Domestic Abuse Related Death Reviews (DARDRs)

This DARDR identified the following learning themes:

• The need for greater professional curiosity and trauma-informed practice
• Improved routine and selective enquiry in health settings, and better understanding of post-separation abuse risks
• The strong links between domestic abuse, mental health, and suicidality
• The importance of timely multi-agency communication
• The role of employers in supporting staff affected by abuse.

This DARDR identified the following learning themes:

• The need for stronger professional curiosity
• Routine enquiry in health and social care settings
• Improved recognition of links between domestic abuse and criminal/sexual exploitation
• Better multi-agency coordination when victims relocate for safety.
• Gaps in safeguarding responses for individuals with complex vulnerabilities
• The importance of robust risk management for high-risk perpetrators, and the role of employers in identifying and supporting staff affected by abuse.

This DARDR identified the following learning themes:

• Missed opportunities to assess Susan as an adult with care and support needs
• The absence of trauma-informed practice
• Insufficient recognition of the links between domestic abuse and suicidality, and gaps in multi-agency coordination across national boundaries
• The need for improved understanding of post-separation abuse, robust referral pathways to specialist domestic abuse services, and consistent application of ‘Think Family’ principles.

This DARDR identified the following learning themes:

• Missed opportunities for routine enquiry into domestic abuse
• A lack of recognition of adolescent-to-parent violence
• Gaps in multi-agency safeguarding processes
• Barriers that prevented Steven from seeking help—such as stigma, cultural norms, and housing insecurity.

This DARDR identified the following learning themes:

• The need for proactive risk assessment
• Recognition of increased danger at separation
• Improved multi-agency information sharing, and stronger links between domestic abuse, mental health, and substance misuse.

This DARDR identified the following learning themes:

• Gaps in practitioners’ understanding of domestic abuse beyond intimate relationships
• Failure to apply the Mental Capacity Act in the context of fluctuating capacity
• Insufficient multi-agency coordination—particularly around housing options and risk management
• The need to improve safeguarding responses for adults with complex needs
• Trauma-informed practice
• Better integration of housing and health services
• Enhanced training on coercion, control, and alcohol-related vulnerabilities to prevent similar tragedies.

This DARDR identified the following learning themes:

• Professional recognition of the risks associated with separation from an abusive partner
• Missed opportunities to make routine and targetted enquiries into possible domestic abuse
• Missed opportunities to refer to specialist domestic abuse services
• Coercion and control and the support needed to challenge abusive behaviours and the normalisation of these .

This DARDR identified the following learning themes:

• The consideration of a co-ordinated multi-agency approach with one single lead professional contacting the adult, to avoid overwhelm
• Utilisation of family engagement and advocacy when an adult refuses to engage or act in their best interests
• Adverse Childhood Experiences ('ACEs') for children witnessing parental domestic abuse
• Multi-agency information sharing
• Consistent consideration of informing adults at risk from partners via the Domestic Violence Disclosure Scheme
• Using a 'whole family' approach to risk management