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 Year of death: 2012 Extracted: 5 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 identified concerns regarding the monitoring of the perpetrator's mental health, particularly in relation to repeat prescriptions and communication between mental health services and the GP. It also questioned the suitability of DHR guidance for cases without prior identified domestic abuse.

Home Office classifications

22 tags

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

  • Victim - physical disability
  • Victim - serious or life limiting illness
  • Perpetrator - case heard in court
  • Perpetrator - was a carer
  • Perpetrator - carer for victim
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - serious or life limiting illness
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • DHR process - family contributed to dhr
  • DHR process - health services recommendations
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

5 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to Black Country Partnership NHS Foundation Trust

To ensure that discharges are appropriate, both for the patient’s well-being and that of their family and the wider community, the DNA (did not attend) policy to be revised and re-launched and compliance monitored

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

Recommendation 2

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

The practice to review their repeat prescribing protocol in respect of antidepressant prescribing to include requirements for periodic medication review to ensure that the patient receives effective treatment.

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

Recommendation 3

Addressed to Sandwell and West Birmingham Clinical Commissioning Group

The practice to receive training on record keeping and consider implementing templates to assist in consultations for those patients with mental health needs in order to ensure effective record keeping is in place and that the patient receives appropriate care.

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

Recommendation 4

Addressed to NHS England, Birmingham, Solihull and Black Country Area Team

That, in order to improve safe practice and patient care, the Safer Sandwell Partnership asks NHS England, Birmingham, Solihull and Black Country Area Team to remind all GPs practices of the potential risks of repeat prescribing protocols, particularly for patients with mental health issues. To support and inform best practice the NHS England, Birmingham, Solihull and Black Country Area Team will also circulate the Medical Protection Society guidance “Repeat prescribing for GPs” (March 2013) to all GPs practices.

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

Recommendation 5

Addressed to Home Office

That; in order to optimise the use of agencies’ resources (notably time and money) most effectively and efficiently, whilst still achieving the purpose of the domestic homicide review; the Safer Sandwell Partnership asks the Home Office to consider the option of different approaches to the undertaking DHRs in different circumstances (cf: the new guidance in relation to children’s reviews ).

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