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

Dudley review

CSP: Dudley Published: December 2022 Year of death: 2016 Extracted: 15 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 highlights the victim's consistent refusal of care and support, alongside the perpetrator's escalating stress and mental health challenges as a carer. Agencies missed opportunities to identify and address the perpetrator's distress and the complex family dynamics, including the victim's self-neglect and long-standing abusive behaviour.

Home Office classifications

24 tags

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

  • Victim - physical disability
  • Victim - mental ill health
  • Victim - serious or life limiting illness
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - carer assessed
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - supervised by mental health services
  • Aggravating factors - psychological or emotional abuse
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

15 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1

Addressed to Dudley’s Community Safety Partnership | Dudley Safeguard Adults Board

Dudley’s Community Safety Partnership works with Dudley Safeguard Adults Board to ensure that Dudley’s Multi-Agency Hoarding Framework and the DSAB Self Neglect Policy are launched and implemented as soon as is possible in 2019 and that further multi-agency Self Neglect and Hoarding Training is commissioned by DSAB.

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

Recommendation 2

Addressed to Dudley’s Community Safety Partnership | Dudley Safeguarding Adult Board | Dudley’s Safeguarding Children Board

Dudley’s Community Safety Partnership should work with Dudley Safeguarding Adult Board and Dudley’s Safeguarding Children Board to re-establish multi-agency training in respect of domestic violence and abuse.

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

Recommendation 3

Addressed to Dudley’s Community Safety Partnership

Dudley’s Community Safety Partnership to receive assurances from all agencies that professional curiosity is included within training and the CSP is assured within 6 months from the date of publication of this report.

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

Recommendation DDS-1

Addressed to Dudley Disability Service

More timely carer’s assessments to be arranged especially in instances whereby carers have expressed stress, distress or inabilities to cope with their caring role.

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

Recommendation DDS-2

Addressed to Dudley Disability Service

To take allegations of harm to others seriously and raise these as safeguards in the first instance when we are made aware of any concerns.

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

Recommendation DDS-3

Addressed to Dudley Disability Service

Collateral checks to be made with other agencies, family and background information sort to inform our safeguarding investigations and threshold decisions on raising cases to a safeguarding investigation.

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

Recommendation DGNHSFT-1

Addressed to Dudley Group NHS Foundation Trust

Develop a level three Adult Safeguarding Training Programme which will include an in depth look at a domestic abuse and self-neglect/hoarding

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

Recommendation DWMHP-1

Addressed to Dudley and Walsall Mental Health Partnership

To ensure that all professionals continue to access the safeguarding practitioners for advice and/or supervision on complex cases, request attendance at multi-disciplinary discussions and reflective practice.

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

Recommendation DWMHP-2

Addressed to Dudley and Walsall Mental Health Partnership

To ensure that professionals continue to work with the MDT following agreement of the information pathway and make sure it is embedded within our workforce.

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

Recommendation DWMHP-3

Addressed to Dudley and Walsall Mental Health Partnership

To continue to ensure all professionals complete required mandatory training enabling them to play a key role in the early identification and response to domestic abuse and coercive and controlling behaviour.

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

Recommendation DWMHP-4

Addressed to Dudley and Walsall Mental Health Partnership

For the Trust to produce further education for staff with the development of a Top 10 Safeguarding Tips including professional curiosity and voice of the adult.

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

Recommendation DWMHP-6

Addressed to Dudley and Walsall Mental Health Partnership

To ensure that any recommendations from the DHR case are included in the safeguarding newsletters, domestic abuse training and bulletins which are circulated to all staff.

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