Domestic Homicide Review Feedback Letter - Sarah

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Ms Alison Sandiford
Bassetlaw, Newark
& Sherwood Community
Safety Partnership
Castle House, Great North Road,
Newark, Notts, NG24 1BY

30 March 2023

Dear Ms Sandiford,

Thank you for submitting the Domestic Homicide Review (DHR) report for Bassetlaw, Newark & Sherwood Community Safety Partnership (CSP) in relation to the death of ‘Sarah’ to the Home Office Quality Assurance (QA) Panel. The report was considered at the QA Panel meeting on 25th February 2023. I apologise for the delay in responding to you.

The QA Panel noted the report must have been challenging to put together given the information available and underlines the importance of this process for suicide as well as homicide. The report gave a strong sense of Sarah voice, and her frustrations in getting the help she needed. The Learning and Recall Event and the involvement of Women’s Aid were noted as good practice.

The QA Panel felt that there are some aspects of the report which may benefit from further revision, but the Home Office is content that on completion of these changes, the DHR may be published.

Areas for final development:

  • Structure:
    • While the review refers to the ‘Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews’, it would be helpful to bring this closer in line, specifically by using the model layout at Appendix 4 of the Guidance as a template.
    • It would be helpful to bring single-agency and multi-agency recommendations together in the main report.
    • The Terms of Reference (TOR) should be brought forward. Given the circumstances of Sarah’s death, these should mention suicide
      specifically. As well as ‘violence’, it may also be appropriate to mention coercive control.
    • The real names of Sarah and Andrew appear in the TOR and should be removed before publication. Likewise, the dates of birth should be removed.
    • At 1.6, it is not clear if the coroner was informed of the DHR or given access to the report. There is also a reference to ‘homicide’ rather than ‘suicide’.
    • stated that Andrew was bailed to Sarah’s address following a drugs arrest. It was unclear if Sarah consented or agreed to this?
    • In section 2, it is understood that Sarah’s sister did not wish to engage with the review in person. However, it would be helpful to set out what steps were taken to contact other parties, for example the wider family (including Tom), or the friends to which Sarah refers, or Andrew or his mother. It would also be helpful to say whether advocacy services were offered as part of the engagement. Given her work as a teaching assistant, Sarah’s employers could also have been contacted.
    • It is not clear what was known around the DASH assessment answering ‘yes’ to the question about depression and suicide.
    • There was poor information sharing and a lack of professional curiosity especially regarding the significant DA incident in 2004 when Sarah was punched and stabbed by Andrew, and Tom was witness to this incident.
    • It may be helpful to say more about Tom as an individual, as well as a witness to domestic abuse. Specifically, Tom seems to have been subject to adverse childhood experiences and that should be referenced formally.
    • In section 3.1, it would be helpful to set out which agency reports were commissioned and how many were received.
    • In section 3.2, it would be helpful to set out the role of the Bassetlaw representative, and at 3.3 the experience of the chair and author. Given the diagnosis of dementia, it may also be helpful to include a medical expert in this area.
    • In section 4, considering the nine protected characteristic, it would be helpful to say if the sex of the victim was relevant. While not formally registered as disabled, it appears that mobility and health issues were important factors in the case and should be explored as such.
    • The QA Panel queried the use of the phrase ‘Domestic Abuse Public Protection Notice’ in relation to DASH. It is not clear how these are connected or if they are describing the same thing. If this is in reference to the civil orders and notices, then it should be noted that currently only Domestic Violence Protection Notices (and Orders) are in use. Domestic Abuse Protection Notices (and Orders) will be piloted next year in a small number of forces.
    • Font and formatting throughout the document should be cross-checked for consistency.

Once completed the Home Office would be grateful if you could provide us with a digital copy of the revised final version of the report with all finalised attachments and appendices and the weblink to the site where the report will be published. Please ensure this letter is published alongside the report.

Please send the digital copy and weblink to This is for our own records for future analysis to go towards highlighting best practice and to inform public policy.

Please also send a digital copy to the Domestic Abuse Commissioner at

On behalf of the QA Panel, I would like to thank you, the report chair and author, and other colleagues for the considerable work that you have put into this review

Yours sincerely,
Lynne Abrams
Chair of the Home Office DHR Quality Assurance Panel

Last Updated on Monday, September 4, 2023