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: January 2025 Year of death: 2020 Extracted: 19 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 identified concerns regarding communication barriers, missed opportunities for domestic abuse enquiry, and insufficient training for carers. It also highlighted how unconscious bias and intersecting identities created additional barriers for older, minoritised women seeking help.

Home Office classifications

12 tags

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

  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - serious or life limiting illness
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

19 recommendations pulled from the report · 8 matched to organisations in the index

Recommendation 1

Addressed to Dudley Domestic Abuse Local Partnership Board

Dudley Domestic Abuse Local Partnership Board to seek evidence-based assurance from its partner agencies that interpreting services are being consistently used with individuals who may be at risk of domestic abuse.

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

Recommendation 2

Addressed to Dudley Domestic Abuse Local Partnership Board

Dudley Domestic Abuse Local Partnership Board to seek evidence-based assurance from its partner agencies that partner agencies are consistently recording who accompanies an adult is present during discussions and assessments

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

Recommendation 3

Addressed to Dudley Safe and Sound | Dudley Domestic Abuse Local Partnership Board

Dudley Safe and Sound to promote safe, targeted and selective enquiry into domestic abuse across front-line health and social services. Dudley Domestic Abuse Local Partnership Board to seek assurance from front line health and social services that routine/ selective enquiry into domestic abuse is embedded into local policy and procedures, and routinely being undertaken, in keeping with the National Institute for Health and Care Excellence, Quality Standard QS 116

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

Recommendation 4

Addressed to Dudley Council

Dudley Council to ensure that all front-line Adult Social Care staff, including carers, have been trained in identifying and responding to domestic abuse

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

Recommendation 5

Addressed to Black Country Integrated Care Board | Dudley Group

Black Country Integrated Care Board and Dudley Group to review the communication pathway to ensure that all notifications concerning ‘did not attend’ issued by the hospital are being received and, where necessary, followed up by primary care.

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

Recommendation 6

Addressed to Dudley Domestic Abuse Local Partnership Board | Dudley Falls Prevention Partnership

Dudley Domestic Abuse Local Partnership Board to recommend to Dudley Falls Prevention Partnership that a domestic abuse focussed review of its policies and procedures is undertaken to ensure (a) that routine enquiry on domestic abuse is systematically included in assessments pre and post discharge after there has been an injury from a fall when considering falls prevention advice with an individual and (b) that public information signposts potential victims of domestic abuse to sources of help. (c) that written awareness materials are also made available in the main community languages in the area.

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

Recommendation 7

Addressed to Dudley Domestic Abuse Local Partnership Board

Dudley Domestic Abuse Local Partnership Board should continue to raise awareness with agencies and the public that domestic abuse occurs across communities and seek assurance that partner agencies are working to effectively address the barriers that Black and minoritised women face, including challenging prejudice and stereotypes that restrict the options available to them.

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

Recommendation 8

Addressed to Dudley Domestic Abuse Local Partnership Board

Dudley Domestic Abuse Local Partnership Board should continue to raise awareness with the public that domestic abuse occurs across the age span and advertise the help that is available. Once its toolkit for working with older people is developed and implemented, Dudley Domestic Abuse Local Partnership Board should monitor the numbers of older people being referred into services and seek assurance that partner agencies are working to effectively address the barriers that older women face, including challenging prejudice and stereotypes that restrict the options available to them.

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

Recommendation 9

Addressed to Dudley health and social care commissioners

Dudley’s health and social care commissioners of domiciliary care to consider introducing contractual requirements that care providers have domestic abuse policies and provide training and support to their care workers in the identification and response to domestic abuse.

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

Recommendation 10

Addressed to Dudley’s health and social care commissioners

Dudley’s health and social care commissioners to consider introducing contractual requirements that require contracted health and care services fully co-operate with domestic homicide and safeguarding reviews.

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

Recommendation 11

Addressed to Dudley Safe and Sound

Dudley Safe and Sound to consider making recommendations to government to extend the persons and bodies responsible for engagement with domestic homicide reviews, under section 9(4) of the Domestic Violence Crime and Victims Act 2004, to include private sector companies engaged in the provision of health and social care services.

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

Recommendation Adult Social Care 1

Addressed to Dudley Council Adult Social Care

72hr post discharge review to be carried out for all urgent care referrals, to ensure any changes in need or identification of aids and adaptations are confirmed in a timely manner.

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

Recommendation Dudley Group NHS Fou

Addressed to Dudley Group NHS Foundation Trust

Raise awareness of staff that they must document who else is present, including friends, family, interpreter at every contact as part of their record keeping

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

Recommendation Dudley Group NHS Fou

Addressed to Dudley Group NHS Foundation Trust

Continue to raise awareness and highlight the need for staff to obtain the wishes and feeling of patients in their care and discharge planning arrangements

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