High Court finds minister was entitled to direct local authority to establish domestic homicide review

The High Court has rejected a local authority’s claim against a decision by a government minister, acting under powers delegated by the Secretary of State for the Home Department, to direct the council to establish a domestic homicide review (DHR) following the death of a woman.

The direction was made pursuant to s.9(1) of the Domestic Violence, Crime and Victims Act 2004.

In Charnwood Borough Council, R (on application) v Secretary of State for the Home Department [2025] EWHC 33 (Admin), Mrs Justice Stacey concluded: “Against the limited information available of the history of CB and M’s relationship and the account of what happened on the night of CB’s death, there was sufficient information for the Minister to conclude, and it was perfectly reasonable and rational for him to decide that it appeared that neglect by M resulted in her death.

“Medical treatment may or may not have saved CB, but the Minister did not need to consider medical evidence on causation along the lines of a clinical negligence trial to make the decision that he did.”

This case arose out of the premature death of a woman, CB, whilst at home with her partner, M.

The police investigation after her death concluded that there was “no evidence of third party involvement” and closed the investigation, and at the subsequent inquest it was recorded as an accidental death by the coroner.

In the proceedings, the claimant, Charnwood Borough Council (CBC), acted in its capacity as lead authority for the Charnwood Community Safety Partnership (CSP).

The claimant challenged a decision by Chris Philp, then Minister of State for Crime, Policing and Fire, acting under powers delegated by the defendant, the Secretary of State for the Home Department (the Secretary of State), which directed the council to establish a DHR following the death of CB.

The judge noted: “A 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 defined group of persons.”

Outlining the chronology and facts of the case, the judge noted that CB died in June 2021. She was at home alone with her partner, M, who called an ambulance at 6.57am.

CB was pronounced dead by the paramedics who arrived at 7.07am, who noted that she had been dead for around two hours before they had arrived.

The pathology report, completed in July 2021, gave the cause of death as internal haemorrhage, abdominal injuries.

The pathologist found that the distribution of injuries appeared to correlate to the account given by M of the previous night – which was that CB had been drinking heavily and fallen down the stairs several times before he managed to get her into bed. After finding her unresponsive in bed the next morning he called an ambulance. The police summary of the pathology report was that a fall down the stairs followed by death at some point over the next few hours was consistent with the observed injuries.

A police investigation concluded in September 2021 that there was no third-party involvement in CB’s death or criminal activity.

The charity Advocacy After Fatal Domestic Abuse (AAFDA) subsequently contacted the then chair of the CSP, a councillor, asking on behalf of CB’s family for her death to be considered for a DHR.

The suggestion was supported by the Chair, who submitted a request to the Leicestershire and Rutland Safeguarding Children Partnership and Safeguarding Adults Board Case Review Group (CRG) to consider whether to recommend to the CSP that a DHR be conducted, under the procedure established locally.

At a meeting in December 2022 the CRG decided not to recommend to the CSP that a DHR be established. It was the view of the legal advisor to the CRG that there was “not enough substantive evidence of a causal link between the previous domestic incidents and CB’s death”.

The judge noted: “If a CSP chooses not to proceed with a DHR, a summary of the case and their rationale is provided to the Home Office which is then verified by a Quality Assurance (QA) Panel made up of voluntary representatives appointed by the Home Office from policing, the probation service, health and third sector domestic abuse organisations.”

AAFDA wrote to the chair of the QA Panel in December 2022 explaining that they and the chair of the CSP were clear that the death met the criteria for a DHR because of the domestic abuse suffered by CB and “the suspicious circumstances of her death pointing to neglect.”

The letter from AAFDA to the QA Panel enclosed a statement from CB’s father which set out a number of incidents of abusive behaviour towards his daughter by M in addition to those reported to the police.

As a result of the AAFDA letter, the Home Office began correspondence with the council. The Home Office was informed in January 2023 that the final decision of the CSP not to undertake a DHR had been made the previous month.

A number of months later, the Minister was provided with a written submission from Home Office officials recommending that a DHR should be directed (the Submission).

The QA Panel’s advice was that the case would benefit from a DHR on the basis that:

• there were a number of abuse incidents between CB and M between 2007 – 2020 involving assault and threatening behaviour with a knife/holding her hostage;
• screenshots of messages shared by the family with the QA Panel showed CB’s intention to leave, patterns of coercive and controlling behaviours and disclosures of domestic abuse to friends.

The Minister accepted the recommendation and issued his decision in a direction to the claimant under s.9(2) of the 2004 Act:

“The decision has been reviewed and I am not satisfied with the conclusions reached by Charnwood Community Safety Partnership (CSP) that there are no lessons to be learned from this tragic death.”

The Deputy Chief Executive of the council wrote to the Minister on 8 August 2023 asking him to review his decision, pointing out that it had not seen the letter from the AAFDA and reiterating the claimant’s view that the statutory criteria were not made out to enable the Minister to direct them to conduct a DHR.

The judge noted that “no substantive response” was received before the claimant’s pre-action protocol letter before action was sent in September 2023.

In its pre-action protocol (PAP) response, the Secretary of State for the Home Department (SSHD) resisted the proposed judicial review in the following terms:

“DHRs are not inquiries into how the victim died or into who is culpable; that is a matter for coroners and criminal courts, respectively, to determine as appropriate. DHRs are not specifically part of any disciplinary inquiry or process. Where information emerges in the course of a DHR indicating that disciplinary action should be initiated, the established agency disciplinary procedures should be undertaken separately to the DHR process.

“[…] The letter [a reference to the pre-action protocol letter sent by the claimant] seems to suggest that the conclusions of the coroner and police are the end of the matter. That is a misreading of the breadth of the discretion and the purpose of a DHR. The police look at potential criminal liability and the coroner looks at the reasons that that individual died. The DHR is an additional process to examine what has gone before including dealing with multi-agency evidence to see if there are any lessons that can be learnt as per section 9(1) of the Act.

“[…] The letter seems to challenge that the SSHD has given a broad interpretation to “or appears to have, resulted from violence abuse or neglect” (emphasis added by Mrs Justice Stacey). There are several interpretations of the facts that could be examined, that is a matter for the DHR to examine in the round. All that is required is that the death ‘appears to have resulted from neglect’. The facts surrounding the death, including the failure to call for medical assistance in a timely manner, can have that interpretation.

“There is on any view of the facts, circumstances that suggest that the death could appear to have resulted from neglect.”

Permission to apply for judicial review was granted by Mrs Justice Lieven in February 2024.

The local authority relied on the following three grounds:

• Ground 1: The Minister implicitly misdirected himself in law that it was sufficient for a DHR to be established to ensure that lessons could be learned from a death, without any express finding that the death appeared to have resulted from domestic violence, abuse or neglect by M. Alternatively, the direction was ultra vires in the absence of such a finding.
• Ground 2: If the decision could be read as implicitly containing a finding that CB’s death appeared to have resulted from domestic violence, abuse or neglect, the decision was not sustainable and in any event was vitiated by a number of public law errors such as Wednesbury irrationality, failure to take account of relevant considerations and taking irrelevant considerations into account.
• Ground 3: The reasons given for the decision in the defendant’s PAP response did not form part of the Minister’s reason at the time of the decision and should therefore be disregarded, but in any event represented a misdirection of law by the Minister by applying a lower threshold for the establishment of a DHR than that set out in the statute. Even if the Minister had correctly directed himself, the conclusion that the necessary test had been satisfied was irrational and had failed to take account of relevant considerations and erroneously considered irrelevant matters.

In response, the defendant submitted there was “careful consideration” of all the available evidence sufficient for the Minister to conclude that the death of CB appeared to have resulted from neglect by her partner, which satisfied the low threshold set out in the statute to entitle the Minister to exercise his responsibility to direct the CSP to establish a DHR to see if lessons could be learnt.

Analysing the first ground, Mrs Justice Stacey said: “It is implicit from a balanced reading of the decision and PAP response that the Minister had a clear understanding from accurately citing the legislation that he was both aware that he could only direct a DHR if CB’s death had, or appeared to have, resulted from violence, abuse or neglect of her by M. It goes without saying from his recitation of the statutory test that CB’s death was in scope and he then quite properly went on to consider whether to exercise his discretion to direct a DHR and if lessons could be learned from it, and he concluded that they could.”

She added: “I find that the word neglect in s.9(1) bears its natural and ordinary meaning, which is the fact of not giving enough care or attention to something or somebody. Nothing more technical or sophisticated is required. […] I also reject the claimant’s submission that one incident would never be sufficient to amount to neglect.”

Based on the submissions from the QA Panel, the judge found that the Minister was “entitled to conclude” that, as identified by the family, it appeared that CB’s death resulted from M’s neglect of her.

She noted: “She was in a vulnerable state and neglected when she fell down the stairs several times fatally injuring herself and M failed to get help.”

Dismissing ground one, she concluded that although it would have been “preferable” if the Minister’s decision letter had “expressly stated” that CB’s death appeared to have resulted from M’s violence, abuse or neglect, and specifically referred to the incidents of his neglect of her, this was not necessary when it was “implicit” from the letter, and the defendant was writing to the CRG which was also familiar with the statutory test and there was no statutory duty to provide reasons.

She added: “But the further reasons in the PAP response letter spell it out more precisely and there is no error of law or misdirection in law as to the causal link.”

Turning to the second ground, the judge said: “In 2(a) the defendant is criticised for not explaining how the coroner’s verdict of accidental death can be squared with CB’s death appearing to have resulted from violence, abuse or neglect of her by M. But the Guidance states that the DHR is not a re-run of the coronial process and it is not inconsistent for a coroner’s verdict to be accidental death and yet there still be an appearance that the death resulted from another’s violence, abuse or neglect.”

She continued: “In ground 2(b) the Minister is criticised for concluding that there had been multiple abuse incidents, when the police had only two filed reports of domestic abuse. There are two problems with the claimant’s argument. Firstly, as confirmed in the PAP response the defendant relies only on neglect and the past domestic abuse incidents are therefore only relevant background and context. Secondly, in any event, the Minister was entitled to conclude that there appeared to have been incidents of domestic abuse as reported by CB to her family, friends and her employer which had escalated in the months leading up to her death.”

Grounds 2(c), (d) and (e) fell away in light of the judge’s conclusions.

Dismissing ground 2, the judge concluded: “I find that the Minister did not need to grapple any more than he did with the reasons given by the police or pathologist as to why CB’s death was not considered to be a homicide at all. He was not looking at the matter as a review of the police charging decision. He was not looking at culpability but applying the statutory test in s.9(1). Although CB’s family were raising issues about the adequacy of the police inquiry and the evidential leads that they considered had not been explored, it was not necessary, or even desirable, for the Minister to engage with those criticisms in his Decision.”

Finally, considering ground 3 of the claim, the judge noted: “I reject the claimant’s linguistic analysis and parsing of the use of the word “could” in the PAP response. It is nit picking. It is obvious that the PAP response uses the word “could” to explain how it is that it appears that CB’s failure to get medical help for CB would on its own amount to neglect causing her death. It does not mean that the Minister had failed to make a decision about how her death appeared, as is obvious from the context.”

Dismissing ground 3, Mrs Justice Stacey concluded: “Against the limited information available of the history of CB and M’s relationship and the account of what happened on the night of CB’s death, there was sufficient information for the Minister to conclude, and it was perfectly reasonable and rational for him to decide that it appeared that neglect by M resulted in her death. Medical treatment may or may not have saved CB, but the Minister did not need to consider medical evidence on causation along the lines of a clinical negligence trial to make the decision that he did.”

She dismissed the claim and ordered that the DHR should now be established by the claimant.

Lottie Winson