About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review

Sandwell review

CSP: Sandwell Published: December 2022 Year of death: 2018 Extracted: 7 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
The review identifies systemic issues including victim-blaming, a lack of professional curiosity, and inadequate recognition of the perpetrator's controlling behaviour. It highlights missed opportunities to use legal remedies and address the victim's specific vulnerabilities, including her Irish Traveller background and economic abuse.

Home Office classifications

47 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

7 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation 1

Addressed to Sandwell Community Safety Partnership

Sandwell Community Safety Partnership should write to the Women's Aid Federation (enclosing a copy of the final report) to ask them to consider strengthening the Women’s Aid Quality Standards concerning evictions from refuges. This should ensure that when a woman is evicted from a refuge, she will still have an exit plan tailored to her individual need and access to ongoing appropriate support. In addition, she should be provided with information on how she can make a complaint or challenge the decision to evict her.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Sandwell Community Safety Partnership

Sandwell Community Safety Partnership should request further detailed information about the training on domestic abuse that is currently provided to staff working in the West Midlands National Probation Service, West Midlands Police, the Crown Prosecution Service, HM Courts Service and the Judiciary. The information should include: a. The number of staff who have accessed both single agency and multi-agency domestic abuse training b. Demonstrate how this training has improved the outcomes for victims of domestic abuse

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Sandwell & West Birmingham Clinical Commissioning Group

Sandwell & West Birmingham Clinical Commissioning Group to sustain funding for Sandwell IRIS domestic abuse intervention until 2022 and beyond, to maintain the current level of 96% uptake by Sandwell GPs.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Sandwell Community Safety Partnership

This domestic homicide review should be used as a case study for domestic abuse training (and other training e.g. substance misuse training). The training should give professionals the confidence to: a. Understand how attitudes of professionals can undermine a victim's ability to escape domestic abuse b. Recognise the specific barriers facing domestic abuse victims from the Irish Traveller community c. Recognise victim-blaming, worthy and unworthy victims, and 'minoritised' victims and how these impact on the lived experience of women d. Challenge organisational culture so that agencies move away from victim-blaming to focus on ways to disrupt perpetrators' activity thus preventing men from being invisible to services e. Identify the local pathways that are in place for victims to access services f. Appreciate how perpetrators can use drugs as a mechanism to control victims

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5

Addressed to Sandwell Community Safety Partnership

When considering safety planning for victims and children, the West Midlands MARAC (multi-agency risk assessment conference) processes should clearly consider the need for relevant partner agencies to seek to make applications for restraining orders/injunctions/domestic violence protection orders as appropriate. The Chair of the conference and wider attendance should be clear where the responsibility lies for each order, and the thresholds for application.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

Addressed to Crown Prosecution Service

The Crown Prosecution Service should consider strengthening its guidance in cases where victims object to the making of an order. The guidance should include the need for a prosecutor to consider the principles arising from the caselaw42, namely the need to balance respect for the wishes of the victim and her right to autonomous decisions about her life, with consideration of whether she is in fear, has been coerced, or does not have capacity to make the objection. Such guidance should include a requirement for the prosecutor to set out those legal principles to the court as well as the available evidence on either side of that equation, whilst remaining in a neutral position with regards to the granting of an order, which remains a matter for the court.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to HM Courts Service | Judiciary

A judge making a decision on whether to grant or decline a restraining order where the victim objects to the making of the order should hear oral evidence from the victim in order to explore whether she is in fear, has been coerced, or does not have capacity to make the objection.

Verified wording from the published review · Original review (PDF) ↗