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

Birmingham review

CSP: Birmingham Published: April 2023 Year of death: 2014 Extracted: 18 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

Agencies missed opportunities to identify and address domestic abuse, including coercive control and stalking, and its impact on children's behaviour. There was a lack of routine enquiry and insufficient awareness among professionals and the victim about the nature and risks of controlling behaviour, particularly post-separation.

Extracted recommendations

18 recommendations pulled from the report

#	Recommendation	Addressed to
Clinical Commissioni	All practice staff should receive training on domestic abuse	Clinical Commissioning Group
Clinical Commissioni	The CCG should highlight to GPs that if a patient is accompanied to appointments, this should be documented	Clinical Commissioning Group
Education: 1	All schools (including Academies, Free and Independent Schools) must commission training on domestic abuse for all staff including special education needs coordinators and behavioural coordinators.	Education
Education: 2	Special educational needs annual review to include questions about home life.	Education
Education: 3	fCAF should still be used within schools to formalise the early help offer to children and families even when a child is subject to a statement of special educational needs .	Education
Education: 4	Closer liaison with alternative provider sites to ensure record retention policies are adhered to effectively.	Education
Forward Thinking Bir	Domestic abuse within the household should be routinely considered as part of the CAMHS initial assessment.	Forward Thinking Birmingham (CAMHS)
Forward Thinking Bir	Training on domestic abuse for all staff.	Forward Thinking Birmingham (CAMHS)
Heart of England Fou	All acute paediatricians to be notified when they see children with problematic and aggressive behaviour which they are asked to investigate that they include inquiries in relation to domestic abuse as part of their investigation	Heart of England Foundation Trust
Heart of England Fou	Documentation in relation to punch injuries presented in under 18s to the Emergency Department must include details of the precursor to the event and assessment of the young person's mood and coping strategies to enable appropriate communication with Primary Care about the event and consideration of self-harm protocols.	Heart of England Foundation Trust
Heart of England Fou	Raise awareness of the Women's Aid drop-in service and audit attendance at the service. The domestic abuse flowchart should include signposting victims to the Women's Aid drop-in service, reminding staff to make a referral to Children's Social Care and informing the victim of this.	Heart of England Foundation Trust
i	The Home Office should consider raising awareness of coercive controlling behaviour by launching a campaign around the legislation that criminalises patterns of coercive, controlling and psychological abuse	Home Office
ii	Birmingham Community Safety Partnership (in conjunction with the Birmingham Violence Against Women and Children Steering Group) should consider raising awareness locally of coercive, controlling and psychological abuse to coincide with the introduction of the legislation (and the Home Office campaign). The campaign should be aimed at the general public  The campaign should (for example) o Help victims from all communities understand patterns of controlling and coercive behaviour. o Highlight the problem of stalking and harassment in order to help victims recognise inappropriate behaviour such as constant texting, the use of trackers and spyware to check where they are and what they are doing. o Equip victims to recognise what is "normal" behaviour and what might be unreasonable or potentially dangerous behaviour by a partner. o Demonstrate the consequences for perpetrators if they:  Stalk or use spyware to track a victim.  Use controlling or coercive behaviour. o Raise awareness of services that can offer help, support and advice.	Birmingham Community Safety Partnership \| Birmingham Violence Against Women and Children Steering Group
iii	Birmingham Community Safety Partnership should request that the Violence Against Women and Children Steering Group should set out the learning outcomes for all domestic abuse training provided by agencies working with children and families. Training must be targeted at both strategic and operational levels and be in line with Birmingham domestic abuse standards. The learning outcomes from domestic abuse training should be embedded in all agencies' commissioned training arrangements and should include knowledge and skills to understand (amongst other things):  The offence of controlling or coercive behaviour  The importance of routine enquiry and speaking with victims on their own  The rationale for documenting when individuals are accompanied to appointments  Information about the use of technology in stalking	Birmingham Community Safety Partnership \| Violence Against Women and Children Steering Group
Stepping Stones: 1	Ensure awareness, and application of, Stepping Stones Family Support Project Domestic Abuse Policy (2015) across the whole of the workforce (through combination of induction, online learning, supervision, face-to-face training, appropriate to role.	Stepping Stones
Stepping Stones: 2	A presentation to be given to the Children’s Services Leadership Team (CSLT, middle managers) about the learning from our involvement in this case – for cascading to service leads and team members.	Stepping Stones
Stepping Stones: 3	In quarter 3 (Oct-Dec) case file audits undertaken will specifically focus on checking the explicit purpose for each visit, evidencing women (especially) are asked about Domestic Abuse at outset of work.	Stepping Stones
Stepping Stones: 4	Ensure the awareness of domestic abuse (zero tolerance) and promote sources of support for adults and children (Childline) across all services – suitable to the age of services users.	Stepping Stones
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗