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

Dudley review

CSP: Dudley Published: November 2023 Year of death: 2018 Extracted: 23 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
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.

Home Office classifications

41 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - psychosis
  • Victim - had been a victim of an abuser before
  • Victim - referred to marac at any time
  • Victim - case heard at marac before homicide
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - idva or other domestic abuse support service 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
  • DHR process - other recommendation themes

Extracted recommendations

23 recommendations pulled from the report · 14 matched to organisations in the index

Recommendation 1

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) ↗

Recommendation 1

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) ↗

Recommendation 1

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 2

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 3

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) ↗

Recommendation 4

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) ↗

Recommendation 4

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) ↗

Recommendation 4

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) ↗

Recommendation 4

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) ↗

Recommendation 5

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) ↗

Recommendation 5

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) ↗

Recommendation 5

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) ↗

Recommendation 6

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) ↗

Recommendation 7

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) ↗

Recommendation 8

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) ↗

Recommendation 9

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) ↗