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.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
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.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | 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. | Dudley Domestic Abuse Local Partnership Board |
| 10 | 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. | Dudley’s health and social care commissioners |
| 11 | 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. | Dudley Safe and Sound |
| 2 | 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 | Dudley Domestic Abuse Local Partnership Board |
| 3 | 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 | Dudley Safe and Sound | Dudley Domestic Abuse Local Partnership Board |
| 4 | Dudley Council to ensure that all front-line Adult Social Care staff, including carers, have been trained in identifying and responding to domestic abuse | Dudley Council |
| 5 | 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. | Black Country Integrated Care Board | Dudley Group |
| 6 | 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. | Dudley Domestic Abuse Local Partnership Board | Dudley Falls Prevention Partnership |
| 7 | 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. | Dudley Domestic Abuse Local Partnership Board |
| 8 | 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. | Dudley Domestic Abuse Local Partnership Board |
| 9 | 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. | Dudley health and social care commissioners |
| Adult Social Care 1 | 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. | Dudley Council Adult Social Care |
| Adult Social Care 2 | Discharge team to review discharge documentation prior to discharge. | Dudley Council Adult Social Care |
| Black Country Integr | Provide IRIS training for the practice | Black Country Integrated Care Board |
| Black Country Integr | Facilitate safeguarding training for all Practice Nursing Staff in Dudley. | Black Country Integrated Care Board |
| Black Country Integr | Introduce a domestic abuse policy in the GP Practice concerned | Black Country Integrated Care Board |
| Dudley Group NHS Fou | Raise awareness and accessibility around use of interpreters | Dudley Group NHS Foundation Trust |
| Dudley Group NHS Fou | 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 | Dudley Group NHS Foundation Trust |
| Dudley Group NHS Fou | 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 | Dudley Group NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||