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.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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.

Home Office classifications

53 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - housing issues
  • Victim - had been a victim of an abuser before
  • Victim - immigration involvement
  • Children - under 18 shared parental responsibility (between victims)
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Child - immigration involvement
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to probation services as a domestic abuse perpetrator
  • Perpetrator - known to housing services as a domestic abuse perpetrator
  • Perpetrator - known to other educational institution as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - supervised by probation services
  • Perpetrator - immigration involvement
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - forced marriage
  • Aggravating factors - honour based violence
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - housing services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

41 recommendations pulled from the report · 11 matched to organisations in the index

Recommendation 1a

Addressed to Safer Solihull Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 1b

Addressed to Safer Solihull Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2

Addressed to Safer Solihull Partnership | Solihull Health and Well-Being Board

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

Addressed to Safer Solihull Partnership

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Safer Solihull Partnership | Solihull Child Safeguarding Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5a

Addressed to Safer Solihull Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5b

Addressed to Safer Solihull Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5c

Addressed to Safer Solihull Partnership | Solihull Safeguarding Children Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5d

Addressed to Safer Solihull Partnership | Office of West Midlands Police and Crime Commissioner

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6a

Addressed to Safer Solihull Partnership | Solihull Community Housing

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6b

Addressed to Regional Domestic Abuse Board of the Office of West Midlands Police and Crime Commissioner

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to Safer Solihull Partnership | Solihull Community Housing | West Midlands Police

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 8

Addressed to Safer Solihull Partnership

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation BSCCG-GP1&2-1

Addressed to Birmingham and Solihull Clinical Commissioning Group

The practice to improve knowledge and skills with regard to identification of domestic abuse by becoming an IRIS accredited practice

Verified wording from the published review · Original review (PDF) ↗

Recommendation BSCCG-GP1&2-2

Addressed to Birmingham and Solihull Clinical Commissioning Group

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation BSCCG-GP3-1

Addressed to Birmingham and Solihull Clinical Commissioning Group

The practice to improve knowledge and skills with regard to identification of domestic abuse by IRIS refresher training

Verified wording from the published review · Original review (PDF) ↗

Recommendation BSWA-1

Addressed to Birmingham and Solihull Women’s Aid

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCH-2

Addressed to Solihull Community Housing

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCSWS-1

Addressed to Solihull Children’s Social Work Service

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCSWS-2

Addressed to Solihull Children’s Social Work Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCSWS-3

Addressed to Solihull Children’s Social Work Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SCSWS-4

Addressed to Solihull Children’s Social Work Service

Strengthen the relationships with specialist domestic abuse services and knowledge of the Solihull domestic abuse pathway

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-DAP-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

To support active risk management across RRP by improving nDelius risk register recording and timely reviews.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-DAP-2

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

Through case oversight and accountability ensure enforcement actions are taken when required.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-DAP-3

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

Implementation of a Case Audit regime to drive and monitor the quality of risk Assessment and risk management practice.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-Final-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-MO-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

RM1 to dip sample the supervision notes of PDM1 to monitor the quality and effectiveness of manager oversights.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-PA-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-PA-2

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

Communicate to NPS via the Service Integration Group the current list of Pathway Interventions that SWM CRC.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-R-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

Planned local management team driven restructuring in cluster to improve staff access to support and build operational resilience.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-T-1

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

To deliver Domestic Abuse refresher training to all Case Management staff.

Verified wording from the published review · Original review (PDF) ↗

Recommendation SWMCRC-T-2

Addressed to Staffordshire and West Midlands Community Rehabilitation Company (now The Probation Service)

To Deliver refresher Safeguarding Training to all Case Management Staff

Verified wording from the published review · Original review (PDF) ↗

Recommendation UHB-1

Addressed to University Hospitals Birmingham NHS Foundation Trust

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

Verified wording from the published review · Original review (PDF) ↗

Recommendation UHB-2

Addressed to University Hospitals Birmingham NHS Foundation Trust

To embed the DA NICE questions into UHB HGS Emergency Departments and assessment areas

Verified wording from the published review · Original review (PDF) ↗

Recommendation UHB-4

Addressed to University Hospitals Birmingham NHS Foundation Trust

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation UHB-5

Addressed to University Hospitals Birmingham NHS Foundation Trust

To promote the benefit of specialist DA services to the staff that work within ED

Verified wording from the published review · Original review (PDF) ↗

Recommendation UHB-6

Addressed to University Hospitals Birmingham NHS Foundation Trust

To continue to seek funding for a co-located IDVA service/purple clinic for ED

Verified wording from the published review · Original review (PDF) ↗

Recommendation WMP-1

Addressed to West Midlands Police | Solihull Community Safety Partnership

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.

Verified wording from the published review · Original review (PDF) ↗