Recurring concern

Domestic abuse risk assessment is unreliable

First to latest report 16 Apr 2015 — 2 May 2026

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
11

What this concern includes

Includes failures of the DASH system and controls specifically dedicated to it, including outdated or unclear forms, failure to complete assessments, inadequate DASH risk-evaluation training, and failure to perform checks or follow-up required for DASH referrals.

What is not included
  • Excludes generic risk-assessment, recording, training or information-sharing deficiencies not explicitly tied to the DASH domestic-abuse risk-assessment system.
  • Excludes deficiencies in wider domestic-abuse investigation, safeguarding or family-safety activity unless they directly concern the operation of DASH risk assessment.
  • Do not treat the seed assertions as establishing final membership.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Somtera Bibi · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete or attempt a DASH risk assessment

    Wider context from the report

    “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour. Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically: (i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family (ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020 (iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened (iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members (v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members (vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse ”

    Source location

    Somtera Bibi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train 60 Trust-wide Domestic Abuse Ambassadors in DASH assessment and provide quarterly supervision through Named Professionals.

    Verbatim wording from the response

    “12. Throughout May and June 2026, the Corporate Safeguarding Team has been delivering training for 60 Trust-wide Domestic Abuse Ambassadors. The training sessions aim to upskill operational staff members to act as a local point of expertise on Domestic Abuse best practice, with Named Professionals as the next point of contact for staffing focus. The training focuses on DASH risk assessment as the tool for assessment. All Domestic Abuse Ambassadors will be provided with quarterly supervision delivered by Named Professionals.”

    Source location

    Response from East London Foundation NHS Trust
    Page 2 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide safeguarding case advice and regular safeguarding supervision, including enhanced inpatient safeguarding huddles and supervision.

    Verbatim wording from the response

    “15. Named Professionals for Safeguarding provide case advice to clinicians when requested. Quarterly Safeguarding Supervision is delivered across the Trust. Inpatient mental health services have a fortnightly huddle and 4 weekly supervision with the Corporate Safeguarding Team.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide staff guidance and regular advice to service users and carers on safeguarding, community safety and police routes for mitigating identified risks.

    Verbatim wording from the response

    “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Family and community safety risks should be addressed through safeguarding, community safety pathways or police liaison rather than direct health responses.

    Verbatim wording from the response

    “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.”

    Source location

    Response from East London Foundation NHS Trust
    Page 3 · response
    Published 10 July 2026

    Open published response

  2. Berkshire

    AI-generated summary

    Angela · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Angela was murdered by her husband at their home on 26 December 2018, aged 41. Before her death, she reported assault and elements of coercive control to Thames Valley Police, but the reported crimes were not recorded or investigated, relevant information was not considered in the risk assessment, and the risk was graded as standard rather than medium. The report raises concerns about frontline understanding of domestic abuse and coercive control, the clarity of the DOM5 risk assessment form, and the non-adoption of a newer domestic abuse risk-assessment tool.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the domestic abuse risk assessment form to clearly include psychological harm from coercive and controlling behaviour within serious harm

    Wider context from the report

    “2. I am concerned that Thames Valley Police’s DASH risk assessment form (called a DOM5) does not make it sufficiently clear that the definition of “serious harm” can include psychological harm from coercive and controlling behaviour. It may be that other formulations of this document nationally do make this clear – I have looked only at the form used by Thames Valley Police. ”

    Source location

    Angela · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add the College of Policing serious-harm definition to the current domestic abuse risk assessment form.

    Verbatim wording from the response

    “You are right to point out that the current TVP Domestic Abuse risk assessment form (Dom5) does not define the term ‘serious harm’. The College of Policing defines the risk of serious harm as follows - ‘A risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible.’ This definition is included in the risk assessment model known as the DARA. I have asked Detective Superintendent ████████ to include this definition on our current risk assessment form.”

    Source location

    Response from Thames Valley Police
    Page 3 · response
    Published 13 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Explore an interim solution for incorporating DARA questions and the serious-harm definition into the current crime-recording system.

    Verbatim wording from the response

    “There are challenges to implementing the DARA risk assessment model within our current version of the NICHE crime recording system. In the future TVP will be looking to adopt an updated NICHE safeguarding and vulnerability module when available. In the mean time I have asked Detective Superintendent ████████ to explore an interim solution. This will include the replacement of the current questions in the DOM5 with the questions contained within the DARA and include clear reference to the College of Policing definition of serious harm which can include psychological harm from coercive and controlling behaviour. This will be attached to the crime recording system in the form of a template. The DARA includes a number of questions designed to assess the level of coercive and controlling behaviour and the level of risk posed.”

    Source location

    Response from Thames Valley Police
    Page 3 · response
    Published 13 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the policing implementation of the DASH risk-assessment tool.

    Verbatim wording from the response

    “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 13 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop, pilot and evaluate the DARA risk-assessment tool and aligned training for identifying coercive-control patterns.

    Verbatim wording from the response

    “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 13 August 2024

    Open published response

  3. East Riding and Hull

    AI-generated summary

    Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    DASH form not adequately updated

    Wider context from the report

    “(7) Evidence was heard that the DASH form may benefit from updating. ”

    Source location

    Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use of DASH risk assessments and vulnerability hubs is an operational policing matter rather than a government matter.

    Verbatim wording from the response

    “Whilst the use of Domestic Abuse, Stalking and Harassment (DASH) risk assessment form and vulnerability hubs are an operational issue for policing, the Government is committed to ensuring that police are equipped to tackle domestic abuse effectively. The Home Secretary commissioned Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) to help police forces to keep strengthening their responses, and to further support the action we set out in our cross-Government Violence Against Women and Girls Strategy, which we published in summer 2021, and Tackling Domestic Abuse Plan. The Government has committed to ensuring all HMICFRS actions are implemented and we have taken decisive action. This will include, for example adding violence against”

    Source location

    Response from Home Office (2)
    Page 2 · response
    Published 3 November 2022

    Open published response

  4. Surrey

    AI-generated summary

    Aliny Godinho · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 8 February 2019, Aliny Godinho was attacked and repeatedly stabbed in Ewell, Surrey, and died at the scene despite emergency medical attention. The report states that Surrey Police’s handling of earlier and same-day domestic abuse reports included failures in risk assessment, safeguarding, investigation, supervision, monitoring, call-centre handling and consideration of cultural risk; the inquest found that her death was probably more than minimally contributed to by Surrey Police.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the Officer in the Case to complete required DASH risk assessment and DA Matters training

    Wider context from the report

    “CONCERN 2 Training of DC ████████: I found that failures by the Officer in the Case, to implement the Domestic Abuse Policy and Procedure in relation to the investigation of Aliny Godinho’s complaint, contributed to the death. The outcome of the officer’s misconduct meeting was a requirement for her to undertake DASH risk assessment and “DA Matters” training by March 2021. The officer is currently working in Surrey Police’s Domestic Abuse Team but has not yet undertaken the required training and I consider this presents an ongoing risk. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide domestic abuse knowledge products covering victim-focused risk assessment, vulnerability, cultural competence, coercive control and Honour Based Abuse.

    Verbatim wording from the response

    “In order to ensure officers are equipped to identify these risks and mitigate them the CoP have provided a range of knowledge products to be applied in domestic abuse cases.”

    Source location

    2022-0149-Response-from-NPCC-and-College-of-Policing_Published
    Page 4 · response
    Published 24 May 2022

    Open published response

  5. Manchester South

    AI-generated summary

    Alfie Gildea · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited police training in domestic abuse risk evaluation and scoring

    Wider context from the report

    “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited. ”

    Source location

    Alfie Gildea · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver rolling virtual continuing professional development covering domestic abuse, coercive control, stalking, risk assessment, DASH, strangulation and related safeguarding topics.

    Verbatim wording from the response

    “Between 2015 and 2020, 2773 PCs completed the Safeguarding for Constables course at Sedgley Park which incorporated coercive and controlling behaviours within a relationship. Further CPD was due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition and typology; the ‘murdered by my boyfriend’ film; coercion and control; stalking and harassment; identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and incident closing codes.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 4 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide clearer domestic abuse risk-grading guidance and disseminate it through continuous professional development and safeguarding training.

    Verbatim wording from the response

    “At the time of GMP’s involvement with Alfie’s parents, the force policy stipulated that officers should take into account the circumstances of the incident, the vulnerability of the victim, and the history of the perpetrator when making a risk assessment. The new force policy offers more guidance to officers around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, such as standard risk, would not be appropriate. This includes:”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 4 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a safeguarding course for officers and staff who evaluate risk and provide formal training on identifying risk factors.

    Verbatim wording from the response

    “This Unit is also working with the People and Development Branch to support a newly designed course which is aimed at officers and staff in the organisation who work in a safeguarding role where they need to evaluate risk and provide formal training to support those staff in understanding risk factors and identifying them at the earliest opportunity.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 4 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

    Verbatim wording from the response

    “I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
    Page 1 · response
    Published 24 December 2020

    Open published response

  6. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct police database checks on standard-risk DASH referrals

    Wider context from the report

    “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out. The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026