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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

25 tags

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

  • Victim - mental ill health
  • Victim - depression
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • DHR process - family contributed to dhr
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service recommendations
  • DHR process - school 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

Extracted recommendations

18 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation Education: 1

Addressed to Education

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.

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

Recommendation Education: 3

Addressed to Education

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 .

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

Recommendation Heart of England Fou

Addressed to Heart of England Foundation Trust

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

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

Recommendation Heart of England Fou

Addressed to Heart of England Foundation Trust

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.

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

Recommendation Heart of England Fou

Addressed to Heart of England Foundation Trust

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.

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

Recommendation i

Addressed to Home Office

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

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

Recommendation ii

Addressed to Birmingham Community Safety Partnership | Birmingham Violence Against Women and Children Steering Group

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.

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

Recommendation iii

Addressed to Birmingham Community Safety Partnership | Violence Against Women and Children Steering Group

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

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

Recommendation Stepping Stones: 1

Addressed to Stepping Stones

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.

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

Recommendation Stepping Stones: 2

Addressed to Stepping Stones

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.

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

Recommendation Stepping Stones: 3

Addressed to Stepping Stones

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.

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

Recommendation Stepping Stones: 4

Addressed to Stepping Stones

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.

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