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
Wolverhampton review
CSP: Wolverhampton
Published: August 2023
Year of death: 2014
Extracted: 45 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 repeatedly failed to recognise and assess the high risk of harm to the victim, leading to missed opportunities for multi-agency intervention and safeguarding, particularly regarding coercive control, threats to kill, and cultural pressures. There was also a lack of focus on perpetrator management.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| Black Country Partne | Review current discharge communication process with Crisis teams and GP. | Black Country Partnership |
| Black Country Partne | Review Domestic Abuse training available to staff internally and externally. | Black Country Partnership |
| Black Country Partne | Raise awareness of domestic abuse with staff within Black Country Partnership Foundation Trust. | Black Country Partnership Foundation Trust |
| Black Country Partne | Review current record keeping to ensure it’s in line with NHSLA and NMC record keeping standards. | Black Country Partnership |
| Haven: 1 | Report writing and Storing Information will be embedded in staff training and Induction | The Haven Wolverhampton |
| Haven: 2 | Multi agency working and Sharing information will be a standing agenda on team meetings. Staff to present good practice examples and potential queries to discuss as a holistic approach. | The Haven Wolverhampton |
| Haven: 3 | The Haven Wolverhampton staff to attend multi agency training for Safeguarding Children and Adults. | The Haven Wolverhampton |
| Haven: 4 | The Haven Wolverhampton to inform Police when the name of the Perpetrator is known. | The Haven Wolverhampton |
| Haven: 5 | The Haven Wolverhampton to contact and seek advice with Children Services if it is disclosed by parents that children have been present when a domestic violence incident has occurred. | The Haven Wolverhampton |
| Royal Wolverhampton | Increase provision of Domestic Violence awareness training for Midwifery and Health Visiting services (base line March 2014). | Royal Wolverhampton Trust |
| Royal Wolverhampton | To review domestic violence guidance and to convert to policy. | Royal Wolverhampton Trust |
| Royal Wolverhampton | Review of standing operating procedures related to domestic violence in midwifery and health visiting services. | Royal Wolverhampton Trust |
| S:1 | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Wolverhampton Partnership will develop plans for skilling up workers to have confidence to undertake safety planning. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Wolverhampton Partnership |
| S:2 | The Safeguarding Children Board, Safeguarding Adults Board and Safer Wolverhampton Partnership will develop an effective assurance process to ensure that all member agencies are implementing and complying with the agreed Overarching Domestic Violence Protocol and its principles. | Safeguarding Children Board | Safeguarding Adults Board | Safer Wolverhampton Partnership |
| S:3 | Safer Wolverhampton Partnership will put in place a strategy for a co-ordinated approach to perpetrator and offender management. | Safer Wolverhampton Partnership |
| S:4 | The Safeguarding Children Board, Safeguarding Adults Boards and Safer Wolverhampton Partnership will: o Deliver a programme of multi-agency, culturally aware training; o Actively engage partners and communities to identify and respond to barriers of service access; o Deliver targeted communications to promote the rights of victims and availability of support within communities where services are under-utilised. | Safeguarding Children Board | Safeguarding Adults Boards | Safer Wolverhampton Partnership |
| S:5 | The Safeguarding Children Board and Safeguarding Adult Board will monitor compliance with the Overarching Domestic Violence Protocol through Section 11 audits and annual assurance statements respectively; The Safeguarding Children Board, Safeguarding Adult Board and Safer Wolverhampton Partnership will extend the availability of training for front-line practitioners. | Safeguarding Children Board | Safeguarding Adult Board | Safer Wolverhampton Partnership |
| S:6 | The Executive Board of the Wolverhampton Domestic Violence Forum will: o Improve coordination and development of MARAC in line with CAADA self-assessment findings; o Ensure the MARAC development plan is fully implemented; o Monitor agency referrals to MARAC and completion of MARAC actions. | Executive Board of the Wolverhampton Domestic Violence Forum |
| The Children’s Centr | Write an agency specific protocol regarding Domestic Violence. | The Children’s Centre |
| The Children’s Centr | All Family Support Workers should undertake annual training on Domestic Violence including cultural aspects. | The Children’s Centre |
| The Children’s Centr | All Children’s Centres should have a named ‘expert’ within their Centre to whom they can refer with issues of Domestic Violence. | The Children’s Centre |
| The Children’s Centr | All Children’s Centres should run a Freedom Programme. | The Children’s Centre |
| The Children’s Centr | Clear information should be gained from referrers who record Domestic Violence on the Referral Form including any historical factors. | The Children’s Centre |
| The Children’s Centr | Cases discussed with Senior staff whether informally or formally e.g. during Supervision or Reflective Practice sessions should be recorded on the family’s Case Notes as per the Case File Audit Policy. | The Children’s Centre |
| The Children’s Centr | The Worker’s name who delivered / was responsible for group delivery such as Stay and Play, Nail and Beauty course is recorded consistently on the Synergy database. | The Children’s Centre |
| The Children’s Centr | All case files have an up to date Risk Assessment. | The Children’s Centre |
| The Health Centre: 1 | The notification of domestic violence must be marked clearly and promptly on all affected GP records so that all members of the team are aware of this. | The Health Centre |
| The Health Centre: 2 | The notification of domestic violence must stimulate internal practice review, along the lines of a significant event analysis. | The Health Centre |
| The Health Centre: 3 | Improved training in domestic violence and safeguarding vulnerable adults | The Health Centre |
| The Health Centre: 4 | Improved access to social services/other agencies for advice and guidance on domestic violence cases for the primary health care team | The Health Centre |
| The Primary School: | All key staff to be aware of indicators of harm in relation to domestic violence. | The Primary School |
| The Primary School: | Review updated models of practice for liaising with external agencies which have been employed following the appointment of the Pastoral Officer. | The Primary School |
| The Primary School: | To be aware of agencies who can support victims of domestic violence. | The Primary School |
| West Midlands Police | West Midlands Police to ensure through training days and the West Midlands Police force intranet site that all police officers and staff are to reinforce the Domestic Abuse Policy (2013). | West Midlands Police |
| Wolverhampton Childr | The Over-Arching Domestic Violence Protocol and Guidance is embedded in policy, practice and delivery. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | All front line practitioners and managers receive specialist domestic violence training. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | Front line practitioners are able to undertake a DASHH risk assessment or have an agreed referral pathway for a DASHH risk assessment to be undertaken as part of any social work assessments that relate to domestic violence. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | All front line practitioners and managers demonstrate cultural awareness in regard to particular vulnerable groups. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | Practitioners need to be clear on stepping up and down arrangements between Early Help Services and Children’s Social Care Services to ensure families continue to be supported. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | Managers to ensure where agreed, cases are closed in a timely manner. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | Practitioners to receive training on outcome focused, time bound care planning. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | There is a developed understanding between Adult and Children Services to promote improved joined up working. | Wolverhampton Children’s Social Care |
| Wolverhampton Childr | Practitioners and managers to ensure a holistic approach is implemented to assessment and action planning to ensure the needs of the children, victims and perpetrators are considered where they wish to remain together. | Wolverhampton Children’s Social Care |
| Wolverhampton Homes: | Review attendance of and contribution to MARAC by Wolverhampton Homes. | Wolverhampton Homes |
| Wolverhampton Homes: | Consider the inclusion of a question specific to issues surrounding domestic violence/abuse as part of the application individuals/households have to make to . register with WH for accommodation | Wolverhampton Homes |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||