2004, was implemented in 2011
and requires CSPs to undertake a multi‐agency review after a
domestic homicide and to produce a DHR. The terms of refer
ence of DHRs are stipulated by the Home Office (Home Office,
2016a, 2018) and, in England and Wales, the definition of domes
tic homicide embraces both intimate partner homicides and family
homicides for those aged over 16 years (ibid). The review process
involves obtaining written reports from agencies who had con
tact with either the perpetrator and/or the victim to identif y the
nature of contact, any assessments made in relation to DVA, sup
port offered or referral to another agency. It also involves talking
to family and friends, as they may have additional knowledge not
available to professionals.
DHRs aim to identify lessons that can be learned to prevent
future domestic homicide. However, as CSPs are locality based,
learning from outside the local area c an be hard to consolidate.
Some regions have already begun analysing clusters of local DHRs
and such studies are informative and illuminate local learning
points. The Home Office conducted two swif t analyses of DHRs
in 2013 (54 DHRs) and in 2016 (40 DHRs). Recommendations
from both studies included: increased training for healthcare pro
fessionals; improved risk assessment and improved responses to
those with complex needs; better record keeping and missed op
portunities for safeguarding children were also identified (Home
Office, 2013, 2016a). Neville and Sanders‐McDonagh (2014) un
dertook an in‐depth analysis of 13 DHRs in the West Midlands,
England, supplemented by eight stakeholder interviews. Risk
assessment, the use of MARAC (Multi‐Agency Risk Assessment
Conferences) and information sharing were highlighted in their
analysis. Sharps‐Jeffrey and Kelly (2016) analysed 32 DHR s from
across England. The six most common themes found were: contact
with a GP, mental health, safeguarding adults, safeguarding chil
dren, informal networks and risk assessment. Monckton‐Smith,
Szymanska, and Haile (2017) used media reports and DHRs to
identif y risk and found that stalking behaviours were present in
94% of cases analysed.
3 | AIMS
The aims of the study were to:
To investigate the characteristics of victims and perpetrators of
domestic homicides
To analyse the relationship characteristics of victims and perpetrators
• To investigate whether informal support and/or formal agencies
knew of domestic violence and abuse prior to the homicide
• To identify contextual elements of domestic homicide
A separate paper has been published with findings relating to families
with children under 18 so these will not be discussed in detail here
(Stanley, Chantler, & Robbins, 2019).
4 | METHODS
All available DHRs from the 322 CSP websites in England and Wales
were retrieved in July 2016. These are public documents and resulted
in 141 DHRs published between July 2011 and June 2016. No ethical
approval was sought as the documents are in the public domain and
anonymised. Drawing on existing literature, a data extraction template
was constructed and refined with use. All DHRs were then read in their
entirety, capturing data on variables relating to victim and perpetrator
characteristics, relationship characteristics and history, risk factors for
abuse, agency responses and notes recording context were made. Data
were then further coded and entered on to an SPSS database. Basic
descriptive analyses were performed across all variables to identify
propor tions, frequencies and averages. A fur ther data trawl was car
ried out af ter the initial analysis to capture more det ailed information
What is known about this topic
• Domestic homicide is highly gendered ‐ the vast majority
of victims are women and the vast majority of perpetra‐
tors are men.
Domestic vio lence and abuse is more prevalent in younger
age groups than older age groups.
What this paper adds
Perpetrator mental health is a significant feature in our
dataset and mental health settings provide opportunities
for intervention.
• Domestic homicide occurs across the life course: in older
as well as younger women.
• Qualitative analysis of domestic homicide reviews illumi‐
nate contextual features of domestic homicides such as
constant movement within, to or from the country, the
inabilit y to move due to a lack of housing options and a
lack of appropriate interpretation arrangements.
    
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CHANTL ER ET AL.
regarding mental and physical health, housing and financial difficulties,
immigration status, and DVA assessments. In relation to mental health,
DHRs were scanned for mention of mental he alth issues with diagnoses
by a general practitioner (GP) or other mental health practitioner also
captured. Mental health was categorised according to the main disorder
types within the DSM‐IV‐TR (American Psychiatric Association, 2000).
A qualitative analysis of a subset of all DHRs involving families
with children under 18 (n = 54) was also undertaken, enabling identi
fication of further themes through an interpretative reading of sec
tions of text across the 54 DHRs (see Stanley et al., 2019). This paper
addresses victim and perpetrator profiles; mental health; character
istics of relationships; service and family awareness of DVA, based
on 141 DHRs. Contextual features reported, particularly the theme
of ‘movement’, draw on the qualitative analysis undertaken on the
subset of 54 DHRs involving families with children under 18 years.
4.1 | Findingsperpetratorandvictimrelationships
Intimate relationships, including former partners, accounted for
77% of all cases (see Figure 1 below). Perpetrators of domestic
homicide were most often the husbands or ex‐husbands of vic
tims (38%), followed by partners/boyfriends (36%) and sons (19%).
In most cases (62%), the instigating factor for homicide was not
cited. In the 38% of cases where it was cited, leaving or ending
the relationship accounted for 29 cases (21%). Family homicides
represented 23% of cases, mostly taking the form of sons commit
ting matricide (19%). For both intimate partner and non‐partner
domestic homicide, the gendered pattern is clear.
4.2 | Victimandperpetratorprofiles
4.2.1 | Gender
In 141 DHRs, 81% of victims of domestic homicide were female; 19%
were male; 86% of perpetrators were male and 14% female.
4.2.2 | Age
Victims ranged in age from 17 and 91 years, with a mean average
age of 45 (taken from primar y victim where there are multiple vic‐
tims). Perpetrators ranged in age from 16 to 82 years, with a mean of
41 years. Frequencies are presented in Figure 2.
Data in respect of age was missing for just under a quarter of
victims (n = 35) and just over a third of perpetrators (n = 48). Despite
missing data, the mean figure from our analysis concurs with the
ONS analysis of domestic homicides.
4.2.3 | Ethnicit y
Ethnicit y data was available for just over a half of victims and perpetra
tors (72 victims and 74 perpetrators) of domestic homicide. Missing
data means that findings regarding ethnicity need to be treated cau‐
tiously as it may be the case that ethnicity is largely recorded where
victims or perpetrators a re visibly different from the white Brit ish pop
ulation, thus victims and perpetrators from other ethnicities may be
falsely over represented in the DHR data set. Bearing this in mind, the
majorit y of victims and perpetrators (54% and 49%, respectively) were
white British. White Europeans formed the second largest category of
victims (14%), followed by Black Caribbean and Black African (11%);
South Asian (10%); Middle Eastern (8%), and other ethnicities (3%). In
relation to perpetrators, White British (49%) was followed by Black
African and African Caribbean (14%); White European (14%); Middle
Eastern (12%); South Asian (6%) and those of mixed ethnicity (4%).
4.3 | Riskindicators
DHRs identified potential risk indicators in victims which may have
heightened vulnerability to victimisation but which might also be
understood as a consequence of DVA: mental health difficulties
(29%), physical health difficulties (29%), alcohol (25%) and housing
problems (16%). Just over a quarter (26%) also had a prior history
of DVA, largely as victims but were also identified as perpetrators
in a few cases. Perpetrators’ histories revealed a range of potential
risk indic ators which may have enhanced risk of perpetrating DVA.
The single largest category was previous violent behaviour (70%),
followed by mental health problems (64%), alcohol problems (48%),
drug problems (37%) and physical health problems (18%). Prior to
FIGURE 1 Relationship to Victim, gender and relationship type
[Colour figure can be viewed at wileyonlinelibrary.com]
FIGURE 2 Age of victims and perpetrators [Colour figure can be
viewed at wileyonlinelibrary.com]
19
22
17 19
12
18
34
18
23
16
20
88
48
0
10
20
30
40
50
60
16 to 25 26 to 35 36 to 45 46 to 55 56 to 65 66+Unspecified
Victims Perpetrators
488 
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   CHANTLER ET AL.
the homicide, a third (33%) of perpetrators had allegations against
them of physical violence to a previous partner and nearly a third
(32%) had allegations of prior violence against the victim themselves.
These findings align with Dobash's and Dobash's (2015) homicide
findings regarding the importance of a history of previous DVA.
Of the potential risk indicators identified above, mental health is
discussed in more detail below.
4.4 | Mentalhealth
Perpetrators’ mental health was a striking feature in our dat aset.
18% of victims and 49% of perpetrators had diagnosed mental
health problems. Figure 3 below illustrates the frequencies of men‐
tal health diagnosis of both victims and perpetrators.
Mood and anxiety disorders formed the bulk of mental health
diagnoses. Victims experienced: depression, anxiety, psychosis
and personality disorders, with depression and anxiety being the
most commonly reported. Nearly two‐thirds (64%) of victims with
a diagnosis experienced more than one disorder – either consec
utively over the life course or concurrently. Perpetrators’ mental
health problems were further complicated by the presence of sub
stance misuse, with just under a quarter (23%) of perpetrators ex
periencing both drug misuse and mental health problems, and just
over a quarter (26%) experiencing both alcohol misuse and mental
health problems. A proportion of homicides (13%) were carried out
by individuals experiencing episodes of acute mental health diffi
culty, who were later placed under hospital orders. Manslaughter
with diminished responsibility accounted for 18% of convictions.
4.5 | Serviceinvolvementandawareness
In half (50%) of the cases, suppor t agencies such as the police
(47%), health (25%), housing (12%), educ ation (5%), children's
social care (15%), adult social care (4%) and domestic violence
organisations (10%) were aware that DVA was present within
the victim‐perpetrator relationship. An awareness of this did
not automatically result in a ser vice to victims. Table 1 shows
which services provided direct services to either victims or
perpetrators and highlight s the high levels of health service
involvement. Perpetrators were often in receipt of mental
health services, but also received services for their physical
health and substance misuse. Housing support services were
involved with nearly a fifth of all victims whilst specialist DVA
services were provided to only 10% and only 9% were provided
with services by Multi‐Agency Risk Assessment Conference
(MARACs) which should assess all high risk domestic abuse
cases in their locality.
4.6 | Family/friendinvolvementandawareness
In nearly half the cases (45%), victims’ and/or perpetrators’ family
members or friends were aware of DVA within the relationship,
with the remaining DHRs either not mentioning others’ aware
ness (17%) or stating that neither family nor friends knew of any
abuse (38%). This level of awareness is close to the 50% of cases
where professional support services were aware of DVA. In total,
DVA was known to either family/friends or professional services
in 64% of cases. The remaining cases (36%), involved relation
ships where either DVA was not a characteristic, it was hidden,
or those who were aware of it were not spoken to by the review
team. Although reported very rarely, only 17 repor ts (12%) re
ferred to victims who received frequent family or peer support,
and this figure was the same for infrequent friend and/or family
support. Only four DHRs (3%) explicitly stated that victims re
ceived no support from friends or family.
FIGURE 3 Mental health diagnoses of domestic homicide
review victims and perpetrators [Colour figure can be viewed at
wileyonlinelibrary.com]
TABLE 1 Services provided to victims and perpetrators
Supportservice Victims Perpetrators
DVA specific services 14 (10%)
Perpetrator programmes 6 (4%)
Police support (e.g. injunctions,
monitoring home)
16 (11%)
Refuge 3 (2%)
Housing support services (any) 26 (18% )
Legal support/advice 12 (9%)
Mental health services 20 (14%) 68 (48%)
Physical health care 56 (40%) 35 (25%)
Education 5 (4%)
Women's Centre 3 (2%)
Substance misuse services 12 (9%) 22 (16%)
Children's Centre services 3 (2%)
Adult social care 9 (6%)
MARAC 13 (9%)
    
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CHANTL ER ET AL.
4.7 | Movement
Among the 54 DHRs analysed qualitatively, the overarching theme
of ‘movement’ was identified in over half the cases (28) where it took
different forms. These included: (a) cases involving migrant s from
the European Union (EU) (n = 5), (b) victims and/or perpetrators from
outside the EU (n = 9), (c) intra‐country movement (n = 7) and (d)
inabilit y to move or having no fixed abode (n = 7). Three key inter‐
linked sub‐themes emerged from this analysis: (a) risk assessment, (b)
language barriers, (c) housing problems.
4.8 | Riskassessment
Improving risk assessment was discussed in most DHRs where
movement was identified. Within the full dataset of 141 cases,
just over a third (35%) had been assessed using a DVA assessment
tool, rating cases at the following risk levels: standard/low (23%),
medium (16%), high (9%) or ver y high (2%). A ssessments were in
frequently referred to (MAR AC), with only 13 cases (9%) receiving
support through MARAC . Of those cases where DVA was known
to services, nearly half of victims (48%) had not received a formal
DVA risk assessment at the time of the victim's death.
DHR134 illustrates key dimensions found in several other
cases. The case involved an Eastern European couple who had
been in a 12‐year relationship and had a 10‐year‐old child. There
had been t wo recorded serious assault s on the victim by her part
ner prior to the homicide. On both occasions, the perpetrator left
the country after each of the assaults but returned later. The per
petrator made threats to kill his partner which were reported to
Children's Social Care (CSC) by the child. The family were referred
to the local MARAC after the first assault, but not the second. The
victim was abducted by her par tner and her dead body was found
in Eastern Europe a couple of months later. The DHR stated:
None of the agencies asked [the victim] about her life
in [Eastern Europe] prior to moving to [name of town
in the UK]. It was as though her life had begun on the
day she arrived in the UK . Had the police or children’s
social care sought information about [the victim’s] life
in [Eastern Europe] they would have learnt that there
had been a series of incidents prior to her arrival in the
UK. This information would have informed their risk as
sessments. (DHR134, p. 46, Overview Report)
This highlights the value of enquiring into the pattern of the rela
tionship rather than dealing with assaults on an incident by incident
basis. Furthermore, this DHR identified a lack of police knowledge of
computer systems between the Police National Database and the UK
Border Agency database. Perpetrators may cross borders to evade de
tection and information sharing may need to take place across interna
tional as well as organisational boundaries.
The issue of movement was central in this case. Once the perpetra
tor left the countr y, it was assumed that the victim was safe and so no
adequate protection was put in place should her abusive partner return
to the UK: No agency considered a contingency plan should the ex‐hus
band return, even though that was an established pattern (DHR134, p. 8,
Executive Summar y). The temporar y absence and movement of the per
petrator obscured the potential for his return and to inflict fur ther harm.
4.9 | Languagebarriers
DHRs 043, 134 and 120 involved Eastern European migrants with
limited/no English language. In DHR 134, an Independent Domestic
Violence Advocate (IDVA) with a shared linguistic background was
allocated to the victim, but it is unclear how other agencies inter
acted with the victim. The victim had contacted all the relevant
authorities but there were discrepancies in basic record keeping be
tween agencies. For example, her name was spelt in dif ferent ways
by agencies so preventing an overview of her case across agencies
and hampering risk assessment. In DHR 120, good practice was evi
denced as interpreters were used, but the DHR noted a significant
challenge surrounding the dependency on interpreters who may be
unfamiliar with domestic violence or have a different cultural perspec
tive of family violence (DHR120, p. 11, Executive Summary). These
issues were also evident in cases involving migrants from outside
the EU. In one DHR, the couple's 12‐year‐old child and male family
friend were used as interpreters and the DHR states:
There is evidence throughout this review that con
sideration of the family’s linguistic needs were not
taken into account when accessing services as they
should have been. Opportunities to seek a [relevant
language] interpreter were often missed. On many
occasions [the child] was used as an interpreter for his
mother and father, or sometimes a family friend. The
vulnerability of both [the victim] and [her child] was
often not considered or recognised.
(DHR132, p. 7, Executive Summary)
The unsuitability of using children as interpreters is well‐doc
umented in the professional practice literature (Chand, 2005;
Sawrikar, 2015); prompting questions about how and why this prac‐
tice continues. The use of a male family friend as interpreter was also
identified as problematic due to his gender and the cultural inappro‐
priateness of discussing DVA with a male friend of her husband: This
is particularly the case given the gender of the friend who interpreted,
his primary relationship being with [the perpetrator]and the cultural
expectations of him in a domestic violence situation (DHR132, p. 98,
Overview Repor t). These examples highlight the impor tance of using
interpreters trained in DVA with the ability to interpret discussion of
taboo topics.
4.10 | Housingproblems
Housing difficulties were identified for 55% of all victims in the
total sam ple, with nearl y a quarter (22%) ex periencing inc onsistent
490 
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or temporary accommodation and nearly a fifth (18%) experienc
ing homelessness. Just over half (51%) of all perpetrators had
housing difficulties, with nearly a quarter (22%) experiencing in
consistent or temporary accommodation and a quarter (25%) ex
periencing homelessness. Qualitative analysis found that families
characterised by frequent moves and transient living presented
difficulties for services. One DHR described the challenges the
numerous moves of this couple (White British) presented for
professionals:
They had multiple aliases and addresses. The address
chronology suggests that they sometimes moved
back and forth bet ween addresses rather than mov‐
ing from one to the next in a linear fashion. [The al‐
leged perpetrator] had poor literacy levels. All these
factors increased the challenge to professionals in
communicating with them and in identifying and as‐
sessing risk (DHR113, p. 7, Executive Summary)
Some DHRs also identified how change of address contrib‐
uted to a lack of free‐flowing information between local authority,
police and health services areas to enable the continuity of care,
which might have enhanced support and protection. For example,
in DHR060, a married couple with three children moved within one
geographical area in North‐East England five times, then moved to
a city in North‐West England and the victim and the children then
moved from there to temporary accommodation before moving to a
permanent address. The frequent moves spanning different police
force jurisdictions culminated in:
…a request from [Police Force A] to [Police Force B]
to check on the welfare of a vulnerable woman and
her three children did not happen despite [Police
Force A] providing the correct address to [Police
Force B]. …the job was passed between divisions,
the entries on the logs grew and no one spotted
that the ultimate information they were seeking
[the victim’s whereabouts] was recorded at the be
ginning of the entries.
(DHR060, pp. 36–37, Overview Report)
In contrast, a small proportion of couples were unable to
physically separate due to a lack of housing options and were
forced to reside in the same property. One victim's sister stated
that the concept of establishing a separate household within the
home was flawed as it magnified tensions within the relationship
(DHR 027, p. 14, Overview Report). This DHR recommended:
Separation should be seen as a process which can magnify risk fac
tors, not a safety plan in itself. All agencies…, should be advised that
the period around separation‐ especially while a couple still share a
home‐ should be seen as a period of enhanced risk of violence, and
should advise service users accordingly (DHR027, p. 14, Overview
Report).
5 | DISCUSSION
The discussion below addresses four key dimensions: age, ethnicit y,
mental health and movement and considers how they might inform
risk assessment in the field of DVA.
5.1 | Age
Victims’ and perpetrators’ ages ranged from 16 to 91 years with
a mean age of 41 years for perpetrators and 45 years for victims.
Domestic homicide thus occurs across the life course, giving rise to
two key point s about how the age of DVA victims is recorded and
understood. First, in relation to recording, the latest Crime Sur vey
for England & Wales (CSEW) reveals that the prevalence of DVA
is highest for women aged 20–24 compared to older women aged
55–59 (ONS, 2019b). The CSEW cut‐off at 59 is based on the as‐
sumption that women over 60 will be less familiar with the self‐com‐
pletion methodology used for the DVA module but it is problematic
as it acts to exclude older women from this important data set.
Furthermore, in England and Wales, the distinction between DVA
and elder abuse serves to camouflage DVA in older women (Robbins,
Banks, McLaughlin, Bellamy, & Thackray, 2016).
Second, for practitioners, the CSEW figures may suggest that do
mestic homicide is more likely to be experienced by younger women.
Carthy and Taylor (2018) suggest that a service emphasis on DVA in
younger adults may undermine confidence and knowledge of services
in older women and deter help seeking. ONS domestic homicide data
also confirms that female victims over the age of 75 are disproportion
ally represented (13%) compared to their population profile (9%; ONS,
2016). Dobash and Dobash’s (2015) study also highlights the need
for further research on older female victims of domestic homicide.
Comparing DVA and domestic homicide age related data underscores
that DVA and domes tic homicide is experienced across ever y age group
and risk as sessment tools ne ed to reflect exp erience over the life c ourse.
5.2 | Ethnicity
Whilst the propor tion of those from groups other than white British
in our DHR sample may appear high (compared to their population
profiles), this does not necessarily reflect a heightened prevalence
of domestic homicide in minority ethnic groups. Recording of eth
nicity was patchy in DHRs published before 2017 but this should
improve following recent guidance stipulating that this should be
recorded (Home Office, 2018). Further research is necessar y to es‐
tablish the role of ethnicity in domestic homicide. An ONS compari
son of homicides and domestic homicides found that female victims
of domestic homicide were less likely to be White (76% compared
with 86% of female victims of non‐domestic homicide), and more
likely to be Asian (12%, compared with 7% of female non‐domes‐
tic homicide victims; ONS, 2019b). However, caution still needs to
be exercised as illustrated by a recent Norwegian study by Vatner,
Friestad, and Bjorkly (2017). They investigated the over‐representa‐
tion of immigrant victims and perpetrators in Norway over a 12‐year
    
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 491
CHANTL ER ET AL.
period and compared the characteristics of these intimate partner
homicides with the native majority perpetrators of such homicides.
They concluded that other factors such as higher rates of unemploy‐
ment, racism and related social disadvantage may be more salient
than ethnicity. The UK , like Norway, has long standing evidence of
social inequality amongst minority ethnic groups (Cabinet Office,
2017) so an analysis at the intersection of class and ethnicity in do‐
mestic homicide is essential to ascertain whether ethnicity can be
considered an independent variable or risk factor.
5.3 | Mentalhealth
Our finding regarding the high incidence of mental health problems
in perpetrators is surprising given that victims experiencing DVA are
more likely to experience mental health problems related to or exac‐
erbated by experiences of DVA (Howard, 2012). The most common
diagnostic combination identified in perpetrators was co‐morbid
depression and anxiety. The Adult Psychiatric Morbidity Survey
(APMS), reported that one in six people (over the age of 16) surveyed
in England met the criteria for a common mental disorder (CMD) in
2014 (APMS, 2016). APMS (2016; as in previous surveys) found that
women were more likely than men to have reported CMD symp‐
toms. However, what is distinctive in our sample is that many more
men (mainly perpetrators) were diagnosed with common mental dis‐
orders (mood and anxiety disorders) than women (mainly victims).
The high frequency of common mental health disorders related to
perpetration of domestic homicide in our sample needs to be contex
tualised against studies that report on mental health and perpetration
of DVA. Hester, Eisenstadt , Jones, and Morgan (2017) found that 71%
of 48 perpetrators who had completed the Drive perpetrators pro
gramme had mental health issues. Hester et al. (2015) also reported
that DVA is experienced or perpetrated by a large minority of men
presenting to general practice who were more likely to have current
symptoms of depression and anxiety. Oram, Trevillion, Khalifeh, Fed er,
and Howard’s (2013) review found that psychiatric disorders (depres
sion, generalised anxiety disorder and panic disorder) were associated
with high prevalence and increased odds of having ever been physi
cally violent against a partner. Button, Angel, and Sherman (2017) ana
lysed data from Leicestershire's police and found that it was five times
more likely that offenders charged with domestic homicide had prior
suicidal warning markers than did all other offenders. The relationship
between mental health disorders and a history of perpetrating DVA
clearly warrant s further exploration but this study suggests that it may
be an indicator of high risk of perpetration of domestic homicide.
5.4 | Movement
Movement was conceptualised in this study as movement across
borders (migration) with its at tendant issues (e.g. English as a sec
ond language); temporary movement or absence of perpetrators;
movement of information between agencies; frequent and tran
sient housing moves as well as the inability to move due to a lack
of alternative housing. Movement is often a means of escaping DVA
but the knowledge that victims who move can remain at risk from
ex‐partners (Stanley, Miller, Richardson‐Foster, & Thomson, 2011;
Humphreys & Thiara, 2003) does not seem to have informed profes
sional intervention in many of these cases. Movement (or inability to
move) is a factor that could usefully be incorporated into DVA risk
assessment. The theme of ‘movement’ highlights the learning oppor
tunities offered by DHRs and the importance of social contex t for
assessing risk.
6 | L I MITATI O N S
There will have been additional domestic homicides during the study
period, which were not yet published by July 2016 or were with‐
held due to the perceived sensitivity of the case (Bridger, Strang,
Parkinson, & Sherman, 2017). Fur thermore, some information is
deliberately vague in DHRs to preserve the confidentiality of fami
lies. However, we are confident that our analysis in relation to key
demographics map on to the ONS data. Although DHRs are a rich
source of information, they are not produced for research purposes.
Extracting even basic information such as demographic data is often
difficult; understanding the context and dynamics of family relation
ships is complex. The variable quality of DHRs also impacts on what
data can be extracted. DHRs offer genuine opportunities for reflec‐
tion and improving service responses to DVA victims, but there is
always the potential for agencies to protect their own reputations
rather than engage in a process of reflective learning.
The absence of a potential risk factor in a case does not neces‐
sarily mean it was not present. In many of the DHRs, the friends and
families of victims and perpetrators declined to participate, limiting
the identification of risk factors to the service records of victim and
perpetrator interactions and documented disclosures to services.
7 | CONCLUSIONS
The analysis of DHRs of fers huge potential to share the learning
culled from them nationally and potentially internationally. More
precise recording of key characteristics within DHRs would greatly
enhance research and the development of risk assessment models.
Detailed research is required which not only illuminates general pat
terns of domestic homicide, but which also employs a more granular
and finely tuned analysis, in relation to sub‐sets of domestic homi‐
cide victims and perpetrators.
Key findings include perpetrators’ mental health disorders,
housing problems, service responses to victims’ lack of English lan
guage skills and movement across borders and within country. The
research literature is clear about the mental health impac ts of DVA
for victims (Howard, 2012). Our study illustrates the importance of
extending this understanding to perpetrators of domestic homicide
as 49% of perpetrators in our sample had diagnosed mental health
issues, strongly suggesting that mental health services are a prime
setting to discuss DVA with perpetrators. The range of agencies that
492 
|
   CHANTLER ET AL.
victims or perpetrators had contac t with prior to the homicide in‐
dicates potential audiences for disseminating learning from DHRs
which should be aimed at improving identification and risk assess
ment in relation to DVA.
The findings on age should help to inform policy and practice of
the high risk of domestic homicide for older women and have im
plications for adult social care services. The relationship between
ethnicity and domestic homicide requires further research as al
though the propor tions for groups other than White British may
appear high (compared to their population profiles), as has been
argued above this does not necessarily reflect a heightened con
cern. The biggest single risk factor for victimisation is gender as the
majority of domestic homicides victims are women. Our qualitative
analysis of themes such as housing needs, language barriers and
movement across and within national borders begins to provide
information that could inform training on domestic homicide pre
vention for a wide range of services and practitioners. The narra
tive format of DHRs and the detailed, incident‐full stories they tell
make them powerful training tools and their potential to drive and
improve policy and practice in the field of domestic violence and
abuse should be exploited to the full.
ORCID
Khatidja Chantler https://orcid.org/0000‐0001‐9129‐2560
Rachel Robbins https://orcid.org/0000‐0002‐6207‐7703
Victoria Baker https://orcid.org/0000‐0001‐9794‐3344
Nicky Stanley https://orcid.org/0000‐0002‐7644‐1625
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Stanley N. Learning from domestic homicide reviews in
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... Although considerably less prevalent than domestic abuse, the far-reaching and tragic effects of domestic homicide have resulted in it being recognised as a significant public health concern (Loinaz et al., 2017;Rai et al., 2020;Salari & Sillito, 2015). Thus far, multi-agency approaches to reviewing and extracting learning from domestic homicides have proven promising in offering ways to identify risk and other contextual factors for these fatal crimes, as well as examining interactions between those involved and a range of agencies and professionals (Chantler et al., 2019). ...
... DHRs are carried out under Section 9 of the Domestic Violence, Crime and Victims Act (2004) and form a crucial part of the Government's strategy to end violence against women and girls (Home Office, 2016a). The main purpose of DHRs is to identify lessons to be learned from past tragedies, improve service responses to domestic abuse and prevent future homicides from taking place (Benbow et al., 2019;Chantler et al., 2019;Monckton-Smith, 2020). The process of carrying out a DHR involves obtaining written reports from agencies who were in contact with the perpetrator and/or the victim to identify the nature of contact, any assessments made in relation to domestic abuse, the support offered or referrals to other agencies (Chantler et al., 2019). ...
... The main purpose of DHRs is to identify lessons to be learned from past tragedies, improve service responses to domestic abuse and prevent future homicides from taking place (Benbow et al., 2019;Chantler et al., 2019;Monckton-Smith, 2020). The process of carrying out a DHR involves obtaining written reports from agencies who were in contact with the perpetrator and/or the victim to identify the nature of contact, any assessments made in relation to domestic abuse, the support offered or referrals to other agencies (Chantler et al., 2019). This forms a chronology of events, providing evidence of patterns of risk and the ways in which it can escalate (Monckton-Smith, 2020). ...
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... Coercive control, in particular, suppresses victimsurvivors' autonomy, liberty, personhood and dignity. 5 Analyses of hundreds of UK multiagency reviews of death and harm (domestic homicide reviews, safeguarding adults reviews, and serious case reviews) [6][7][8][9][10][11][12][13][14] show that the UK's National Health Service (NHS) has more contact with victims and perpetrators than any other agency or service. [7][8][9][10] One analysis illustrated that the NHS is the most common target for recommendations in domestic homicide reviews. ...
... [7][8][9][10] One analysis illustrated that the NHS is the most common target for recommendations in domestic homicide reviews. 7 A frequently cited failing across these analyses is that healthcare professionals (HCPs) did not properly document [6][7][8][9][10][11][12] and/or share information [6][7][8][9][10][11][12][13][14][15] related to DVA. Resultantly, no front-line professional had the whole picture of risk and no-one responded to the risk. ...
... [7][8][9][10] One analysis illustrated that the NHS is the most common target for recommendations in domestic homicide reviews. 7 A frequently cited failing across these analyses is that healthcare professionals (HCPs) did not properly document [6][7][8][9][10][11][12] and/or share information [6][7][8][9][10][11][12][13][14][15] related to DVA. Resultantly, no front-line professional had the whole picture of risk and no-one responded to the risk. ...
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... Victims of AFH are often older than intimate partner homicide victims (Benbow et al, 2018;Chantler et al, 2020). Older men are at lower risk than women of domestic homicide and are more likely to be murdered by a son/grandson than their spouse/ partner (Heide, 2014;Bows, 2019;Chantler et al, 2020). In these cases men are more at risk from other men. ...
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... A second question relates to the level of detail and timeframe for "looking back" required for review purposes whilst providing maximum anonymity to the family involved. Chantler et al. (2020) found that the quality of DVFR/DHRs varied in England and Wales and that the timeframe for reviews differed despite having common terms of reference. In the US and in Canada, privacy laws restrict what information agencies can provide to the review team Websdale, 2020). ...
... For relevant organizations to utilize the learning from DVFR/DHRs, access to the published reports is necessary. UK studies (Benbow et al., 2019;Chantler et al., 2020) suggest that DVFR/DHR reports should be readily accessible for research and subject to regular review so that learning from DVFR/DHRs is maximized. The difficulties in obtaining DVFR/DHRs in England and Wales for research purposes has been documented (Benbow et al., 2019;Bridger et al., 2017;Sharps-Jeff & Kelly, 2016). ...
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... DHRs are not undertaken specifically for research purposes, nor are DHR reports produced with this goal in mind (Chantler et al, 2020). Nevertheless, DHR reports are potentially a rich data source, individually and in aggregate. ...
... One re-occurring theme, related to the focus of this article, is the quality and content of DHR reports (Home Office, 2016a; Stanley et al, 2019). Concerns include, for example, the problematic recording of ethnicity data (Benbow et al, 2019;Chantler et al, 2020). Reflecting this, a systematic review examining 11 DHR/ DVFR studies reported a common recommendation for standardised data collection (Jones et al, 2022). ...
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... The link between IPA and substance use has yet to be fully deciphered Radcliffe et al., 2019). A recent analysis of domestic homicide reviews in England (of which 77% were intimate partners) found that nearly half (49%) of domestic homicide perpetrators experienced both drug or alcohol misuse and mental health problems (Chantler et al., 2019). ...
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... To date, the literature has primarily considered DHR case profiles, notably case circumstances, as well as the learning and recommendations produced (Chantler et al., 2020;Home Office, 2016a;Sharp-Jeffs & Kelly, 2016). DHR data have also been used to explore the experience of specific cohorts, including the experience of children (Stanley et al., 2019) and older people (Benbow et al., 2019). ...
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In England and Wales, Domestic Homicide Reviews (DHRs) examine domestic abuse-related deaths to identify lessons to be learned. However, their emergence as a policy initiative has been little considered. To address this gap, a thematic discourse analysis of policy documents to 2011 was undertaken, examining the justification for, and conceptualization of, DHRs before their implementation. It is argued that DHRs were constructed as a taken-for-granted good, through which multi-agency partners would generate learning while the (gendered) subject was silenced. Attending to aspirations, contradictions, and tensions in the emergence of DHRs has implications for their understanding and operationalization in the present.
... While limited, research on older people's experiences of domestic abuse (Wydall, Zerk & Newman, 2015;SafeLives, 2016) and findings from services for older victims of domestic abuse (Solace Women's Aid, 2016) have drawn attention to the fact that the most common type of perpetrator in domestic abuse against older people is not an intimate partner but an adult child (primarily a son). Emerging research into domestic homicides and domestic homicide reviews also indicates that when a domestic homicide involving family members occurs, it is most often the murder of a parent (Chantler et al., 2019;Montique, 2019;Bates et al., 2021). ...
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Parricide is underresearched in the UK, and the contexts of this gendered form of violence are poorly understood. Heide’s typology provides an advanced understanding of parricide in the United States, where the majority of parent-killings involve firearms. This article develops a UK-based analysis of the contexts of parricide, combining national statistics with police case study data ( n = 57) and case review data ( n = 21). Our findings indicate that mental illness plays a key role, combined with a gendered context of “parental proximity” and the simultaneous responsibilization and marginalization of parent-victims (particularly mothers), supporting the need for feminist analyses of parricide.
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