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
Solihull review
CSP: Solihull
Published: April 2023
Year of death: 2014
Extracted: 8 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 identifies missed opportunities by agencies to recognise and respond to the perpetrator's acute mental health crisis, exacerbated by selective family disclosures and cultural attitudes towards mental health. It also highlights deficiencies in inter-agency communication, call-handling, and custody procedures for vulnerable individuals.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1a | That West Midlands Police and Hertfordshire Constabulary and commissioners of police custody health services relevant to these two Police areas should, in consultation with mental health services, consider the effectiveness of their mental health screening processes upon detention in light of the circumstances of this case. They should provide assurances back to the Safer Solihull Partnership of the robustness of the current systems to ensure that screening questions recognise and initiate appropriate response for vulnerable mentally disordered individuals held in detention. It is suggested that a screening tool such as POLQUEST or equivalent tool should be adopted where present screening questions are less extensive than those in this model. Assurances should be given upon the date of completion of any changes. | West Midlands Police | Hertfordshire Constabulary | Commissioners of Police Custody Health Services |
| 1b | Assurances are sought that training of all detention staff is provided to include POLQUEST or equivalent tool that improves their awareness of mentally vulnerable individuals and offenders and enable early identification of concerns. | West Midlands Police | Hertfordshire Constabulary |
| 2 | That where a POLQUEST or equivalent screening tool has identified a mentally vulnerable offender/individual at immediate risk at the time of arrest/or whilst in custody, a post release referral to mental health services should be made with the consent of the individual but subject to criteria established by Police forces without their consent if necessary and with regard to current guidance and legislation concerning disclosure or where other people are, or maybe, at risk including children. Assurances are sought from West Midlands Police and Hertfordshire Constabulary that their current processes are compliant with this recommendation and if not what action will be taken in reply to achieve this as a minimum. | West Midlands Police | Hertfordshire Constabulary |
| 3 | That pre-release risk assessment should be completed for all vulnerable detainees released from police custody. Custody staff should in addition ensure appropriate referrals on release and obtain appropriate expert advice on the safety of others following the release of a detained person. Assurances are sought from West Midlands Police and Hertfordshire Constabulary that their current processes are compliant with this. | West Midlands Police | Hertfordshire Constabulary |
| 4 | West Midlands Police and West Midlands Ambulance Service Domestic Homicide Review leads or relevant organisational leads should jointly consider the learning from this Domestic Homicide Review relating to call handling and review practice and procedures where incidents require both services. • This should include ensuring that call assessors from either service consistently identify risk within medical emergencies that may also be disorder or a risk of criminal injury to any person, or vice versa • West Midlands Ambulance Service should ensure that their Computer Aided Dispatch system allows risk from criminal injury and disorder identified during a call about a medical emergency, to be ‘flagged’ to ensure that this information is always shared with West Midlands Police to allow officers to respond appropriately • Both services should review how incidents are supervised to ensure identified risk has been addressed before the Computer Aided Dispatch system is closed • Both services to identify why current procedures can allow crucial information obtained by a call assessor not to be passed to a call handler and consequently not be shared with responders and effect necessary changes • The Manual Dispatch Terminal used by the ambulance service should be reviewed to ensure that it is capable of providing a responder with both key medical but also critical safety information (West Midlands Ambulance Service) • Training of call assessors should be reviewed to ensure it challenges assumptions arrived at from the tone and emotion of the caller Assurances are sought from West Midlands Police and West Midlands Ambulance Service of their organisational response to each of the points within this recommendation. The response should provide a statement back to Safer Solihull Partnership of any remedial action to be taken to meet these points as a minimum. | West Midlands Police | West Midlands Ambulance Service |
| 5 | That West Midlands Ambulance Service should review the SADPERSON risk assessment tool currently used by responders to predict future suicide or repetition of self-harm, in the light of current NICE guidance giving specific consideration to the fact that it should not be relied upon for this purpose. The service should give assurances back to Safer Solihull Partnership that it is compliant with nationally recognised best practice for assessing risk of self harm/suicide and change both their policy and practice accordingly. | West Midlands Ambulance Service |
| 6 | That West Midlands Police and Hertfordshire Constabulary in the light of section 9 of the Care Act 2014, consider and demonstrate that they understand local policies and procedures for Local Authority or Healthcare services; especially where it is believed a detainee has such care and support needs. That West Midlands Police and Hertfordshire Constabulary should identify with custody healthcare commissioners how, (with the consent of the detainee,) such referrals should be made and provide assurances back to the Safer Solihull Partnership of their considerations and findings. | West Midlands Police | Hertfordshire Constabulary |
| 7 | That the Safer Solihull Partnership require its five responsible authorities (Council, Police, Fire, Probation and Health) to include within its safeguarding training for front line practitioners the relationship between mental health and cannabis use. NHS England to be included. | Solihull Council | West Midlands Police | Fire | Probation | Local Health Services (Solihull) | NHS England |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||