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
Wolverhampton review
CSP: Wolverhampton
Published: April 2023
Year of death: 2011
Extracted: 25 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 highlights systemic failures in inter-agency information sharing, inconsistent risk assessments, and inadequate referrals for domestic violence and safeguarding concerns. Agencies often focused solely on the perpetrator's mental health, overlooking the victim's and child's safety and cultural vulnerabilities.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Safer Wolverhampton Partnership to seek assurance from Wolverhampton Safeguarding Children Board that all agencies are meeting the requirements and statutory obligations under Working Together to Safeguard Children | Safer Wolverhampton Partnership |
| 10 | The Safer Wolverhampton Partnership to seek assurance from Black Country Partnership Foundation Trust that its guidance for the Care Programme Approach is reviewed and implemented accordingly and evidenced to the Safer Wolverhampton Partnership within 3 months from the date this report is accepted by the Safer Wolverhampton Partnership. | Safer Wolverhampton Partnership |
| 11a | The Safer Wolverhampton Partnership to satisfy itself that Policies are in place to ensure the timely transfer of full and accurate school records to support the needs of children and young people. | Safer Wolverhampton Partnership |
| 11b | The Safer Wolverhampton Partnership to satisfy itself that policies are in place to demonstrate that Children and Young Person’s Services are informed if a known child moves school or there is a change in the child’s circumstances. | Safer Wolverhampton Partnership |
| 12 | Safer Wolverhampton Partnership require that the Black Country Partnership Foundation Trust and recommend that the Walsall Healthcare NHS Trust review their processes of information exchange to ensure that the outcomes of assessments under the Mental Health Act 1983 and Care Programme Approach documents and covering letters that are passed between themselves and other agencies are accurate and up to date, and report the findings of their reviews to the Safer Wolverhampton Partnership within 6 months of the date this report is accepted by the Safer Wolverhampton Partnership. | Safer Wolverhampton Partnership |
| 13 | The Safer Wolverhampton Partnership to require the statutory agencies to demonstrate that services they provide and those they commission, particularly the Black Country Partnership Foundation Trust, and recommend that the Dudley and Walsall Mental Health Partnership NHS Trust, when undertaking Mental Health Assessments under Mental Health Act 1983, exercise their duty of care to ensure the safety of any patient and others including the patient’s family before making a decision not to arrange an admission under Mental Health Act 1983 | Safer Wolverhampton Partnership |
| 14 | The Safer Wolverhampton Partnership to require the Black Country Partnership Foundation Trust to review its discharge communications to ensure appropriate discharge information is sent to the GP within 48 hours of a patient discharge. | Safer Wolverhampton Partnership |
| 15 | The Safer Wolverhampton Partnership to require the Black Country Partnership Foundation Trust to demonstrate that it actively encourages all patients with severe and enduring mental ill-health to register with a local GP. | Safer Wolverhampton Partnership |
| 16 | The Safer Wolverhampton Partnership should require the Black Country Partnership Foundation Trust to demonstrate that, before patients are discharged into the care of a family member, an individual carer’s assessment is offered to the family member to ensure they fully understand and appreciate the consequences of the discharge. If this is refused, a comprehensive risk assessment of the home situation should be carried out. | Safer Wolverhampton Partnership |
| 17 | Safer Wolverhampton Partnership to request assurance from the Wolverhampton Safeguarding Children Board that all agencies are aware of the referral pathway and process to services for children with counselling needs and ensure that, when known, issues of domestic violence or safeguarding are highlighted to ensure that appropriate outcomes are achieved and that there is robust monitoring to ensure that this occurs. | Safer Wolverhampton Partnership |
| 18 | The Safer Wolverhampton Partnership to require statutory agencies to demonstrate that within services they provide internally and commission there is a robust policy for providing interpreting services excluding the use of family members or friends except in extreme emergencies. | Safer Wolverhampton Partnership |
| 19 | The Safer Wolverhampton Partnership to require West Midlands Police to demonstrate that officers investigate reported incidents even if the suspect is subject to mental health treatment, to ensure that the full circumstances of the offence are known and a proper assessment of the risk to others is ascertained. | Safer Wolverhampton Partnership |
| 2 | The Safer Wolverhampton Partnership to seek assurance from Wolverhampton Safeguarding Adults Board that all agencies are meeting the legal obligations and requirements under ‘No Secrets’ and working to the Interagency Safeguarding Policy and Procedures and the associated requirements. | Safer Wolverhampton Partnership |
| 20 | The Safer Wolverhampton Partnership seek assurances from the Safeguarding Children and Adult Boards that, as part of their quality assurance processes, the statutory agencies annually monitor their domestic violence training plans and those of services they commission | Safer Wolverhampton Partnership |
| 21 | Safer Wolverhampton Partnership to ensure that all agencies providing services to children, families and adults have up to date contact details for all Specialist Domestic Violence Services within Wolverhampton to ensure that agencies are able to demonstrate that they signpost and refer victims appropriately to Domestic Violence Services. | Safer Wolverhampton Partnership |
| 22 | Safer Wolverhampton Partnership to seek assurances from the Safeguarding Children and Adults Boards that work carried out with children and adults at risk: Is outcome focused and of a high quality; and generates specific referrals for service provision; And that: there is timely and effective information exchange; and there is a process of challenge and monitoring when information sharing is poor and inadequate. | Safer Wolverhampton Partnership |
| 23 | Safer Wolverhampton Partnership to seek assurance that recommendations contained in individual agency IMRs have been implemented within 6 months from the publication of this Overview Report. | Safer Wolverhampton Partnership |
| 24 | Safer Wolverhampton Partnership should ensure that systems are in place to evidence the progress in relation to the recommendations made in this report. | Safer Wolverhampton Partnership |
| 3 | The Safer Wolverhampton Partnership to develop and monitor the implementation of a City-wide Domestic Violence Protocol to ensure appropriate referrals are made where children and adults are at risk from Domestic Violence and ensure the statutory agencies are providing and commissioning services in accordance with the Protocol. | Safer Wolverhampton Partnership |
| 4 | Safer Wolverhampton Partnership to ensure the relevant NHS Commissioning body has disseminated the guidance ‘Responding to Domestic Abuse’ from Royal College General Practitioners dated June 2012 to all GP practices, and required each GP Practice to nominate a member of staff to implement the guidance and provide a list of the nominated persons to the Safer Wolverhampton Partnership as evidence that this has been completed within 12 months from the date this report is accepted by the Safer Wolverhampton Partnership. | Safer Wolverhampton Partnership |
| 5 | The Safer Wolverhampton Partnership to ask the Domestic Violence Forum to develop an inventory of all relevant risk assessment tools and procedures currently used in Wolverhampton by Safeguarding Children and Safeguarding Adults services to promote: Consistency of language across them; The development of a pathway between them; Clarity and understanding of the different risk assessment tools and procedures used locally across the services; and Triggers to identify situations of Domestic Violence, Safeguarding Children and Adults and implement appropriate action And further, to require that the Safeguarding Children Board and the safeguarding Adults Board demonstrate that relevant Health, Social Care and Housing front line staff are aware of the inventory and are facilitating appropriate holistic risk assessments | Safer Wolverhampton Partnership |
| 6 | The Safer Wolverhampton Partnership to develop, publicise and implement a clear multi-agency pathway for agencies to refer High Risk cases to MARAC and require the statutory agencies: to demonstrate that their staff and those of services they commission are aware of their responsibilities and the processes for referring into a MARAC both in Wolverhampton and elsewhere; and to demonstrate that the multi-agency pathway is implemented. | Safer Wolverhampton Partnership |
| 7 | The Safer Wolverhampton Partnership to require the Wolverhampton Safeguarding Children Board to: ensure that statutory, independent and voluntary agencies who commission or provide services for children and young people review their individual agency’s training and awareness of staff regarding the referral process for children considered in need or at risk of significant harm; ensure that all agencies review their internal training policies and those of services they commission in respect of Domestic Violence and demonstrate that they are fit for purpose, current and reviewed annually. Training to include awareness training for all staff and volunteers up to its most senior management and supervisors; and ensure inter-agency training is commissioned regarding Domestic Violence Management to include the referral process to MARAC, Child Protection and Safeguarding Adults and to raising awareness of MARAC, DASH and the Barnardo’s Risk Assessment. | Safer Wolverhampton Partnership |
| 8 | The Safer Wolverhampton Partnership to require health service commissioners to demonstrate that they are commissioning services with appropriate and effective discharge planning procedures in place. | Safer Wolverhampton Partnership |
| 9 | The Safer Wolverhampton Partnership to convene an inter-agency workshop to facilitate a protocol for the development and implementation of Multi-agency Action Plans, to include a dispute resolution process and a review process, and to ensure and monitor its implementation. | Safer Wolverhampton Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||