A joint Domestic Homicide Review (DHR) and Safeguarding Adults Review into the death of Doris (pseudonym) has been published today by the Norfolk Community Safety Partnership and the Norfolk Safeguarding Adults Board, to enable lessons to be learned and shared as widely as possible to safeguard victims in the future.

Doris was in her eighties when she was killed by her lodger, Chris (pseudonym), in 2021.  The review examines the agency contact with Doris and the perpetrator in the months prior to her death.

Natalie Cowland, independent chair for NSAB, said:

'On behalf of members of the Norfolk Safeguarding Adults Board I would like to offer our sincere condolences to Doris's family and friends for their loss.  Words cannot fully capture the pain and grief caused by this, and our thoughts remain with those whose lives have been forever changed.  

I would like to reiterate the value that Doris's family and friends input played in gaining an understanding about Doris and her life and to identifying areas of improvement in safeguarding practice.  NSAB and its partners accept the recommendations and are committed to using the lessons to make improvements in the way services work together.'

Click here to read the full report

Executive summary

The learning and recommendations from the review highlight themes around:

• listening to families when concerns are raised
• recognising coercive control and the links to cuckooing
• informed risk assessment
• professional curiosity
• mental capacity assessment
• recording and sharing information between agencies
• improved training to recognise all forms of domestic abuse

The review recommendations form a multi-agency action plan that is overseen by NSCP and NSAB to ensure that the lessons and recommendations are actioned, embedded and shared widely to support and drive changes in practice.

Training is delivered through regular webinars across the partnership and a dedicated professional's portal to continue to raise awareness and understanding among practitioners to safeguard and protect future life.