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: May 2025
Year of death: 2021
Extracted: 36 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 systemic failures in recognising and responding to escalating domestic abuse, including coercive control and reproductive coercion. Agencies lacked professional curiosity, timely engagement, and effective information sharing, contributing to the victim's unaddressed needs and suicide risk.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Dudley Safe and Sound to seek from West Midlands Police and Crime Commissioner an analysis of West Midlands Police response times for domestic abuse incidents. | Dudley Safe and Sound | West Midlands Police and Crime Commissioner |
| 10 | Health and social care services in Dudley to advise Dudley Safe and Sound (i) how remote working has impacted upon their ability to make safe enquiry into domestic abuse since the Covid pandemic and (ii) how they now maximise opportunities for routine, selected or targeted enquiry into domestic abuse and mitigate risk. | Health and social care services in Dudley |
| 2 | Dudley Safe and Sound to promote the connection between suicide and domestic abuse with the Dudley Suicide Prevention Partnership and jointly consider the recommendations for local areas promoted by the Zero Suicide Alliance, as follows: • “Include Domestic Abuse as an explicit priority within your local multi-agency Suicide Prevention Strategy. • Ensure your local Real Time Suicide Surveillance system asks specific questions about domestic abuse including: victim, perpetrator, children; the type of abuse; whether current or former relationship. • Ensure domestic abuse training is completed by all mental health staff. (Consider making this a commissioning condition). • Ensure mental health and suicide prevention training completed by all domestic abuse staff. (Consider making this a commissioning condition). • Ensure provision of recovery (including trauma aware elements) programmes for female and male victims of domestic abuse in the months and years after the abuse has stopped. • Undertake a detailed analysis of RTSS • Undertake a detailed analysis of data held by Mental Health Services • Consider revising risk assessments to ask the following questions of both the victim and the perpetrator: have you self-harmed? Have you felt suicidal? Have you made a suicide attempt? (and over different time periods)…. • Ensure that local suicide bereavement services are trained / experienced in supporting families after the suicide of a DA victim or perpetrator.” (Kent and Medway Public Health, 2022) | Dudley Safe and Sound | Dudley Suicide Prevention Partnership |
| 3 | Dudley Safe and Sound to forge links with the Black Country Healthcare NHS Foundation Trust and support the Trust in its endeavour to secure ‘real-time-surveillance’ data on suicide, and also support the Trust to develop a plan to promptly deliver support to family and friends, as appropriate. | Dudley Safe and Sound | Black Country Healthcare NHS Foundation Trust |
| 4 | Dudley Safe and Sound to share the report of this review with Dudley Suicide Prevention Partnership to ensure that the heightened risk of suicide amongst Gypsy, Roma, Traveller Communities and the ramifications of suicide are illustrated and feeds into the Suicide Prevention Strategy. | Dudley Safe and Sound | Dudley Suicide Prevention Partnership |
| 5 | Black Country Women’s Aid and CHADD to provide assurance to Dudley Safe and Sound that the pathway for referrals to specialist domestic abuse services from DART are effective and that there is feedback provided where engagement has not been possible with a victim of domestic abuse. | Black Country Women’s Aid | CHADD |
| 6 | Dudley Safe and Sound to seek from partner agencies (i) how they are promoting an understanding of coercive control within their workforce and (ii) what impact their workforce development on coercive control has had on their practice, including the impact upon the identification, risk assessment and response to domestic abuse | Dudley Safe and Sound | partner agencies |
| 7 | Dudley Safe and Sound to ensure that activities to raise awareness and prevent domestic abuse in Dudley also target the Traveller community | Dudley Safe and Sound |
| 8 | Dudley Safe and Sound to provide and promote targeted messages to young people experiencing abuse in their relationships in their public communication channels, using language that is accessible to young people, and signposting them to the dedicated support that is available for them. Dudley Safe and Sound to work with further and higher education establishments in their area to: • promote awareness specifically about domestic abuse in young people’s relationships and educational sabotage • introduce direct questioning on domestic abuse when a pregnancy is disclosed by a young woman • promote the specialist services that are available to those experiencing domestic abuse across the age range • monitor the outcomes of their awareness raising in further and higher education through increased disclosure of domestic abuse by young people, recognising that domestic abuse is under-reported in this age range | Dudley Safe and Sound | further and higher education establishments |
| 9 | Dudley Safe and Sound to share this report with Birmingham Community Safety Partnership to ensure that those issues which have relevance can be addressed across the two areas. | Dudley Safe and Sound | Birmingham Community Safety Partnership |
| BCHC_1 | Assurance required within the health visiting service that process is applied when there are workforce absences. | Birmingham Community Healthcare NHS Trust |
| BCHC_2 | BCHC safeguarding team to develop guidance for practitioners to apply and support professional curiosity practices. A working group to be commenced, lead by safeguarding head of service and named nurse safeguarding children to support the development of an aide memoir to enhance clinical practice. | Birmingham Community Healthcare NHS Trust |
| BCHC_3 | BCHC practitioners will have access to shared cared records. Access rights and remit are being escalated. This will allow practitioners access to read only information of any child or young person in relation to health and children services | Birmingham Community Healthcare NHS Trust |
| BCHC_4 | Assurance required within Birmingham Forward Steps that the process for reviewing and documenting in records is as per BCHC record keeping policy. | Birmingham Community Healthcare NHS Trust |
| BCHFT_1 | Information sharing and record keeping related to parental concerns are to be clearly evidenced and documented within individual records. Any risks pertaining to or impact on parental capacity should be considered as part of any ongoing assessments conducted by BCHFT staff across the Trust when considering transferrable risks | Black Country Healthcare NHS Foundation Trust |
| BCHFT_2 | Risk assessments to be routinely completed as part of the health visiting holistic assessment following incidents such as domestic abuse, mental health episodes and any other safeguarding concerns or changes in life circumstance that may impact on risk. | Black Country Healthcare NHS Foundation Trust |
| BCHFT_3 | If there is no health representation at DART meetings there needs to be a clear assurance process in place to ensure all incidents are being disseminated in a timely way and acted upon within the appropriate timescales | Black Country Healthcare NHS Foundation Trust |
| BCHFT_4 | Joint assessments to be considered if there are 2 agencies or more involved in or aware of DART incidents. | Black Country Healthcare NHS Foundation Trust |
| BCHFT_5 | To provide evidence-based assurance that actions to build professional curiosity and confidence to address domestic abuse have been effective in the identification, protection and support to children and families experiencing domestic abuse. | Black Country Healthcare NHS Foundation Trust |
| BCHFT_6 | To provide assurance that there is safe continuity of care from health visitors for families with young children when they move out of the Dudley area. The Trust to provide evidence that verbal handover is systematically being done prior to the transfer of health visiting records from one area to another | Black Country Healthcare NHS Foundation Trust |
| DCASC_1 | Develop Suicide Risk Process for front of house and MASH | Dudley Council Adult Social Care |
| DCCSEH_1 | Family support staff absence. Cases to be monitored by line manager during staff absence. Cases are RAG rated in respect of known risks and contact is maintained with families through the use of the duty system operated within each Family Support Team. Consideration given to re-allocate cases if RAG rating is RED or staff absence is longer than 4 weeks. | Dudley Council Children’s Services - Early Help |
| DCCSEH_2 | Agreed contact levels with families should be maintained and a dynamic risk assessment carried out if contact is unsuccessful. This should include consideration of undertaking a home visit where it is assessed it is required. | Dudley Council Children’s Services - Early Help |
| DCCSEH_3 | All Family Support staff to complete the Domestic Abuse Basic Awareness training as part of their induction plans. Opportunities for staff to develop and enhance their skills and understanding of domestic abuse and suicide prevention are considered within staff supervision and annual reviews. A system of monitoring staff development uptake is developed and regularly shared with line managers. | Dudley Council Children’s Services - Early Help |
| DCCSEH_4 | Early help services continue to adopt a ‘whole family’ approach which should include perpetrators of domestic abuse in all Early Help Assessments and plans | Dudley Council Children’s Services - Early Help |
| DCCSEH_5 | Early help services understand the importance of timely referrals to specialist domestic abuse agencies when consent to do so has been received. Where there are barriers to referral to certain services, alternative options need to be explored to meet the needs of service users. | Dudley Council Children’s Services - Early Help |
| DGNHSFT_1 | To improve awareness in the Emergency Department of Domestic Abuse indicators and selective enquiry. | Dudley Group NHS Foundation Trust |
| DGNHSFT_2 | Domestic Abuse Policy to be updated to reflect staff responsibilities when patient has taken an overdose, suicidal ideation, suicide attempts or self-harm and consideration around discharge | Dudley Group NHS Foundation Trust |
| NTU_1 | To introduce direct enquiry on domestic abuse during conversations concerning pregnancy and maternity for affected students. | Nottingham Trent University |
| PC_1 | Develop practitioner’s professional curiosity and recognise it as vital in completing a holistic assessment and is utilised by GP Practice clinicians | Primary Care |
| PC_2 | The Domestic Abuse Policy update that is now due includes the addition of direct questioning and the documenting of when a client is seen alone or the parties present | Primary Care |
| PC_3 | Alerts are considered in relation to identifying the risks and needs of the patient including a link between a parent and child’s records | Primary Care |
| UHB_1 | Routine enquiry should be asked 3 times throughout pregnancy including the postnatal period when the patient is seen face to face, if the patient attends and is accompanied, staff are to try and create an opportunity and safe space to complete routine enquiry | University Hospitals Birmingham NHS Foundation Trust |
| WMP_1 | To provide assurance to Dudley Safe and Sound about the accuracy of their risk assessments in domestic abuse | West Midlands Police |
| WMP_2 | To report to Dudley Safe and Sound on the impact of the use of the ‘Child Abuse App’ on the identification and response to children when responding to domestic abuse incidents | West Midlands Police |
| WMP_3 | To explore whether adopting the ‘opting in’ approach, that has been implemented with victims of rape and serious sexual assault, would be similarly effective and could be implemented for all victims of domestic abuse. | West Midlands Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||