DARDR / SAR Susan (2024)

This joint Domestic Homicide Review (DHR) and Safeguarding Adults Review (SAR) was published in May 2024 and examines the circumstances surrounding the death of Susan, aged 26, who tragically died by suicide in July 2020 after moving from Scotland to Salford to escape domestic abuse.

The review explores Susan’s long history of mental health difficulties, adverse childhood experiences, and repeated disclosures of abuse by her partner, alongside the challenges posed by cross-border information sharing and the Covid-19 pandemic.

Key learning themes include:

• 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
• 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.

These lessons aim to strengthen safeguarding responses and prevent similar tragedies in the future.

DHR and SAR in the case of Susan final report (PDF, 571kb)

Feedback letter from the Home Office in the case of Susan (PDF, 132kb)