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: 2020
Extracted: 25 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 weaknesses in the National Probation Service's supervision and risk management of the perpetrator, particularly concerning alcohol misuse and domestic abuse history. Health professionals also missed opportunities to identify domestic abuse in the victim.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1.1 | BSOL ICB to improve identification and response to victims primary care, and an improved access to specialist support. Review is undertaken on the rate of referrals into IRIS, broken down by practice. A summary report of the findings to be presented to the IRIS steering group. Action plan developed which reflects the findings of the review, to include tactics to address practices with below expected referrals. IRISs advocate educators to engage with all practices deemed to be infrequent/low referrers to offer an action plan to improve confidence in ‘asking the question’ | NHS Birmingham & Solihull Integrated Care Board | Birmingham and Solihull Women’s Aid |
| 1.1 | Actively address identified poor practice by supporting middle managers (SPO), to implement practice development policies. Hold regular meetings with SPO to discuss improvement practice cases and support SPO in taking policy forward where necessary. | National Probation Service |
| 1.1 | Undertake active enquiry for domestic abuse in consultations involving mental illness, alcohol or substance misuse, chronic pain and other associated health conditions that are known to be associated with domestic abuse | NHS Birmingham and Solihull Integrated Care Board |
| 1.1 | Included within our training packages. | University Hospitals Birmingham |
| 1.2 | BSWA to work in partnership with the ICB Safeguarding to identify good practice in the delivery of IRISi. to and share good practice in relation to iRISi and Domestic Abuse across Birmingham and Solihull Primary Care. | Birmingham and Solihull Women’s Aid | NHS Birmingham & Solihull Integrated Care Board |
| 1.2 | Raise awareness via a number of methods such as a communication campaign, newsletters and briefings for staff. | University Hospitals Birmingham |
| 1.3 | NHS ICB BSOL ICB safeguarding team to review primary care polices & procedures for identifying and managing domestic abuse, and to assess effectiveness. | NHS Birmingham & Solihull Integrated Care Board |
| 2.1 | BSMHFT should identify how routine questioning in line with NICE guidance in relation to domestic abuse, could be enhanced and measured by adapting current risk assessment tools to include mandatory fields. Our current risk screening tool prompts practitioners to consider domestic abuse when it talks about harm to and from others, there is a free text box for practitioners to add context. BSMHF are currently unable to add in a tick box to confirm that routine enquiry has been completed to gather specific data on this. Following on a domestic abuse audit that was completed in Dec 2022, we sent out a Survey Monkey to teams that receive regular safeguarding supervision. The uptake of the survey was poor. The Safeguarding Team are now planning to pilot assurance Visits to 2 identified clinical teams receiving regular safeguarding supervision. This will commence in Sept 2024. One of the key lines of enquiry will be asking about domestic abuse. | Birmingham and Solihull Mental Health Foundation Trust |
| 2.1 | Actively seek Performance information to ensure that Offender Managers are supervised within the ‘touch stone’ model | National Probation Service |
| 2.1 | Raise awareness through staff briefings, newsletters and communication campaigns | University Hospitals Birmingham |
| 2.2 | Promote Management of Acute Alcohol Withdrawal policy through briefings, newsletter | University Hospitals Birmingham |
| 3.1 | NPS to provide SSP with a timescale for the implementation of the Framework for Management of Level 1 MAPPA cases and report to the SSP when that Framework is in place. | National Probation Service | Safer Solihull Partnership |
| 3.1 | To liaise with local NHS/Public health commissioners in ensuring that commissioned services meet the needs of local offending population needs. Where there are deficits to work with commissioners in addressing deficits / adaptations contracts moving forward. | National Probation Service |
| 3.1 | Raise awareness of domestic abuse via staff training and communication campaigns. | University Hospitals Birmingham |
| 3.2 | Continue to promote the NICE domestic abuse questions when there is an indicator or disclosure of domestic abuse. | University Hospitals Birmingham |
| RECCOMMENDATION 1 | Middle managers carrying out direct engagement with Offender managers should implement the new quality assurance and supervision framework to enable best practice and senior managers should support the management of quality and performance issues arising from this. | National Probation Service |
| RECCOMMENDATION 1 | To improve the identification of domestic abuse at both Practices and provide support to female patients who are experiencing or have experienced abusive relationships via the IRIS Advocate Educator. | NHS Birmingham and Solihull Integrated Care Board |
| RECCOMMENDATION 1 | Continue to promote a ‘think family’ approach. | University Hospitals Birmingham |
| RECCOMMENDATION 2 | Middle and Higher Managers ensure that all Offender Managers are supervised according to the new Touchpoints model which embeds a structured approach to accountability and professional curiosity. The Touchpoints model is new and supports Policies already in place regarding staff supervision, reflective practice group sessions and personal/ individual sessions. Countersigning of assessment also enables frequent analysis of practice and areas for improvement. | National Probation Service |
| RECCOMMENDATION 2 | Ensure staff recognise and respond when a patient presents with alcohol misuse and who to sign post to. | University Hospitals Birmingham |
| RECCOMMENDATION 3 | It is imperative that local providers have good communication links with Offender Mangers and take an active role in risk management plans where relevant. The NPS should work with commissioners and substance misuse service providers to ensure that local commissioning arrangements meet the needs of offenders and that there are specific protocols for offenders on statutory supervision | National Probation Service |
| RECCOMMENDATION 3 | Continue to raise awareness of domestic abuse and encourage staff to ask NICE questions when there are indicators of domestic abuse (including substance misuse) and safe to do so. | University Hospitals Birmingham |
| Recommendation One | The Safer Solihull Partnership would seek assurances from NHS Birmingham & Solihull Integrated Care Board and Birmingham and Solihull Women’s Aid (BSWA) who deliver IRISi, that they will review the effectiveness of the IRISi programme to identify why referral rates are low and support all necessary improvements to recognise and respond to victims of domestic abuse more effectively. | Safer Solihull Partnership | NHS Birmingham & Solihull Integrated Care Board | Birmingham and Solihull Women’s Aid |
| Recommendation three | The Safer Solihull Partnership recognises that the National Probation Service (NPS) have published a new National framework for the Management of Level 1 MAPPA Cases, that once implemented in the West Midlands, could reduce the risk of the unsafe management of an offender, that occurred in this case. The Partnership would seek assurance from NPS that this Framework will be adopted in the West Midlands without delay. | Safer Solihull Partnership | National Probation Service |
| Recommendation two | The Safer Solihull Partnership would seek assurances from Birmingham and Solihull Mental Health Foundation Trust that they engage with Mental Health teams and support any necessary improvements needed to recognise and respond to victims of domestic abuse. | Safer Solihull Partnership | Birmingham and Solihull Mental Health Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||