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: April 2023 Extracted: 11 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 missed opportunities by agencies to identify risks related to the perpetrator's alcohol misuse and controlling behaviour, coordinate support for the child, and address communication barriers for the victim.

Home Office classifications

16 tags

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

  • Victim - had been a victim of an abuser before
  • Children - subject to child protection or domestic abuse prior to homicide
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

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

Recommendation 1

Addressed to Sandwell Safeguarding Children Board

Sandwell Safeguarding Children Board provides assurance that the Lead Professional role (as outlined in Working Together 2015) is understood by all local partner organisations and embedded in practice.

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

Recommendation 1

Addressed to Black Country Partnership NHS Foundation Trust

To review a referral form against good practice exemplars from other similar providers and propose amendments

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

Recommendation 1

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

Safeguarding Training to be provided for clinicians in primary care settings on how to approach difficult topics with patients to include the toxic trio, the impact of alcohol misuse on parenting capacity and the signs, symptoms and behaviours children may display when living in a household where there is domestic abuse, and Record Keeping.

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

Recommendation 2

Addressed to Safer Sandwell Partnership Board

By September 2017, Safer Sandwell Partnership Board will ensure that work to address domestic abuse, alcohol issues and work with Polish and other Eastern European communities and families is better integrated across the Board’s sub groups and in the delivery plans of key partners, so that we better engage them in preventing and reducing domestic abuse, and in alcohol misuse prevention, treatment and support programmes. We will set specific outcomes and actions to achieve effective support for Polish and Eastern European domestic abuse victims and their families.

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

Recommendation 2

Addressed to Black Country Partnership NHS Foundation Trust

Propose that the Tier 2 provider routinely checks ECAF upon receipt of particular referrals to ensure Early Help contacts and risks are collated

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

Recommendation 2

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

A safeguarding advice and support pathway for primary care to be developed and disseminated to GP practices in Sandwell and West Birmingham.

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

Recommendation 3

Addressed to Safer Sandwell Partnership

The Safer Sandwell Partnership to contact key organisations involved with this DHR and the Domestic Abuse Strategic Partnership partners and remind them of the learning from both DHRs regarding the use of interpreters; the importance of the appropriate use of interpreters and asking for assurance (with evidence) that interpreters are being appropriately used.

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

Recommendation 3

Addressed to Black Country Partnership NHS Foundation Trust

Review of a specific policy DNA /standard operating procedure against good practice exemplars from other similar providers and update as necessary

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

Recommendation 3

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

GP practices in Sandwell and West Birmingham will be advised that best practice indicates the use of interpreting services (face to face or language line) during health consultations with clients whose first language is not English, and that domestic abuse resources in alternative languages will be displayed in all GP practices.

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

Recommendation 4

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

A ‘new to practice’ patient protocol is developed by the GP safeguarding forum for use by practices in Sandwell and West Birmingham.

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

Recommendation 5

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

Every practice should have a DNA to include ‘Was Not Brought’ (for children) policy that contains guidance on record keeping.

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