A review of 302 domestic homicides recorded in a seven-year period has found that the majority of those killed had been “hiding in plain sight”, having made contact with the police, health services and other public agencies before their death.
Nicole Jacobs, the government’s independent domestic abuse commissioner for England and Wales, said the findings highlighted an ongoing lack of “political will” at national level to learn from what were often avoidable deaths.
Every domestic homicide of those aged over 16 is subject to a formal review and recommendations are made, but Jacobs said there had been an insufficient analysis of the outcomes by the Home Office and other government departments.
Based on 302 reviews after domestic abuse-related deaths between 2012 and 2019, collated by Manchester Metropolitan University for the commissioner, she said it was clear that lives had been lost where action could have been taken.
Analysis of the cases highlighted the need for the police to be using the same sort of tactics they deploy to tackle organised crime, including surveillance of suspected perpetrators, Jacobs said.
Instead, of the 46 homicide reviews where recommendations had been made at the time of the crime to the criminal justice agencies such as the police or probation service, 52% of victims had been in contact with the police before they were killed.
The analysis also found that 57% of perpetrators had criminal records for abuse offences before murdering their victim.
In the NHS, there is no national formal model for a nurse or doctor to flag that a patient may have suffered from domestic violence, the commissioner said.
Among the 58 reviews where recommendations had been made for the health services, 78% of victims and 69% of perpetrators had been to physical health services such as GPs or hospitals prior to the homicide.
In the worst-case scenario, Jacobs said there could be no follow-up at all of an individual who arrived at hospital with signs of being abused.
“They would think, well, I have no idea what to do”, she said. “And so even though I think this person has been injured, or their medical concern has to do with abuse, it’s in the ‘too hard to do’ box. It’s opening a can of worms that I don’t know what to do anything with.”
Jacobs added: “Even when you’re talking about health discharging, [when] they know there’s been injuries related to domestic abuse, or they’ve had someone, say, within maternity services, who they are really concerned about, there’s still a lot to improve just in the basic kind of discharging to the GP.”
While the frontline services at a local level would collaborate and coordinate following a domestic homicide, the lessons were going unheeded at a national level, it is claimed.
She said: “There needs to be some political will to make sure that some of the things that we know are working well are not so patchwork. Our systems were never built with an understanding of domestic abuse, full stop. So in a way, it’s the systemic changes that we need.
“There’s clearly things that have not happened. You know, for each one of these findings, there will have been a group of people who had loads of detail in front of them, who said: OK, we can acknowledge this was a missed opportunity, that we really missed a key way of reaching out to this person for help.”
On Tuesday, the charity Killing Women erected 106 placards outside parliament representing each of the women killed in the past 12 months.
Jacobs said that in her first meeting with the new home secretary, James Cleverly, she had championed the need for the best practice of some of the 43 police forces in England and Wales to be followed by all.
She said: “[The political will] has been lacking for years. I mean, I don’t put it on any one doorstep of any one politician because domestic abuse is something that we have known for many years is one of the highest crimes reported to the police. And yet we don’t have a consistent response. We don’t have kind of end-to-end, what is excellent practice, what you would expect.”
• This article was amended on 6 December 2023. Owing to an error in the information supplied to us, an earlier version said that the review by the domestic abuse commissioner was of cases from a four-year period (2015-19), rather than a seven-year period (2012-19).
