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: September 2025 Year of death: 2022 Extracted: 9 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 highlights concerns regarding the perpetrator's history of alleged domestic abuse, the inadequate multi-agency information sharing that led to him being granted a firearms license, and the victim's diminishing autonomy under subtle coercion and control.

Extracted recommendations

9 recommendations pulled from the report

#	Recommendation	Addressed to
1	Sharing information concerning risk and vulnerability with Higher Education institutions. The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Investigate the development of a ‘disclosure form’ which will require the agency making the submission to the MARAC (or other relevant multi-agency arrangement) to secure the consent of the client to disclose necessary information to other MARAC Partners prior to the MARAC submission being made. The disclosure form – with the relevant information – could then be shared securely with each Partner on the MARAC prior to the meeting taking place. This disclosure form may allow – where necessary – information to be shared with institutions of Higher Education; • Consider whether safeguarding training could be shared across the interface with higher education services within the CSP area to help share knowledge of local agencies and their threshold for providing support; • To consider forging links with the Staffordshire and Stoke-on Trent CSPs to share their training across the interface with the Universities within their organisational footprint.	Safe and Sound (the Dudley Community Safety Partnership)
2	Firearms Licensing The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seek assurance from the West Midlands Police that the DARA3 is applied for first responders and the use of DASH is promoted as a dynamic assessment, specific to the client, used for conducting secondary risk assessments; • Consider the development of a multi-agency assessment of firearms applications and invites the MARAC Governance Group to act as the assessing Panel; • Invite the West Midlands Police to apply a resolution to any GDPR issues at the point of application by explicitly informing the applicant that their application will be referred to a multi-agency forum for assessment; • Apply due diligence to a process whereby, as necessary, applications that may have potential for risk to transfer to children, colleagues, family members, etc. to be referred to the appropriate safeguarding authority and the employee alert system across Dudley MBC	Safe and Sound (the Dudley Community Safety Partnership)
3	Adverse experiences in early adulthood The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seek assurance from partners that trauma informed practice is being embedded across the Borough • Assess the development of trauma informed practice, specifically for people seeking asylum	Safe and Sound (the Dudley Community Safety Partnership)
4	Use of the Pathfinder Toolkit and NICE Guidance. The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seek assurance from all Partners that they have suitable and effective domestic abuse and safeguarding training which is available to their staff	Safe and Sound (the Dudley Community Safety Partnership)
5	Suicide and the impact on family and friends The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Establish links with the Black Country Healthcare NHS Foundation Trust and supports the Trust in its endeavour to secure ‘real-time-surveillance’ (RTS) data on suicide and supports the Trust to develop a plan to promptly deliver support to family and friends, as appropriate; • Seek support and guidance from the Offices of HM Coroner to deliver the ambition to secure ‘real-time surveillance’ data and also to drive the delivery of the recommendations from the National Confidential Inquiry into Suicides and Mental Health (NCISH); • Deliver these particular recommendations in tandem with the Recommendations made by the Panel for DHR-9, specifically: o To promote the connection between suicide and domestic abuse; o Include domestic abuse as an explicit priority within the suicide prevention strategy; o Ensure that the RTS system asks specific questions about domestic abuse.	Safe and Sound (the Dudley Community Safety Partnership)
6	Prescribing practice The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seek assurance from the Pharmacy Clinical Network that systems are in place to support safe and effective prescribing, particularly for drugs that can be abused and/or may lead to dependency	Safe and Sound (the Dudley Community Safety Partnership)
7	Hate Crime, Anti-Social Behaviour and Domestic Abuse The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seeks assurance that all officers – Police, the ASB Team, housing services and others – consider domestic abuse when receiving referrals concerning hate crime and/or anti-social behaviour and vice versa; and • That there are clear routes into appropriate services when hate crime and/or anti-social behaviour coupled with domestic abuse is identified.	Safe and Sound (the Dudley Community Safety Partnership)
8	Placing ‘alerts’ onto EMIS The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Establish links with IRISi and seek clarification for the decision to step-down the use of certain READ codes, which results in them no longer being promoted on the IRIS training; • Invites IRISi to consider supporting the re-introduction of key domestic abuse related READ codes into the training programme; • Ensure IRISi continues to promote in its training programme specific codes for people subject to a history of domestic abuse (14XD, 14X3); domestic abuse in the household (13Wd); being a victim of domestic abuse (14XG).	Safe and Sound (the Dudley Community Safety Partnership)
9	Family Safeguarding The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Work with the Children’s Social Care Service to support the ongoing work regarding ‘Think Family’ and other ‘strength based’ models; • Offer particular support to the implementation of “Family Safeguarding”, which commenced within the Borough from July 2023; • Encourage partners to work together and with other Partnerships (including the Safeguarding Board) to promote and deliver a programme to support the adoption of the ‘Think Family’ ethos and model of delivery.	Safe and Sound (the Dudley Community Safety Partnership)
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗