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Review highlights importance of routine enquiry and persistent follow-up due to hidden nature of domestic abuse and mental health

A Domestic Homicide Review*(DHR) into the death of Sarah (pseudonym) has today been published by the Norfolk Community Safety Partnership (NCSP) to enable lessons to be learned and shared as widely and thoroughly as possible to reduce the risk of such tragedies happening in the future.

Sarah took her own life in May 2021. She had endured a lifetime of domestic abuse, including physical, mental, financial abuse and coercive control. The learning coming from the review highlighted that:

  • agencies need to ensure staff can recognise and respond to domestic abuse;
  • there are opportunities to strengthen safety planning for those who self-harm or are suicidal; and
  • where agencies signpost victims, best practice is to follow up.

The review identified a number of potential links to self-harming behaviour including adverse childhood experience, alcohol as a feature of impulsive overdoses and menopause as a potential risk factor.

Primary and secondary healthcare also identified opportunities to streamline the referral pathway to secondary mental healthcare.

The review recommendations respond to these learning points through reviewing and updating domestic abuse policy and training, particularly around recognising and responding to the signs of domestic abuse; improving primary care’s ability to recognise and safety plan for suicidal patients; ensure those who self-harm are in receipt of appropriate care and support; and responding to suicide risk factors, including the menopause and alcohol misuse. The Partnership has developed an action plan to deliver on all the recommendations detailed in the report appendices and will continue to be progressed by the partnership.

Mark Stokes, Chair of the Norfolk Community Safety Partnership said: “The Domestic Homicide Review Panel and the members of the Norfolk Community Safety Partnership would like to offer their sincere condolences to Sarah’s family and friends.

This review has been undertaken in order that lessons can be learned and shared from this tragedy - we appreciate the information provided by Sarah’s family and a close friend who were able to shine a light on her life.

Sarah’s life course makes the impact of abuse on mental health all too clear. We must learn from this case by increasing our understanding of the complex yet clear relationship between domestic abuse and mental health.”

The full Domestic Homicide Review report into the death of Sarah can be found here: www.norfolk-pcc.gov.uk/who-we-are/community-safety-partnership/domestic-homicide-reviews-dhrs/published-domestic-homicide-reviews/

*A Domestic Homicide Review (DHR) is a locally conducted, multi-agency 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 relative, partner or member of the same household. DHRs were established on a statutory basis by the Domestic Violence, Crime and Victims Act 2004.

A DHR panel consists of key members of staff from statutory, non-statutory, third sector and charitable agencies who provide support for victims of domestic abuse. Working together in this way will ensure the voice of the victim is addressed through the lessons learnt and recommendations of this DHR.

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