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: June 2026
Year of death: 2022
Extracted: 38 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 multi-agency communication, information sharing, and risk assessment regarding domestic abuse, mental health, and anti-social behaviour. A lack of professional curiosity and consistent supervision led to missed opportunities to safeguard the victim and the perpetrator, compounded by issues of gender bias and inadequate use of legal powers.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| BCHFT 1 | To ensure there is a process for carer’s assessments to be offered as mandatory if a carer is identified and included in any active process. | Black Country Health Care Foundation Trust |
| BSMHFT 1 | A review of the current domestic abuse policy and consideration to be given to gender bias within this - Update domestic abuse policy to include guidance regarding recognition of gender bias and to see victims of DA face to face rather than telephone /video contact. | Birmingham and Solihull Mental Health Foundation Trust |
| BSMHFT 2 | An audit to identify evidence that routine enquiry and appropriate use of risk management tools is taking place during clinical contacts with service users. - Dip Sample audit – sample identified from MARAC. | Birmingham and Solihull Mental Health Foundation Trust |
| BSMHFT 3 | A review into seeking to establish why routine enquiry does not appear to be embedded within practice. - Survey Monkey Questionnaire to ask clinicians if they ask routine enquiry and if not why. | Birmingham and Solihull Mental Health Foundation Trust |
| BSMHFT 4 | To develop a network of ‘safeguarding supervisors’ with a view to additional training and support into clinical areas.- To train all safeguarding supervisors in routine enquiry and share the learning form themes form DHR’s. | Birmingham and Solihull Mental Health Foundation Trust |
| BSMHFT 5 | BSMHFT Staff to offer face to face appointments where domestic abuse is a factor, BSMHFT to review current policy for face to face versus remote video/ telephone contacts. | Birmingham and Solihull Mental Health Foundation Trust |
| BSOL ICB 1 | GP Medical Practice 4 to receive IRIS training and become an IRIS Practice. (Identification and Referral to Improve Safety) specialist DA programme and training for GP’s. | NHS Birmingham and Solihull ICB |
| BSOL ICB 2 | GP Medical Practice 3 to receive refresher IRIS training. | NHS Birmingham and Solihull ICB |
| BSOL ICB 3 | Both Practices to have a Was Not Brought/ Did Not Attend policy. | NHS Birmingham and Solihull ICB |
| BSOL ICB 4 | Both Practices to Improve Record keeping by Clinicians and Administrative Staff | NHS Birmingham and Solihull ICB |
| BSOL ICB 5 | GP Medical Practice 4 to Link Households | NHS Birmingham and Solihull ICB |
| BSOL ICB 6 | GP Medical Practice 3 to train of Staff who are responsible for coding of Mental Health Disorders | NHS Birmingham and Solihull ICB |
| BSOL ICB 7 | Both Practices to have a policy on following up vulnerable patients upon receipt of any correspondence, including A and E letters, which highlights abuse or mental health concerns (even if they are under Secondary Care). | NHS Birmingham and Solihull ICB |
| DHR 1 | Solihull Safeguarding Partners and participating agencies in the DHR, should reassure SSP they will ensure: - • A multi-agency meeting will be called, or a strategy discussion held where applicable, to make certain, risk assessments and communication between practitioners, consider the full facts of an adult at risk or associated adult, in order that necessary safeguarding action is taken. • Professionals should be encouraged to challenge the decisions or actions by another agency in a safeguarding enquiry. Practitioners should raise the concerns to their line manager and if the matter is unresolved should use either the SSP Escalation Policy2 or their own agencies escalation policy to address the issue in question. • Remind supervisors and practitioners through training, of their responsibilities of effective information sharing, risk assessments, comprehensive record keeping, and communication, that it is imperative for safeguarding and the protection of adults at risk. | Solihull Safeguarding Partnership | Participating Agencies |
| DHR 2 | It is recommended that the safeguarding partners and voluntary agencies involved in the DHR reassure SSP that in adult at risk cases the following initiatives are considered and where relevant, enacted: • Practitioners to enact existing Domestic Violence Protection Notices and Orders (to be known in the future, when rolled out in England, as DAPN and DAPO’s) that consolidates protection orders and non-molestation orders under the Domestic Abuse Act 2021. • Utilise Home Office ASB Guidance 2022, community protection notices, orders, and court injunction initiatives in cases of persistent ASB incidents. • Police in DA cases, where there is sufficient evidence, when the victim does not or is unable to support a criminal prosecution, to consider CPS evidence led victimless prosecutions, if it is appropriate for the case, in order to protect an adult at risk. | Solihull Safeguarding Partnership | Participating Agencies |
| DHR 3 | It is recommended that safeguarding partners and voluntary agencies involved in the DHR reassure SSP that they will ensure staff: - • Know their powers or action to take when the signs and symptoms of coercive, emotional, and manipulative controlling behaviour of an adult at risk are identified, in conjunction with the Domestic Abuse Act 2021. • To be alert to situational violence and the role of violent resistance alongside intimate partner violence as describe in Johnson (2008) typology of intimate domestic violence. • Enquiries must be conducted as to the suitability of the role of a carer, where safeguarding concerns of domestic abuse and other serious concerns have been raised to ensure compliance with Local and National Safeguarding Adult Policy and Procedures and the outcome shared with relevant agencies to support practice. | Solihull Safeguarding Partnership | Participating Agencies |
| DHR 4 | It is recommended that safeguarding partners and voluntary agencies involved in the DHR reassure SSP that their supervisors and staff will ensure: - • Agencies should conduct their own risk assessment and not rely on the interpretation of another agency and refer to the MARAC if an agency professional considers it a potential risk requiring action to be taken. • A domestic abuse case or any safeguarding referral should not be closed without supervision oversight, to ensure that all available action, levels of risk assessments and safeguarding plans are completed with the rationale recorded. • More professional curiosity must be displayed to ensure that practitioners consider all aspects of domestic abuse of an adult at risk, to protect their health and well-being, utilising the supportive services of an IDVA, other support services and to address incident led responses to ensure they are comprehensively risk assessed where necessary. | Solihull Safeguarding Partnership | Participating Agencies |
| DHR 5 | It is recommended that West Midlands Police, reassure SSP that they will: - • Ensure their supervisors and staff are cognisant of domestic abuse and anti-social behaviour guidance, in order to recognise and take remedial action to address any increase in the volume and intensity of incidents, utilising current DA and ASB legislation and other available powers. • To ensure the continued dip sampling of the quality of WMP domestic abuse investigations to ensure good practice and lessons are being learnt, including from previous statutory reviews, HMICFRS inspections, and complying with Local and National Safeguarding Adult Policies and Procedures. | West Midlands Police |
| DHR 6 | It is recommended that safeguarding partners and voluntary agencies involved in the DHR, reassure SSP that in adult at risk cases where there is a possible concern of poor mental health and a lack of mental capacity, they must ensure that a Mental Capacity Assessment is always considered or seek the advice from a Mental Health Professional or Independent Mental Capacity Advocate, to ensure the ‘best interest’ decision is being taken and their risk is assessed, as capacity can fluctuate according to a person’s complex needs. | Solihull Safeguarding Partnership | Participating Agencies |
| DHR 7 | It is recommended that the Solihull MBC Safeguarding Partners, and voluntary organisations, reassure Solihull Safeguarding Partnership that their staff are made aware of and ensure that adult at risk safeguarding referrals are diligently submitted to the SMBC ASC Triage Process of Safeguarding Referrals within the Adult Duty Team, for screening and necessary action to be completed. | Solihull Safeguarding Partnership | Voluntary Organisations |
| DHR 8 | It is recommended that the Solihull MBC Adult Social Care: - • Promote the awareness of the SMBC ASC Triage Process of Safeguarding Referrals within the Adult Duty Team, including the existing safeguarding referral pathways for the expectations and information of multi-agency partners. • To ensure greater visibility on Solihull MBC’s website of the Triage Process of Safeguarding Referrals which should be readily accessible to multi-agency safeguarding partners, agencies, and professionals. | Solihull MBC Adult Social Care |
| SCH 1 | Undertake Hate Crime awareness training for Contact Centre Staff | Solihull Community Housing |
| SCH 2 | Define the routes to give an effective response to Hate Crime following initial report. | Solihull Community Housing |
| SCH 3 | Develop professional curiosity through training and development for identified staff. | Solihull Community Housing |
| SCH 4 | Housing Options Officers to buddy and shadow Neighbourhood Officers at partnerships to improve networks. | Solihull Community Housing |
| SCH 5 | Hold Joint Team Meeting Event(s) with Mental Health Service centre. | Solihull Community Housing |
| SCH 6 | Introduce a buddy system between Housing Options Staff and Neighbourhood Staff. | Solihull Community Housing |
| SCH 7 | Undertaking timely and dynamic risk assessments. | Solihull Community Housing |
| SCH 8 | Brief all staff on Interpreting services and how to offer and access them. | Solihull Community Housing |
| SCH 9 | Produce Guidance for SCH staff for clarity working with GPs and how to make referrals. | Solihull Community Housing |
| UHB 1 | DA - Meeting to be arranged with Trust IDVAs to discuss perpetrator pathway. | University Hospitals Birmingham |
| UHB 2 | DA - Perpetrator pathway to be written and agreed at Board. | University Hospitals Birmingham |
| UHB 3 | Update Missing persons procedure (Datix system). | University Hospitals Birmingham |
| UHB 4 | Audit of those who leave ED before assessment. | University Hospitals Birmingham |
| Walsall ICB 1 | Feedback to GP Practice regarding the good practice identified. | NHS Black Country ICB |
| Walsall ICB 2 | Remind GPs at their forums that it is important to ask about DA at every appointment after there has been disclosed and a flag should be added to the patient record. | NHS Black Country ICB |
| WMP 1 | Increase knowledge of referrals for vulnerable adults and increase use of referral portal. Increase officers’ general knowledge of vulnerability; what it entails, types of vulnerability and how to manage vulnerability when it is identified. | West Midlands Police |
| WMP 2 | A mandatory video training package will be created with instructions on when to use the portal, how to use the portal and the potential outcomes following referrals made via the portal. | West Midlands Police |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||