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: 2018
Extracted: 23 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review identified systemic issues in understanding and responding to the breadth of domestic abuse, coercive control, and stalking, alongside inconsistent risk assessments and information sharing regarding perpetrator history. Challenges in engaging victims with multiple disadvantages and shortcomings in multi-agency coordination were also noted.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Dudley Safe and Sound should review and seek assurance about the degree to which agencies support front-line staff and their supervisors to understand this breadth and range of domestic abuse, coercive control and stalking behaviours as well as identify and respond to risk. | Dudley Safe and Sound |
| 1 | Funding to be secured for an Independent Domestic Violence Advocate in the Emergency Department. | Dudley Group NHS Foundation Trust |
| 1 | To ensure that all professionals continue to access the safeguarding practitioners for advice and that they play a key role in the early identification and response to domestic abuse and coercive and controlling behaviour. | Dudley and Walsall Mental Health Partnership NHS Trust |
| 1 | Monitor the impact of the IRIS Programme within primary care | Dudley Clinical Commissioning Group |
| 2 | Dudley Safe and Sound should continue to raise public awareness specifically about domestic abuse, coercive control, stalking and harassment | Dudley Safe and Sound |
| 2 | Continue to work toward meeting the NICE Quality Standard on Domestic Violence and Abuse QS116 | Dudley Group NHS Foundation Trust |
| 2 | To ensure that all staff complete their mandatory domestic abuse training and for the Safeguarding Team to promote and encourage staff to attend external training sessions. | Dudley and Walsall Mental Health Partnership NHS Trust |
| 2 | Continue to work to meet NICE Quality Standard on Domestic Violence and Abuse | Dudley Clinical Commissioning Group |
| 3 | Dudley Safe and Sound should ensure that the Domestic Violence Disclosure Scheme is well known by agencies and the public alike. | Dudley Safe and Sound |
| 3 | Domestic abuse training to continue to emphasise the connection between domestic abuse and substance misuse. | Dudley Group NHS Foundation Trust |
| 3 | To identify themed DHR case studies to be included in the safeguarding newsletters, domestic abuse training and bulletins which are circulated to all Trust staff. | Dudley and Walsall Mental Health Partnership NHS Trust |
| 3 | Domestic abuse training to emphasise the importance of ‘asking the question’ | Dudley Clinical Commissioning Group |
| 4 | Dudley Safe and Sound and Safeguarding Boards should seek assurance from agencies that services and pathways are trauma-and-gender informed and flexible enough to effectively engage with women facing multiple disadvantage, using the West Midlands Domestic Violence Standards and the trauma-and-gender informed principles of the national Women’s Taskforce on Mental Health as guides. | Dudley Safe and Sound | Safeguarding Boards |
| 4 | Emergency Department staff to receive bespoke training in regard to alcohol misuse and local services available to give advice and support. | Dudley Group NHS Foundation Trust |
| 4 | For the Trust to develop the of Top 10 Safeguarding Tips which will support staff in their day to day practice by sharing key learning points. | Dudley and Walsall Mental Health Partnership NHS Trust |
| 4 | Raise awareness of domestic abuse, National Centre for Domestic Violence and stalking amongst professionals and patients | Dudley Clinical Commissioning Group |
| 5 | Black Country Women’s Aid to provide evidence of effective interventions and engagement methodology for victims who present with multiple and complex issues that may have resulted in them disengaging from other services. | Black Country Women’s Aid |
| 5 | Safeguarding training to continue to discuss self-neglect and possible indicators. | Dudley Group NHS Foundation Trust |
| 5 | As an area of good practice, the Trust will ensure that staff are alert to non-verbal behaviours and be encouraged to collate a genogram to understand the family network. This is following compilation of the combined agency chronology as it is now evident that both the victim and the perpetrator had troubled childhoods and they both experienced stressful or traumatic events, including physical and sexual abuse. Children raised in environments where violence, assault and abuse are common will often come to believe this behaviour is normal and therefore find it difficult to establish and maintain healthy relationships. These ACEs (Adverse Childhood Experiences) are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan and overtime could have contributed to them both developing negative coping mechanisms. | Dudley and Walsall Mental Health Partnership NHS Trust |
| 6 | Dudley Safe and Sound should seek assurance from its agencies that they are able to accurately record and access records on an abuser’s previous violent history and apply this to current risk assessments and responses. | Dudley Safe and Sound |
| 7 | West Midlands Police should provide evidence of the improvements made in the policing of domestic abuse to Dudley Safe and Sound, particularly compliance and impact of the changes concerning: the mandatory completion of DASH; referrals to specialist domestic abuse and alcohol treatment agencies, and the impact of portable mobile devices. | West Midlands Police |
| 8 | Adult Social Care should provide evidence of how it has improved its response to MARAC and achieved outcomes for domestic abuse victims in the following areas: • Prioritisation of MARAC cases and workload capacity of staff enabling an urgent response • Co-terminosity between Multi-Agency Safeguarding Hub and MARAC • Effective communication between Adult Social Care MARAC representative and allocated social workers • Effective internal escalation and feedback to MARAC when task cannot be fulfilled • Effective working relationships with IDVA service | Adult Social Care |
| 9 | Dudley Safe and Sound should consult with the Office of the Police and Crime Commissioner and evidence how the recent improvements to MARAC arrangements have impacted upon agency involvement, victim safety and holding perpetrators to account. | Dudley Safe and Sound |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||