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
Solihull review
CSP: Solihull
Published: October 2025
Year of death: 2018
Extracted: 41 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 agencies' understanding and response to coercive control, stalking, and economic abuse. There was an over-reliance on the victim for safety, insufficient perpetrator accountability, and a lack of holistic consideration of intersectional vulnerabilities. Police response delays were also noted.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1a | Safer Solihull Partnership raises the awareness of the public and professionals about stalking as a form of domestic abuse and of the availability of Stalking Protection Orders to protect those individuals affected. | Safer Solihull Partnership |
| 1b | Safer Solihull Partnership raises the awareness of the public and professionals about ‘tech’ abuse and seeks assurance from agencies that ‘tech’ abuse features proportionately within their risk assessments and safety planning procedures. | Safer Solihull Partnership |
| 2 | Safer Solihull Partnership shares this report with Solihull Health and Well-Being Board in order to support the extension of the IRIS Programme across all GP practices and to support the provision of domestic abuse pathways incorporating Independent Domestic Violence Advisors across all Emergency Departments in the area. | Safer Solihull Partnership | Solihull Health and Well-Being Board |
| 3 | Safer Solihull Partnership to consider what is needed to create a cultural change in how each of the agencies understand and respond to coercive control including seeking evidence on how agencies are: • providing a focus on demystifying coercive control and including the evidence from this review of grooming, surveillance, stalking and harassment; physical and sexual violence and threat; forced marriage; threats of suicide and self-harm; threats to harm family; isolation, imprisonment and economic abuse • determining how to evidence whether a robust and improved understanding of coercive control has become embedded into each organisation • monitoring the evidence of change in how the understanding of coercive control has become embedded into each organisation • understanding so-called ‘honour’ based violence in the context of domestic abuse • understanding how individual identities and structural inequalities create barriers and further marginalisation for Black and Minoritised women | Safer Solihull Partnership |
| 4 | Safer Solihull Partnership to share this report with Solihull Child Safeguarding Partnership in order that a domestic abuse focussed review of multi-agency responses to child protection to ensure that: • the impact of coercive control upon the non-abusing parent is explored and understood • the reasons why a non-abusing parent may mistrust services and minimise their experiences of abuse, to themselves and others, are understood and meaningful engagement and help-seeking enabled • there is not an over-reliance upon non-abusing mothers to keep the child safe without effective safety planning and necessary multi-agency interventions. • domestic abuse perpetrators are not invisible to child protection assessments and that they are held accountable for their abuse and threat to the family. • separation from an abuser is not being automatically ‘required’ of mothers without effective safety planning and necessary multi-agency interventions in recognition of the additional risk that is entailed. | Safer Solihull Partnership | Solihull Child Safeguarding Partnership |
| 5a | Safer Solihull Partnership promotes, with both professionals and the public, the use of Domestic Violence Protection Orders and Notices, and forthcoming Domestic Abuse Protection Notices and Orders, for the protection of both adult and child victims of domestic abuse in order that they are greater utilised. | Safer Solihull Partnership |
| 5b | That the Partnership monitors the usage of DVPNs and DVPOs, and thereafter DAPNs and DAPOs, to ensure that the promotion has been effective across each domain. | Safer Solihull Partnership |
| 5c | Safer Solihull Partnership shares this report with Solihull Safeguarding Children Partnership in order that (a) promotion of DVPOs and DVPNs are undertaken with the children’s workforce to protect children and their non-abusing parent in plans ranging from early help to child protection and (b) that preparations are made for updating child protection procedures, and best practice promoted in the application of the Domestic Abuse Act 2021, including the recognition of child victims of domestic abuse and the application of DAPOs by safeguarding practitioners. | Safer Solihull Partnership | Solihull Safeguarding Children Partnership |
| 5d | That the Partnership shares the report with the Office of West Midlands Police and Crime Commissioner and requests that they monitor the regional use of Domestic Violence Protection Orders and Notices, and the transition to Domestic Abuse Protection Notices and Orders by nominated agencies. | Safer Solihull Partnership | Office of West Midlands Police and Crime Commissioner |
| 6a | Safer Solihull Partnership seeks assurance from Solihull Community Housing that the Sanctuary Scheme is fully embedded as a response to the prevention of homelessness and that referrals into the scheme are being made by a broad range of agencies including those that have a responsibility to refer under the Homelessness Reduction Act 2017. | Safer Solihull Partnership | Solihull Community Housing |
| 6b | The Regional Domestic Abuse Board of the Office of West Midlands Police and Crime Commissioner to enable a consistency of approach and pathways to Sanctuary Schemes across the region in order to strengthen the effectiveness of referrals to the scheme. | Regional Domestic Abuse Board of the Office of West Midlands Police and Crime Commissioner |
| 7 | Safer Solihull Partnership should seek assurance from Solihull Community Housing and West Midlands Police that domestic abuse is being identified and appropriately responded to when masked by complaints of anti-social behaviour in a residential setting. | Safer Solihull Partnership | Solihull Community Housing | West Midlands Police |
| 8 | Safer Solihull Partnership to share an update with the bereaved family in 12 months’ time, concerning what has changed as a result of the domestic homicide review and subsequent action plans and the family have an opportunity to contribute to change | Safer Solihull Partnership |
| BSCCG-GP1&2-1 | The practice to improve knowledge and skills with regard to identification of domestic abuse by becoming an IRIS accredited practice | Birmingham and Solihull Clinical Commissioning Group |
| BSCCG-GP1&2-2 | Practices to review systems of receiving information, and the progression of information which gives rise for safeguarding concerns to be discussed, either within the Practice or multi-agency forum. | Birmingham and Solihull Clinical Commissioning Group |
| BSCCG-GP3-1 | The practice to improve knowledge and skills with regard to identification of domestic abuse by IRIS refresher training | Birmingham and Solihull Clinical Commissioning Group |
| BSWA-1 | To remind all staff and volunteers, and new staff through induction training about the importance of checking where callers live before signposting or referring. To amend the content of information resources to ensure that the information for Solihull services is clearly identifiable. | Birmingham and Solihull Women’s Aid |
| SCH-1 | Improve the organisation wide response to Domestic Abuse | Solihull Community Housing |
| SCH-2 | Investigate options for collecting and responding to ‘intelligence’ which may indicate a risk of domestic abuse. To introduce into procedures the need for follow-up contact with the householder where indicators or reports of domestic abuse come to their attention | Solihull Community Housing |
| SCH-3 | Improve information to customers on pathways and procedures (Housing Options service) | Solihull Community Housing |
| SCSWS-1 | To raise the profile and understanding about Domestic Abuse and Coercion and Control. This will include what coercion and control looks like ‘on the ground’ when practitioners at Family Support and Social Work level are working with families. Acknowledging the potential for coercive and controlling behaviour needs to be routine within the process of assessing domestic abuse. Recognising the increased risk of separation | Solihull Children’s Social Work Service |
| SCSWS-2 | To provide assurance about the responses to cases at Domestic Abuse Triage and MASH have been appropriate in respect of the known information and history where there are concerns about Domestic Abuse and coercion and control. Ensure management oversight of interventions, particularly when there is an escalation. Managers to ensure that all required tasks and that a holistic approach to domestic abuse has been undertaken before closing a file. | Solihull Children’s Social Work Service |
| SCSWS-3 | To understand how effectively relevant Risk Assessment tools like the DVRIM, DVRAM, and the DASH, and standard assessment tools are informing social work assessments where Domestic Abuse and coercive behaviour is a concern. This should include an understanding about the quality of safety planning which is part of the social work assessment process which should include consideration of how the family and network is supporting safety, and conversations with the perpetrator. It should also include consideration of the Signs of Safety model and how safety is being seen over time. | Solihull Children’s Social Work Service |
| SCSWS-4 | Strengthen the relationships with specialist domestic abuse services and knowledge of the Solihull domestic abuse pathway | Solihull Children’s Social Work Service |
| SWMCRC-DAP-1 | To support active risk management across RRP by improving nDelius risk register recording and timely reviews. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-DAP-2 | Through case oversight and accountability ensure enforcement actions are taken when required. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-DAP-3 | Implementation of a Case Audit regime to drive and monitor the quality of risk Assessment and risk management practice. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-Final-1 | The learning from this review, together with outstanding recommendations and actions for probation services, be adopted by the new organisational model for the Probation Service in the region. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-MO-1 | RM1 to dip sample the supervision notes of PDM1 to monitor the quality and effectiveness of manager oversights. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-PA-1 | Process Guidance for completing Domestic Violence and Safeguarding Checks to be re-issued to all Solihull team practitioners and follow up with check of 10 cases within the team (with Domestic Abuse Flags) for such checks. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-PA-2 | Communicate to NPS via the Service Integration Group the current list of Pathway Interventions that SWM CRC. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-R-1 | Planned local management team driven restructuring in cluster to improve staff access to support and build operational resilience. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-T-1 | To deliver Domestic Abuse refresher training to all Case Management staff. | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| SWMCRC-T-2 | To Deliver refresher Safeguarding Training to all Case Management Staff | Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service) |
| UHB-1 | Robust and bespoke training around Routine Enquiry to ensure that midwives follow the guideline, and it is recorded appropriately to enable the domestic abuse midwife to audit effectively | University Hospitals Birmingham NHS Foundation Trust |
| UHB-2 | To embed the DA NICE questions into UHB HGS Emergency Departments and assessment areas | University Hospitals Birmingham NHS Foundation Trust |
| UHB-3 | To continue with UHB current DA training and strategy | University Hospitals Birmingham NHS Foundation Trust |
| UHB-4 | To issue standards to the ED in relation to history taking to include who attends with patients (name and relationship), use of information relating to previous attendances and use of safeguarding alerts on children’s records. | University Hospitals Birmingham NHS Foundation Trust |
| UHB-5 | To promote the benefit of specialist DA services to the staff that work within ED | University Hospitals Birmingham NHS Foundation Trust |
| UHB-6 | To continue to seek funding for a co-located IDVA service/purple clinic for ED | University Hospitals Birmingham NHS Foundation Trust |
| WMP-1 | To provide assurance to Solihull Community Safety Partnership on the effectiveness of responses to domestic abuse in the following regards: • Checking previous history of domestic abuse when responding to an incident and when considering risk (first responders and supervisors) • Considering all possible lines of enquiry following reports of domestic abuse, including interviewing third parties and voluntary interviews with perpetrators • Identifying and responding to coercive control and economic abuse • Identifying and responding to stalking and harassment • Ensuring that crimes relating to domestic abuse, coercive control stalking and harassment are not missed • Beyond lock-changes, ensuring that full Sanctuary measures are considered when a domestic abuse victim is under threat as well as the possibility of rehousing • Ensuring that Domestic Abuse Protection Orders are considered and undertaken when appropriate • Referring domestic abuse victims to local specialist services with their consent • Ensuring that full information about the nature of abuse to a child and parent is shared with partner agencies in order to enable a fuller multi-agency assessment of risk • Ensuring understanding of the separate responsibilities of officers and public protection units in safeguarding domestic abuse victims considered to be facing a standard level of risk. | West Midlands Police | Solihull Community Safety Partnership |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||