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: 51 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 across agencies in recognising and responding to escalating domestic abuse and coercive control, including inadequate risk assessment, information sharing, and a reliance on victims to protect themselves, rather than proactive intervention against the perpetrator.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| Birmingham and Solih | review their systems of receiving and progressing information which give rise to safeguarding concerns and to improve knowledge and skills in domestic abuse. | Birmingham and Solihull Clinical Commissioning Group |
| Birmingham and Solih | become an IRIS practice, whereby they would be trained and supported to routinely enquire about domestic abuse in specific situations, and to review their systems for receiving and progressing information where there are safeguarding concerns. | Birmingham and Solihull Clinical Commissioning Group |
| Birmingham and Solih | undertakes refresher IRIS training, nonetheless. | Birmingham and Solihull Clinical Commissioning Group |
| Overview Recommendat | Solihull Community Safety 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. | Solihull Community Safety Partnership |
| Overview Recommendat | Solihull Community Safety 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 | Solihull Community Safety Partnership |
| Overview Recommendat | 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 |
| Overview Recommendat | Solihull Community Safety Partnership to consider what is needed to create a cultural change in how each of the agencies understand and respond to coercive control including: • 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 | Solihull Community Safety Partnership |
| Probation Services - | Ongoing safeguarding checks need to be completed by probation practitioners and ongoing risk management activities when risks have been disclosed and new information is obtained | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Practice needs to improve in the identification, recognition and understanding of domestic abuse and links to risk management | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | A more proactive and investigative approach needs to be undertaken when concerns around domestic abuse/disputes are disclosed | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Manager oversights need to be effective in identifying and supporting probation practitioners to identify the nature of changing risk | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Requests for information need to be timely and completed in-line with the agreed multi agency processes | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Ensure that SWM CRC has communicated clearly to the National Probation Service about the suite of interventions that are available for delivery to service users in order to inform effective sentencing requirements. | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Improved practice is needed in relation to timely enforcement | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | Organisational restructure has been needed for the Solihull team in order to build resource capacity and resilience. | Staffordshire and West Midlands Community Rehabilitation Company |
| Probation Services - | the review has recommended that learning from this review, together with outstanding recommendations and actions for probation services, be adopted by the new organisational model in the region. | The Probation Service |
| Solihull Children’s | Acknowledging the potential for coercive and controlling behaviour needs to be routine within the process of assessing domestic abuse | Solihull Children’s Services |
| Solihull Children’s | Domestic abuse specific assessment tools such as DASH and DVRIM need to be used in order to facilitate a broader understanding of domestic abuse and the context of harm for mother and child | Solihull Children’s Services |
| Solihull Children’s | Clarity over relationships and clarity over the sequence of events needs to be established using a genogram and chronology. In this case it was evident that the whole chronology had not been taken into account and some staff were unclear about the relationship of the perpetrator to both the victim and the child | Solihull Children’s Services |
| Solihull Children’s | All relevant information on a child’s file must be explored | Solihull Children’s Services |
| Solihull Children’s | When positive change is seen, the ability to sustain that change needs to be considered (whether a non-molestation order will have the required effect) | Solihull Children’s Services |
| Solihull Children’s | Perpetrators should be involved in the assessment in a safe way and not invisible to the child protection process | Solihull Children’s Services |
| Solihull Children’s | Wherever possible, extended family networks should be involved and promoted as part of the process of building safety plans and the ability of the family network to sustain support is considered. | Solihull Children’s Services |
| Solihull Children’s | Supervisors have a role in ensuring each of the above is present in assessment and safety planning. | Solihull Children’s Services |
| Solihull Children’s | Recognising the increased risk of separation | Solihull Children’s Services |
| Solihull Children’s | The need to strengthen record keeping as a number of important points were not recorded including home visits | Solihull Children’s Services |
| Solihull Children’s | The need for management oversight of interventions, particularly when there is an escalation | Solihull Children’s Services |
| Solihull Children’s | Managers need to ensure that all required tasks and an holistic approach to domestic abuse have been undertaken before closing a file | Solihull Children’s Services |
| Solihull Children’s | The need to strengthen relationships with specialist domestic abuse services and knowledge of the Solihull domestic abuse pathway | Solihull Children’s Services |
| Solihull Community H | strengthening their policies and pathways for domestic abuse across the organisation including the issues that were relevant for the victim: the need for timely responses to homelessness through domestic abuse | Solihull Community Housing |
| Solihull Community H | strengthening their policies and pathways for domestic abuse across the organisation including the issues that were relevant for the victim: the relationship between anti-social behaviour and domestic abuse | Solihull Community Housing |
| Solihull Community H | strengthening their policies and pathways for domestic abuse across the organisation including the issues that were relevant for the victim: the pathways for identifying domestic abuse victims from patterns of disrepair | Solihull Community Housing |
| Solihull Community H | strengthening their policies and pathways for domestic abuse across the organisation including the issues that were relevant for the victim: the need to look holistically at Sanctuary responses for home safety as well as the need for rehousing when lock changes are required | Solihull Community Housing |
| Solihull Community H | explore accreditation through the Domestic Abuse Housing Alliance in order to provide a ‘whole organisation’ approach to domestic abuse. | Solihull Community Housing |
| University Hospitals | 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 |
| University Hospitals | To embed routine domestic abuse enquiry following the NICE recommended domestic abuse questions into Emergency Departments and assessment areas | University Hospitals Birmingham NHS Foundation Trust |
| University Hospitals | To continue to deliver the current domestic abuse training programme and strategy | University Hospitals Birmingham NHS Foundation Trust |
| University Hospitals | To issue standards to the Emergency Department 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 |
| University Hospitals | To promote the benefit of specialist domestic abuse services to the staff that work within the Emergency Department | University Hospitals Birmingham NHS Foundation Trust |
| University Hospitals | To continue to seek funding for a co-located Independent Domestic Violence Advisor service within the Emergency Department | University Hospitals Birmingham NHS Foundation Trust |
| West Midlands Police | Checking previous history of domestic abuse when responding to an incident and when considering risk (first responders and supervisors) | West Midlands Police |
| West Midlands Police | Considering all possible lines of enquiry following reports of domestic abuse, including interviewing third parties and voluntary interviews with perpetrators | West Midlands Police |
| West Midlands Police | Identifying and responding to coercive control and economic abuse | West Midlands Police |
| West Midlands Police | Identifying and responding to stalking and harassment | West Midlands Police |
| West Midlands Police | Identifying and responding to so-called ‘honour-based’ violence and abuse | West Midlands Police |
| West Midlands Police | Ensuring that crimes relating to domestic abuse, coercive control stalking and harassment are not missed | West Midlands Police |
| West Midlands Police | 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 | West Midlands Police |
| West Midlands Police | Ensuring that Domestic Abuse Protection Orders are considered and undertaken when appropriate | West Midlands Police |
| West Midlands Police | Referring domestic abuse victims to local specialist services with their consent | West Midlands Police |
| West Midlands Police | Ensuring that necessary information about the nature and history of reported abuse to a child and abused victim is shared with partner agencies in order to enable an informed multi-agency assessment of risk of abused victim and child. | West Midlands Police |
| West Midlands Police | 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 |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||