Summary AI-generated
Verify against the full report at the source link
The review highlights systemic failures in recognising and responding to the victim's long history of domestic abuse, coercive control, and stalking, exacerbated by substance misuse and mental ill-health. Concerns include inconsistent risk assessment, lack of perpetrator accountability, and challenges in engaging the victim with support services.
Extracted recommendations
23 recommendations pulled from the report · 14 matched to organisations in the index
Addressed to
Dudley Safe and Sound
Dudley Safe and Sound should review and seek assurance about the degree to which agencies support front-line staff and their supervisors to understand this breadth and range of domestic abuse, coercive control and stalking behaviours as well as identify and respond to risk.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Group NHS Foundation Trust
Funding to be secured for an Independent Domestic Violence Advocate in the Emergency Department.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley and Walsall Mental Health Partnership NHS Trust
To ensure that all professionals continue to access the safeguarding practitioners for advice and that they play a key role in the early identification and response to domestic abuse and coercive and controlling behaviour.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Clinical Commissioning Group
Monitor the impact of the IRIS Programme within primary care
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Safe and Sound
Dudley Safe and Sound should continue to raise public awareness specifically about domestic abuse, coercive control, stalking and harassment
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Group NHS Foundation Trust
Continue to work toward meeting the NICE Quality Standard on Domestic Violence and Abuse QS116
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley and Walsall Mental Health Partnership NHS Trust
To ensure that all staff complete their mandatory domestic abuse training and for the Safeguarding Team to promote and encourage staff to attend external training sessions.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Clinical Commissioning Group
Continue to work to meet NICE Quality Standard on Domestic Violence and Abuse
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Safe and Sound
Dudley Safe and Sound should ensure that the Domestic Violence Disclosure Scheme is well known by agencies and the public alike.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Group NHS Foundation Trust
Domestic abuse training to continue to emphasise the connection between domestic abuse and substance misuse.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley and Walsall Mental Health Partnership NHS Trust
To identify themed DHR case studies to be included in the safeguarding newsletters, domestic abuse training and bulletins which are circulated to all Trust staff.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Clinical Commissioning Group
Domestic abuse training to emphasise the importance of ‘asking the question’
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Safe and Sound | Safeguarding Boards
Dudley Safe and Sound and Safeguarding Boards should seek assurance from agencies that services and pathways are trauma-and-gender informed and flexible enough to effectively engage with women facing multiple disadvantage, using the West Midlands Domestic Violence Standards and the trauma-and-gender informed principles of the national Women’s Taskforce on Mental Health as guides.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Group NHS Foundation Trust
Emergency Department staff to receive bespoke training in regard to alcohol misuse and local services available to give advice and support.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley and Walsall Mental Health Partnership NHS Trust
For the Trust to develop the of Top 10 Safeguarding Tips which will support staff in their day to day practice by sharing key learning points.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Clinical Commissioning Group
Raise awareness of domestic abuse, National Centre for Domestic Violence and stalking amongst professionals and patients
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Black Country Women’s Aid
Black Country Women’s Aid to provide evidence of effective interventions and engagement methodology for victims who present with multiple and complex issues that may have resulted in them disengaging from other services.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Group NHS Foundation Trust
Safeguarding training to continue to discuss self-neglect and possible indicators.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley and Walsall Mental Health Partnership NHS Trust
As an area of good practice, the Trust will ensure that staff are alert to non-verbal behaviours and be encouraged to collate a genogram to understand the family network. This is following compilation of the combined agency chronology as it is now evident that both the victim and the perpetrator had troubled childhoods and they both experienced stressful or traumatic events, including physical and sexual abuse. Children raised in environments where violence, assault and abuse are common will often come to believe this behaviour is normal and therefore find it difficult to establish and maintain healthy relationships. These ACEs (Adverse Childhood Experiences) are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan and overtime could have contributed to them both developing negative coping mechanisms.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Safe and Sound
Dudley Safe and Sound should seek assurance from its agencies that they are able to accurately record and access records on an abuser’s previous violent history and apply this to current risk assessments and responses.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
West Midlands Police
West Midlands Police should provide evidence of the improvements made in the policing of domestic abuse to Dudley Safe and Sound, particularly compliance and impact of the changes concerning: the mandatory completion of DASH; referrals to specialist domestic abuse and alcohol treatment agencies, and the impact of portable mobile devices.
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Adult Social Care
Adult Social Care should provide evidence of how it has improved its response to MARAC and achieved outcomes for domestic abuse victims in the following areas:
• Prioritisation of MARAC cases and workload capacity of staff enabling an urgent response
• Co-terminosity between Multi-Agency Safeguarding Hub and MARAC
• Effective communication between Adult Social Care MARAC representative and allocated social workers
• Effective internal escalation and feedback to MARAC when task cannot be fulfilled
• Effective working relationships with IDVA service
Verified wording from the published review · Original review (PDF) ↗
Addressed to
Dudley Safe and Sound | Office of the Police and Crime Commissioner
Dudley Safe and Sound should consult with the Office of the Police and Crime Commissioner and evidence how the recent improvements to MARAC arrangements have impacted upon agency involvement, victim safety and holding perpetrators to account.
Verified wording from the published review · Original review (PDF) ↗