The Domestic Abuse Commissioner, Nicole Jacobs, has raised serious concerns that many of the recommendations made following Domestic Abuse Related Death Review (DARDRs) are not being acted upon - particularly those sent to the Home Office and other national bodies.
These recommendations are not just bureaucratic exercises; they are hard-learned lessons from tragedies. They are designed to improve responses to domestic abuse and prevent further lives being lost. But the Commissioner warns that a lack of oversight at the top of government means that crucial opportunities to protect survivors are being missed.
This issue is more than a matter of process. Behind every review is a person who has died - and a set of findings that help ensure no one else faces the same fate.
What is a Domestic Abuse Related Death Review?
A Domestic Abuse Related Death Review (DARDR) is conducted when someone dies as a result of domestic abuse. The aim is to understand what happened, identify any gaps in the system, and recommend changes to prevent further deaths.
Previously known as Domestic Homicide Reviews, the scope was recently expanded to included suicides linked to domestic abuse, acknowledging the devastating mental and emotional toll that abuse can take.
Each review examines the contact the victim had with various organisations - such as police, health services, social services, and charities - and asks where there were missed opportunities to offer support or intervention.
From there, the review produces recommendations for both local and national agencies. These can range from improving information sharing between services to updating training for frontline staff, to changing national policy.
Since the passing of the Domestic Abuse Act, all reviews are sent to the Domestic Abuse Commissioner. The Home Office has also created a central library of these reviews, giving the Commissioner access to a wealth of information about the patterns and failures that lead to deaths in the context of domestic abuse.
What the Commissioner’s Research Found
To address the issue of accountability for implementing recommendations, the Home Office funded the Domestic Abuse Commissioner to run a pilot independent oversight mechanism.
The pilot worked with 21 local authorities, tracking how they responded to DARDR recommendations and also monitoring how national bodies handled the recommendations sent to them.
The findings present a mixed picture:
Local Level
At the local level, most recommendations were reported as being implemented. However, there was a lack of independent scrutiny. Much of the information came from self-assessment by the agencies involved, and the Commissioner’s team did not have the resources to verify whether actions had truly been taken or whether changes had made a real difference in practice.
National Level
The situation at the national level was more worrying. Between 2019 and 2021, there were 110 national recommendations, the majority directed at the Home Office - the government department responsible for public safety.
In some cases, government departments didn’t even know that recommendations had been made to them. In others, there was no follow-up to inform the review authors whether any action had been taken.
The Commissioner described this as a “deeply concerning” picture - one that suggests critical lessons from these deaths are not being learned or acted upon in a consistent way.
Why This Matters
Domestic Abuse Related Death Reviews are not hypothetical exercises. They are built on the reality of someone’s death and the devastating impact that has on families, friends, and communities.
When recommendations go unimplemented, it means the same failures can happen again - and they do. Every missed action increases the risk to other people currently living with domestic abuse.
The Commissioner has stressed that without top-level government oversight and accountability, the purpose of these reviews is undermined. The cycle of tragedy continues when the system designed to prevent it is not working as intended.
Calls for Action
The Commissioner’s report is clear about the steps that need to be taken:
Moving Forward
The Commissioner’s findings highlight a crucial truth: recommendations alone do not save lives - it’s the implementation that matters. Every DARDR contains lessons written in the harshest possible terms. Those lessons must lead to action.
For the families of those who died, there is an understandable expectation that no one else should suffer the same loss for the same reasons. Yet without proper oversight, we risk repeating mistakes instead of learning from them.
Implementing recommendations is not simply about compliance - it’s about ensuring that the death at the centre of each review was not in vain. It’s about sending a clear message to survivors of domestic abuse that their safety is a priority.
A Shared Responsibility
Domestic abuse is a complex issue that demands a coordinated response across police, healthcare, education, housing, and government. When a DARDR identifies failings, the responsibility to act lies with everyone - from frontline workers to senior ministers.
The Commissioner’s report is a wake-up call. It’s a reminder that the systems designed to protect people can only work if the lessons from tragedy are taken seriously and acted upon without delay.
If we are serious about preventing further deaths linked to domestic abuse, then these recommendations cannot be allowed to gather dust. They must be implemented, monitored, and embedded into everyday practice at every level of our response.
At its heart, this is about more than statistics, percentages, or policy documents. It’s about lives that could be saved - if only the warnings we already have are heard, and acted upon.
The choice now lies with those in positions of power: will they let history repeat itself, or will they make the changes needed to protect survivors and prevent further avoidable deaths?
