Domestic Homicide Reviews : Is there any learning from Serious Case Reviews?


This blog will look at some of the lessons learned from Serious Case Reviews much of which could be transferrable learning for the individuals and agencies who may find themselves organising and participating in Domestic Homicide Reviews.

 “Serious case reviews present a lasting testimony and memorial to children who die in horrific circumstances. This must be remembered in the deliberations about learning from these reviews.”


It is with a heavy heart that I note the increased number of areas conducting Domestic Homicide Reviews[i], not because of the process per se but the inevitable precursive tragedy.

Many Community Safety Partnerships, Multi Agency Risk Assessment Conferences (MARACs) and Domestic Abuse Forums are at the beginning of their journey in conducting these reviews, although some have conducted reviews on a voluntary basis for some time.

The Local Government Group and its members are doing a great job in sharing ideas, good practice and lessons learned about how in practical terms to conduct a review here, here and here (registration required).

 The purpose of a Domestic Homicide Review (DHR) is to:

  • Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
  • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
  • Apply these lessons to service responses including changes to policies and procedures as appropriate; and
  • Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.

Sadly, many DHRs will run alongside a Serious Case Review[ii] (SCR). Unlike DHR which were required by stature from 13 April 2011, SCR legislation has been in effect since 1 April 2006.

Although these procedures have fundamental differences in terms of their purpose, they also have striking similarities.

This blog will look at some of the lessons learned from SCRs much of which could be transferrable learning to the agencies who could find themselves participating in DHRs. I hope this will provide some food for thought which might avoid circumstances where a DHR is required.

“Serious case reviews present a lasting testimony and memorial to children who die in horrific circumstances. This must be remembered in the deliberations about learning from these reviews.”

Department of Education Research

Research has been commissioned every two years into SCR to provide an overview of themes and trends across England.

This blog will look at the reviews notified April 2005 – March 2007 and April 2007 – March 2009 (ie covering the period of the Local Safeguarding Children Boards Regulations 2006)

Building on the Learning from Serious Case Reviews (covering period 2007-2009 and reflection of two previous biennial reviews)

Key Learning from 3 biennial reviews (coving 2003 – 2009) 

  • The prime purpose of a serious case review is to learn lessons to improve the ways in which individuals and agencies work to safeguard and promote the welfare of children. The newly revised Working Together (HM Government 2010) emphasised that this is about individual and collective working (not just about working together) and that the lessons need to be acted upon quickly. The understanding of the child and his or her daily life experiences should be at the centre of the review and the learning. Serious case reviews are not enquiries into how the child died or was seriously harmed, and are not part of disciplinary processes.
  • The incident that prompts a serious case review is not always prompted by poor practice. Children can die even when practitioners have acted in an exemplary fashion.
  • Scoping of reviews needs to be managed carefully so that it is possible to make sense of the child and his or her circumstances and services offered within a current and a historical family context. Some areas kept the scoping timescale brief and manageable, but captured good information about the child and family through a succinct summary of early family history or a „light touch. chronology.
  • Family involvement was often common practice and learning from the child death overview processes was helpful in normalising this. Reasons for not involving family members mostly revolved around delay prompted by ongoing court proceedings and family sensitivities. 
  • Practitioner involvement: None of the practitioners interviewed felt adequately involved in the SCR process or its subsequent learning. This did not help the lasting distress practitioners experience when involved with families where children die through abuse. 
  • Embedding the learning in practice was taken seriously. Examples of positive practice in monitoring recommendations and making them achievable were given. Dissemination of learning included briefing seminars, training events, newsletters and bulletins or brief reports outlining key issues.

Some Facts and Figures

  • There was a 43% increase in the number of deaths, and a 111% rise in the number of serious harm cases, which were the subject of a serious case review between 2003-05 and 2007-09
  • The substantial growth in the number of reviews arguably diverts funds from operational services that can protect children. It has to be asked whether this is now beginning to outweigh the benefits to be gained from the learning
  • Domestic violence, substance misuse, mental health problems and neglect were frequent factors in the families backgrounds, and the combination of these factors is particularly toxic. The incidence of these risk factors is likely to be under recorded in the notifications

 The Serious Case Review Process

  •  There was substantial variation in style and content of the published executive summaries. While some contained full information, others provided very little detail about the specific case, withholding even basic information on gender, age or other characteristics. While providing minimal information protects anonymity, on the other hand it can limit wider access to the learning from an individual case.
  • Some cases did not proceed to serious case review following notification. There was inconsistency in the decision making. Reasons for decisions not to proceed with serious case review included:
    • Not meeting criteria/threshold  for review
    • Insufficient information
    • Alternative methods of review proposed
    • Concerns about media, publicity and problems of timing

The full report can be viewed here

Understanding Serious Case Reviews and their Impact (covering 2005-2007)

Key Findings and Learning Points 

  • The chaotic behaviour in families was often mirrored in professionals’ thinking and actions. Many families and professionals were overwhelmed by having too many problems to face and too much to achieve. These circumstances contributed to the child being lost or unseen. The capacity to understand the ways in which children are at risk of harm is complex and requires clear thinking. Practitioners, who are overwhelmed, not just by the volume of work but also by its nature, may not be able to do even the simple things well. Good support, supervision and a fully staffed workforce is crucial.
  • The local overview reports often provided insufficient information to achieve a clear understanding of the case and the incident which led to the child being harmed or killed. Information about men was very often missing and in many reviews so was information about the child. Service provision and inter-agency working cannot be fully understood in isolation from a full analysis of the case and of the agencies’ capacity and organisational climate.
  • Reluctant parental co-operation and multiple moves meant that many children went off the radar of professionals. However, good parental engagement sometimes masked risks of harm to the child.” 

Some Facts and Figures

  •  high levels of current or past domestic violence and / or parental mental ill health and / or parental substance misuse, often in combination, were apparent.
  • Where children were aged 0-5 physical assault was the major cause of death and most older adolescents died through suicide
  • There was a dearth of information about men in most serious case reviews; failure to take fathers and other men connected to the families into account in assessments; rigid thinking about father figures as all good or all bad; and the perceived threat posed by men to workers
  • Unrealistic expectations were sometimes placed on staff with low level generic child care qualifications working in health (and social care and education) and early intervention services to prevent neglect and abuse

 The Serious Case Review Process

  •  Most overview reports failed to provide enough information to achieve a clear understanding of the case and the incident which led to the child being harmed or killed. The focus on interagency working often meant there was little detail about the child, about the parents’ past and very little about men in these families
  • the serious case review documentation included little about the agencies’ context and ‘climate’ and their capacity to safeguard children effectively
  • Only two of the 106 reviews undertaken in 2005-2006 were completed within the required four month time scale.
  • A positive Local Safeguarding Children Board (LSCB) media strategy helped to avoid defensive responses to media interest.

 The full report can be viewed here

[i] A “domestic homicide review” means a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by(a) a person to whom he was related or with whom he was or had been in an intimate personal relationship, or (b) a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.

 [ii] “Serious case reviews are local enquiries into the death or serious injury of a child where abuse or neglect are known or suspected.”  Brandon et al (2007) Case Reviews and their Impact

One thought on “Domestic Homicide Reviews : Is there any learning from Serious Case Reviews?

  1. Pingback: Domestic Homicide Reviews : Is there any learning from Serious Case Reviews Pt II? | Crimematters for Crime Matters

Leave a Reply

Your email address will not be published. Required fields are marked *