Lucy - Domestic Homicide Review

Published on 19th March 2018

Lever arch file and pen

Today, Cheltenham Strategic Leadership Group, has published a domestic homicide review.

Cheltenham Strategic Leadership Group, the community safety partnership for Cheltenham, has today published a domestic homicide review into the death of Lucy, a Cheltenham teenager and her unborn child, Sarah. Lucy was 24 weeks pregnant when she was strangled by her 18 year old partner, Daniel. Daniel was Sarah’s father.

Domestic Homicide Reviews are a statutory requirement and are conducted when the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a relative, household member or someone they have been in an intimate relationship with.

The purpose of the review has been to understand whether agencies could have potentially prevented Lucy and Sarah’s deaths and to establish whether there are lessons to be learnt from this case about the way in which organisations and partnerships carried out their responsibilities to safeguard their wellbeing.

As Lucy was a teenager, the review has also considered how best agencies should understand the dynamics of relationships between teenagers that feature domestic abuse, including better understanding of the issue of coercive control.

The review has come forward with six learning points that are supported by 23 actions. Progress has already been made against several of these actions and Cheltenham Strategic Leadership Group will work with Gloucestershire Safeguarding Children Board and with Safer Gloucestershire to hold agencies to account for the delivery of the remainder.

Lucy and Sarah were also subject to a serious case review which was published in July 2016. The Domestic Homicide Review process commenced after the Serious Case Review.

Cllr. Steve Jordan, Chair of Cheltenham Strategic Leadership Group said: “This complex review has taken a long time to bring to a conclusion – this reflects the seriousness that all agencies have taken to understand the issues that Lucy faced; to analyse their engagement with her and to honestly appraise where they could have improved.

“I would like to thank all the agencies for their hard work and input into the review.

“We hope that the publication of the review will shine a light on the challenges that agencies have of working with teenagers who want to be independent and make their own choices, yet in so doing, may be putting themselves at risk of harm. We have identified six recommendations that we believe will increase agencies abilities to safeguard the wellbeing of teenagers like Lucy.

“I would also like to thank both sets of families that have had their lives shattered by this tragedy. Our heartfelt condolences go out to them and I would ask that the media respects their wishes for privacy.”

The overview report and action plan is available from our website

For media enquiries, contact:  Jemima Lawson, communications officer telephone 01242 775050, email


Lucy is a pseudonym agreed with the family and some information has been excluded from the report which may identify individuals, such as specific dates and detail of certain incidents, and some information the family would like to remain private.

Cheltenham Strategic Leadership Group is the relevant community safety partnership for this DHR and the review has been coordinated in line with the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, published in August 2013 and subsequently updated in December 2016.

What are Domestic Homicide Reviews?

A Domestic Homicide Review (DHR) is a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by:

(a) a person to whom they were related or with whom they were or had been in an intimate personal relationship, or

(b) a member of the same household as themselves, held with a view to identifying the lessons to be learnt from the death.

A review panel consisting of members from local and statutory agencies, led by an independent chair will review each agency’s involvement with the individuals involved and consider recommendations to improve agency’s responses in the future. In doing this, agencies will improve their responses to domestic violence and abuse, and work better together to prevent such tragedies occurring in the future.

Domestic Homicide Reviews are not inquiries into how someone died or who is to blame. They are not part of any disciplinary process. They do not replace, but will be in addition to, an inquest or any other form of inquiry into the homicide.

Terms of Reference

The general terms of the reference are:

  1. Decide whether in all the circumstances at the time, any agency or individual intervention could have potentially prevented Lucy’s death.
  2. Review current responsibilities, policies and practices in relation to victims of domestic abuse – to build up a picture of what should have happened and review national best practice in respect of protecting young adults from domestic abuse.
  3. Examine the roles of the organisations involved in her case; the extent to which she had involvement with those agencies, and the appropriateness of single agency and partnership responses to her case to draw out the strengths and weaknesses.
  4. Establish whether there are lessons to be learnt from this case about the way in which organisations and partnerships carried out their responsibilities to safeguard her wellbeing.
  5. Identify clearly what those lessons are.
  6. Identify whether, as a result, there is a need for changes in organisational and/or partnership policy, procedures or practice in Gloucestershire in order to improve our work to better safeguard victims of domestic abuse.

The specific terms of reference are set out below:

  1. Consider how best agencies should and individuals understand the dynamics of relationships between teenagers that feature domestic abuse, including the issue of supreme control of the abuser upon the victim.
  2. Appraise if is there a gap in services around working with young people who are considered to be involved in perpetrating domestic violence. 
  3. Explore how professionals and services can optimise support to young people who have left abusive partners and ensure they are able to sustain that separation and independence.
  4. Consider when a woman who is subject to domestic violence is pregnant, what additional safeguards should be in place to protect the young woman and unborn child.
  5. Consider any incidence of, and impact of any possible collusion by others such as peers.
  6. Consider how young people who may be aware that peers are being subjected to domestic abuse, can be supported to share information to safeguard the victim, including sharing information on social media.

The six learning points:

Learning point 1: Ensure that young people have access to preventative work on healthy relationships.

Learning point 2: The need for early intervention adopting an inclusive family-based approach.

Learning point 3: Young people should get the right support at the right time.

Learning point 4: Professionals need to recognise and respond to the indicators of relationship harm among young people including coercive control.

Learning point 5: Professionals need to be able to navigate the challenges between young people’s autonomy and the duty of professionals to keep them safe.

Learning point 6: How do professionals and the wider community recognise and respond to abusive and controlling behaviours and engage with the abuser.