How can we learn the lessons from DHRs?
This blog was first published by Safelives as part of Spotlight #8: Parenting through domestic abuse.
A Domestic Homicide Review (DHR) is an important part of the coordinated community response, albeit after a tragedy. There are understandable criticisms of DHRs. Why do we invest so much money, time and energy into a case after someone has died? Why do they take so long? What actually changes as a result? These are all good questions, some of which I have wrestled with in other blogs. But perhaps put those questions aside for a moment. Consider instead what a DHR is trying to do. The promise of a DHR is to try and understand the experiences of a victim. In the words of the Statutory Guidance: to ‘articulate the life through the eyes of the victim (and their children)’. That includes talking with, and being guided by, the questions and concerns of family and friends. A DHR is also about learning lessons by considering how professionals and agencies individually or collectively worked together, as well as thinking more generally about responses to domestic abuse including what might help or hinder access to support. And lastly, a DHR should make meaningful recommendations. All this with the goal of bringing about meaningful change and trying to reduce the likelihood of future homicides.
But problems with information sharing are a recurring theme in DHRs. In a 2016 report by the Home Office, communication and information sharing were identified as an issue in 76% (25 out of 33) of the DHRs sampled. For anyone familiar with other kinds of reviews, including those relating to children and adults, that finding won’t be a surprise.
In my experience as a DHR chair, there are two common issues with information sharing. Sometimes information just isn’t shared. During a DHR in Bexley, which considered the death of Nargiza, we found that an agency considered making a Marac referral but for various reasons hadn’t. Consequently, when Nargiza’s case was later heard at a Marac, critical information was missing. It’s not possible to know if that additional information could have changed the ultimate outcome; but it’s fair to say that if it had been available the Marac would have had a starkly different understanding of Nargiza’s experiences, risks and needs.
Other times, information is known but isn’t acted upon. In a DHR in Lambeth, the victim (Sophia) was contacted by Children’s Services as a result of an allegation by her ex-partner. The complaint itself was likely an example of ‘abuse of process’. That wasn’t recognised, in part because Children’s Services took an incident-based approach. But it was also clear that Children’s Services didn’t draw on the information known to other agencies – including the police, a domestic abuse service and schools. That was significant because those other agencies had part of the bigger picture of Sophia’s experiences, as well as the behaviour of the perpetrator. The result was that the case was assessed as low risk and closed.
While these two cases were very different, they have something in common. In the first, information wasn’t shared. In the second, information wasn’t acted on in the way we might have expected. For both Nargiza and Sophia, it meant that their needs (and the risks they faced) were not understood and there were missed opportunities to intervene.
What frustrates me is we keep having the same conversation about information sharing.
Spin those two issues about information sharing on their head for a moment. What happens when a victim doesn’t share information? Or doesn’t act on in information the way we might have expected? All too often, they get blamed. I have seen that in some DHRs which focus on what a victim did or didn’t tell professionals, while others set out what services were offered and then explain that a victim ‘declined to engage’ or ‘didn’t take up support’.
That’s just not good enough. We are holding victims to one standard but often find ways to explain away the same scenario if a professional or an agency does it. Worse than that, even when we recognise that information sharing wasn’t good enough, the lesson doesn’t seem to be getting learned.
Of course, it’s easy for me to write this. There are a whole range of other factors at play, from the role of services through to demand. But frankly, we shouldn’t be having this conversation time and time again. It extracts too great a toll on victims and their loved ones, including those who are murdered.
We need to stop victim blaming, reflect on our own practice, and be open to challenge – whether that comes from service users, other professionals or the families and loved ones of those who have been murdered.
So, what’s my closing thought? Well, ultimately DHRs are about trying to improve the response to domestic abuse and to prevent future homicides. It’s still too difficult to find published DHRs, although the government has committed to building a national repository in its response to the recent consultation on the Domestic Abuse Bill. In the meantime, look at your local or regional Community Safety Partnership website, read the Home Office report I mentioned earlier or check out Standing Together’s DHR Case Analysis.
Ask yourself, which findings are relevant to me or my team or agency? How can I apply the learning, whether that’s in frontline practice or the commissioning of services? We shouldn’t have to keep learning the same lessons. Unfortunately, that’s not going to change overnight. But change it can. To get there – and in doing so, to honour those who have died, hold perpetrators accountable, and hopefully prevent future homicides – each of us needs to play our part in making sure the lessons really are learned.