Dear Mrs Louise Hunt - HM Senior Coroner for Birmingham and Solihull Regulation 28 Report to Prevent Further Deaths - Raneem Oudeh and Khaola Saleem I am writing to follow up on our letter to you dated 11 th November 2022, and I would now like to provide a more comprehensive update for you to your Regulation 28 Report dated 3 November 2022, arising from the inquest of Raneem Oudeh and Khaola Saleem. In your report you raised that the inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed in 2018 and the problem continues with cases not being investigated due to lack of resources in the department. Further areas of concern raised in the inquest will be addressed in the response to the second regulation 28 notice. Changes in PPU structure and staffing since 2018 The Public Protection Department (PPU) was restructured in 2019. One of the reasons the new structure was put in place, was because it was identified that the Domestic Abus.e Teams found it difficult to manage complex investigations alongside high volume DA reports and individuals in custody with the associated statutory time constraints. The Domestic Abuse Teams were replaced by Adult Investigation Teams and Adult Complex Investigation Teams. The Adult Complex Investigation Teams investigate the most serious and protracted cases including attempt murder, rape and honour-based violence offences. This allows the Adult Investigation Teams to focus on the volume of Domestic Abuse (DA) offences which includes assaults and harassment. Resources The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff. Now the number of police officers and staff allocated to managing DA across the West Midlands region is 441. This number includes both police officers and staff working in the Adult Investigation Teams, Safeguarding Teams and the Civil Interventions Team, who manage civil orders relating to DA. The figure can vary slightly on a weekly basis owing to individual staff movement and also includes 30 tutored students, who come into the PPU as part of their training rotations. The staffing of the Eastern Adult Investigation Team (Previously the Coventry and Solihull team) is now 73 officers and staff. An internal audit by the Office of Police Crime Commissioner (OPCC), completed in 2022, considered that the staff have a manageable volume of work. Preventing crime, protecting the public and helping those in need west-rrndlands.pollce.uk

In comparing staff numbers in August 2018 to current levels this shows a 43% increase for DA staffing across the West Midlands, and a 37% uplift in staffing for the Eastern area which directly covers Coventry and Solihull. In addition to this, there are also officers and staff on the Adult Complex Teams who investigate the most serious DA offences as already outlined. Review and Allocation Team The Review and Allocation Team (R&A) was established within the PPU department restructure in 2019 and is responsible for reviewing all crime reports that go to the Adult Investigation Teams. One of the purposes of the R&A team is to ensure a consistent and high-quality approach to the initial assessment and allocation of DA offences. They also remove this function from the investigation Sergeants, affording those Sergeants greater time and focus to manage ongoing investigations and persons in custody. The R&A team is made up of three teams that review each crime and use a bespoke template to determine the progress of the investigation. If there are further lines of investigation the report is allocated to one of the investigation teams to progress. In some cases, further information is required from the victim in order to inform the decision and the R&A team will facilitate this. The R&A team will check the Domestic Abuse Risk Assessment (DARA) grading and any history of previous incidents. This is to ensure the correct risk grade has been determined before a report is filed or allocated for further investigation. In addition, the R&A team can re-grade the risk where appropriate to do so. The decision to take further Criminal Justice action must involve consideration of the proportionality and necessity of doing so. However, the availability and capacity of staff on the PPU investigation teams is not a determining factor on whether a report may be filed and the R&A team sit independently of the DA investigation teams. The R&A Inspector is responsible for managing the performance of the team and ensuring that appropriate filing and allocation decisions are being made. The supervisory team carry out periodic sampling of the reports to quality assure the decision making and discuss themes and issues to ensure a consistent approach. The Inspector carries this out as a quarterly review. A sample of three reports per officer are reviewed by the supervisory team who will consider templates being completed and consistency of allocations/decision making. Feedback is then given back to the teams with the findings. Scrutiny Panel In July 2022 a Scrutiny Panel was formed to help to quality assure our crime review processes, where external partners from the Domestic Abuse Independent Advisory Group review reports filed by the R&A team with an Inspector. The Panel's function is to advise on the appropriateness of the decision making and to promote best practice across the teams. Feedback is disseminated as appropriate and the insights used to improve wider practice. Following the inaugural meeting of the Panel, additional guidance was added to the draft R&A procedural guidance document to assist staff in better rationalising their allocation and filing decisions. The group has met again in December where a further selection of cases were reviewed and learning identified, which will be subject of feedback. The group have now agreed to meet three times during a calendar year. Preventing crime, protecting the public and helping those in need west-m1dlands.police.uk

Screening process Alongside the R&A process, all DA crime reports that are allocated to the Adult Investigation Teams are screened to determine whether an immediate arrest of the suspect is required, considering the risk posed by the suspect and Code G of the Police and Criminal Evidence Act 1984. This process takes place every morning to screen all relevant reports from the previous 24 hours. Suspects who are not arrested are monitored through local tracking documents to ensure that enquiries continue to be made to locate and detain them. There is management scrutiny of the tracking documents and intervention with the relevant Neighbourhood Policing Unit (NPU) if the number of outstanding suspects goes above the agreed threshold levels with that NPU. This threshold level is different in each NPU given their size and the volume of DA reports that are recorded for the geographical location. Overall DA suspect management is subjected to scrutiny by the PPU senior management and a Force wide monthly performance panel review process. Initial Investigative Reviews The Adult Investigation Team Sergeants review the crime reports sent to them by the R&A Team each shift to ensure that reports are triaged and allocated expeditiously. The Sergeants complete a written review, set investigative actions and allocate the reports to individual officers and staff on their teams. The Sergeants' reviews, action setting and allocations are subject to a quarterly audit by the relevant Detective Chief Inspector as well as a further quarterly review led by the PPU Policy Manager who undertakes a full review of a dip sample of crimes to assess the quality of the supervisory input. This has led to an improvement in utilising a supervisor template, linked to THRIVE+, for all supervisors. Periodic reviews The Adult Investigation Team Sergeants are responsible for completing periodic reviews of ongoing investigations at least every 28 days. The CONNECT system, which is used to manage investigations, generates a task reminder to help manage this process. Where possible reviews are completed as part of a discussion with the Officer in Charge (OIC) of the investigation to monitor what progress has been made and set further investigative actions where required. The Sergeants also review and manage all investigations when a suspect is in custody. The Sergeants must continually assess whether there is a likelihood that an investigation will meet the current Crown Prosecution Service (CPS) charging test. If it is met, the matter will be referred to the CPS to determine whether charges are appropriate or, in certain circumstances, the suspect may be offered an Out of Court Disposal (OOCD). OOCDs are available in certain circumstances in standard and medium risk cases (taken from the DARA), where the victim is supportive of this outcome and the suspect has admitted their involvement. The OOCD may require the suspect to undertake a DA perpetrator programme and/or to address underlining contributory factors such as drug/alcohol misuse. Preventing crime, protecting the public and helping those in need west-mid lands. police. u k

In circumstances where the Sergeant deems that the test is not met and there is no likelihood that it will be met after proportionate enquiries, the Sergeant will file the report. The Sergeants follow an investigation and filing checklist to assist them in this determination. The checklist includes consideration as to whether an Evidence Led Prosecution can be made. A quarterly audit is undertaken of filed matters. In addition, there is consideration of utilising civil orders including Domestic Violence Protection Notices (DVPNs) to protect the victim. Crown Prosecution Service {CPS) and PPU meeting In 2022 a scrutiny panel was established, consisting of a CPS lawyer and a senior police manager in PPU, to review five instances where a decision has been made to take no further action by the police and five instances where a CPS prosecutor has made the decision to take no further action in order to identify any points of learning and best practice. The investigation team Inspectors also review decisions to take no further action by their Sergeants on a monthly basis as part of general team management. Conclusion The management of DA reports requires input from a number of different Force departments, working effectively together. DA reports are given particular scrutiny and priority because of the inherent vulnerability and risk that they involve. Each point in the process is subject of supervisory scrutiny in order to maximise the quality of the policing response and a monthly DA Performance meeting is chaired by the DA Superintendent lead to monitor and manage performance at a departmental level. I hope that the above information offers reassurance that DA investigation in the West Midlands Police PPU is effectively managed and resourced and that decisions to file reports of DA are made in a proper manner with an appropriate level of scrutiny. The force is committed to ensuring that victims of DA receive a high quality of service and understands that this requires the allocation of sufficient suitably trained staff.

Chief Constable Preventing crime, protecting the public and helping those in need west-midlands.pol1ce.uk

Dear Mrs Louise Hunt - HM Senior Coroner for Birmingham and Solihull Regulation 28 Report to Prevent Further Deaths - Raneem Oudeh and Khaola Saleem I am writing to follow up on our letter to you dated 11 th November 2022, and I would now like to provide a more comprehensive update for you to your Regulation 28 Report dated 3 November 2022, arising from the inquest of Raneem Oudeh and Khaola Saleem. In your report you raised that the inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed in 2018 and the problem continues with cases not being investigated due to lack of resources in the department. Further areas of concern raised in the inquest will be addressed in the response to the second regulation 28 notice. Changes in PPU structure and staffing since 2018 The Public Protection Department (PPU) was restructured in 2019. One of the reasons the new structure was put in place, was because it was identified that the Domestic Abus.e Teams found it difficult to manage complex investigations alongside high volume DA reports and individuals in custody with the associated statutory time constraints. The Domestic Abuse Teams were replaced by Adult Investigation Teams and Adult Complex Investigation Teams. The Adult Complex Investigation Teams investigate the most serious and protracted cases including attempt murder, rape and honour-based violence offences. This allows the Adult Investigation Teams to focus on the volume of Domestic Abuse (DA) offences which includes assaults and harassment. Resources The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff. Now the number of police officers and staff allocated to managing DA across the West Midlands region is 441. This number includes both police officers and staff working in the Adult Investigation Teams, Safeguarding Teams and the Civil Interventions Team, who manage civil orders relating to DA. The figure can vary slightly on a weekly basis owing to individual staff movement and also includes 30 tutored students, who come into the PPU as part of their training rotations. The staffing of the Eastern Adult Investigation Team (Previously the Coventry and Solihull team) is now 73 officers and staff. An internal audit by the Office of Police Crime Commissioner (OPCC), completed in 2022, considered that the staff have a manageable volume of work. Preventing crime, protecting the public and helping those in need west-rrndlands.pollce.uk

In comparing staff numbers in August 2018 to current levels this shows a 43% increase for DA staffing across the West Midlands, and a 37% uplift in staffing for the Eastern area which directly covers Coventry and Solihull. In addition to this, there are also officers and staff on the Adult Complex Teams who investigate the most serious DA offences as already outlined. Review and Allocation Team The Review and Allocation Team (R&A) was established within the PPU department restructure in 2019 and is responsible for reviewing all crime reports that go to the Adult Investigation Teams. One of the purposes of the R&A team is to ensure a consistent and high-quality approach to the initial assessment and allocation of DA offences. They also remove this function from the investigation Sergeants, affording those Sergeants greater time and focus to manage ongoing investigations and persons in custody. The R&A team is made up of three teams that review each crime and use a bespoke template to determine the progress of the investigation. If there are further lines of investigation the report is allocated to one of the investigation teams to progress. In some cases, further information is required from the victim in order to inform the decision and the R&A team will facilitate this. The R&A team will check the Domestic Abuse Risk Assessment (DARA) grading and any history of previous incidents. This is to ensure the correct risk grade has been determined before a report is filed or allocated for further investigation. In addition, the R&A team can re-grade the risk where appropriate to do so. The decision to take further Criminal Justice action must involve consideration of the proportionality and necessity of doing so. However, the availability and capacity of staff on the PPU investigation teams is not a determining factor on whether a report may be filed and the R&A team sit independently of the DA investigation teams. The R&A Inspector is responsible for managing the performance of the team and ensuring that appropriate filing and allocation decisions are being made. The supervisory team carry out periodic sampling of the reports to quality assure the decision making and discuss themes and issues to ensure a consistent approach. The Inspector carries this out as a quarterly review. A sample of three reports per officer are reviewed by the supervisory team who will consider templates being completed and consistency of allocations/decision making. Feedback is then given back to the teams with the findings. Scrutiny Panel In July 2022 a Scrutiny Panel was formed to help to quality assure our crime review processes, where external partners from the Domestic Abuse Independent Advisory Group review reports filed by the R&A team with an Inspector. The Panel's function is to advise on the appropriateness of the decision making and to promote best practice across the teams. Feedback is disseminated as appropriate and the insights used to improve wider practice. Following the inaugural meeting of the Panel, additional guidance was added to the draft R&A procedural guidance document to assist staff in better rationalising their allocation and filing decisions. The group has met again in December where a further selection of cases were reviewed and learning identified, which will be subject of feedback. The group have now agreed to meet three times during a calendar year. Preventing crime, protecting the public and helping those in need west-m1dlands.police.uk

Screening process Alongside the R&A process, all DA crime reports that are allocated to the Adult Investigation Teams are screened to determine whether an immediate arrest of the suspect is required, considering the risk posed by the suspect and Code G of the Police and Criminal Evidence Act 1984. This process takes place every morning to screen all relevant reports from the previous 24 hours. Suspects who are not arrested are monitored through local tracking documents to ensure that enquiries continue to be made to locate and detain them. There is management scrutiny of the tracking documents and intervention with the relevant Neighbourhood Policing Unit (NPU) if the number of outstanding suspects goes above the agreed threshold levels with that NPU. This threshold level is different in each NPU given their size and the volume of DA reports that are recorded for the geographical location. Overall DA suspect management is subjected to scrutiny by the PPU senior management and a Force wide monthly performance panel review process. Initial Investigative Reviews The Adult Investigation Team Sergeants review the crime reports sent to them by the R&A Team each shift to ensure that reports are triaged and allocated expeditiously. The Sergeants complete a written review, set investigative actions and allocate the reports to individual officers and staff on their teams. The Sergeants' reviews, action setting and allocations are subject to a quarterly audit by the relevant Detective Chief Inspector as well as a further quarterly review led by the PPU Policy Manager who undertakes a full review of a dip sample of crimes to assess the quality of the supervisory input. This has led to an improvement in utilising a supervisor template, linked to THRIVE+, for all supervisors. Periodic reviews The Adult Investigation Team Sergeants are responsible for completing periodic reviews of ongoing investigations at least every 28 days. The CONNECT system, which is used to manage investigations, generates a task reminder to help manage this process. Where possible reviews are completed as part of a discussion with the Officer in Charge (OIC) of the investigation to monitor what progress has been made and set further investigative actions where required. The Sergeants also review and manage all investigations when a suspect is in custody. The Sergeants must continually assess whether there is a likelihood that an investigation will meet the current Crown Prosecution Service (CPS) charging test. If it is met, the matter will be referred to the CPS to determine whether charges are appropriate or, in certain circumstances, the suspect may be offered an Out of Court Disposal (OOCD). OOCDs are available in certain circumstances in standard and medium risk cases (taken from the DARA), where the victim is supportive of this outcome and the suspect has admitted their involvement. The OOCD may require the suspect to undertake a DA perpetrator programme and/or to address underlining contributory factors such as drug/alcohol misuse. Preventing crime, protecting the public and helping those in need west-mid lands. police. u k

In circumstances where the Sergeant deems that the test is not met and there is no likelihood that it will be met after proportionate enquiries, the Sergeant will file the report. The Sergeants follow an investigation and filing checklist to assist them in this determination. The checklist includes consideration as to whether an Evidence Led Prosecution can be made. A quarterly audit is undertaken of filed matters. In addition, there is consideration of utilising civil orders including Domestic Violence Protection Notices (DVPNs) to protect the victim. Crown Prosecution Service {CPS) and PPU meeting In 2022 a scrutiny panel was established, consisting of a CPS lawyer and a senior police manager in PPU, to review five instances where a decision has been made to take no further action by the police and five instances where a CPS prosecutor has made the decision to take no further action in order to identify any points of learning and best practice. The investigation team Inspectors also review decisions to take no further action by their Sergeants on a monthly basis as part of general team management. Conclusion The management of DA reports requires input from a number of different Force departments, working effectively together. DA reports are given particular scrutiny and priority because of the inherent vulnerability and risk that they involve. Each point in the process is subject of supervisory scrutiny in order to maximise the quality of the policing response and a monthly DA Performance meeting is chaired by the DA Superintendent lead to monitor and manage performance at a departmental level. I hope that the above information offers reassurance that DA investigation in the West Midlands Police PPU is effectively managed and resourced and that decisions to file reports of DA are made in a proper manner with an appropriate level of scrutiny. The force is committed to ensuring that victims of DA receive a high quality of service and understands that this requires the allocation of sufficient suitably trained staff.

Chief Constable Preventing crime, protecting the public and helping those in need west-midlands.pol1ce.uk

Dear Mrs Hunt, Thank you for your letter of 04 November 2022 to the Home Secretary enclosing a copy of a Preventing Future Deaths Report produced by the Senior Coroner following the inquest of Raneem Oudeh and Khaola Saleem. Your letter has been passed to the interpersonal abuse unit as the unit responsible for domestic abuse for a response. I would like to begin by expressing my condolences to the loved ones of Khaola Saleem and Raneem Oudeh. For a mother and daughter to lose their lives in this way is truly heart-breaking. I understand that through the inquest process, the Coroner has identified an area of concern regarding staffing the domestic abuse team within the Public Protection Unit of West Midlands police force in the handling this case. The Coroner notes that the inquest was told that whilst the case officer understood more needed to be done, the report was filed due to not having the staffing capacity to investigate the case which they believe leaves an immediate concern to victims of domestic abuse and controlling or coercive behaviour. Domestic abuse is a terrible crime and the Government is committed to doing everything we can to tackle it. Action at all stages of the police response should ensure the effective protection of victims and children, while allowing the Criminal Justice System to hold the offender to account and an effective investigation to be completed in all reported cases of domestic abuse. Our expectation is that the police deal with every victim and survivor of domestic abuse with compassion, empathy, and understanding. The Domestic Abuse Act 2021 alongside a comprehensive action plan of other non- legislative measures, will provide further protections to the millions of people who experience domestic abuse. It will strengthen measures to bring perpetrators to justice, as well as transform the support we give to victims ensuring they have the protection they deserve. Controlling or coercive behaviour is a particularly insidious form of domestic abuse, which we know does not stop at the point of separation. Indeed, such abuse can persist and often increase as the perpetrator seeks to retain control over the victim. That is why through the

Domestic Abuse Act 2021 we extended the controlling or coercive behaviour offence. This means that the offence will soon apply to intimate partners, ex-partners or family members, regardless of whether the victim and perpetrator live together. In order for the new offence to be effectively implemented and to further assist frontline agencies in identifying, investi- gating and evidencing domestic abuse offences, we are updating the Controlling or Coercive Behaviour Statutory Guidance. The updated Statutory Guidance will be published in early 2023, in line with the extended offence coming into force. The Government's Tackling Domestic Abuse plan, published in March 2022, will see more than £230 million invested including £140 million for supporting victims, and over £81 million for tackling perpetrators over the next three years. The Government are also adding violence against women and girls to the Strategic Policing Requirement meaning it will be set out as a national threat for police forces to respond to, alongside other threats such as terrorism, serious and organised crime, and child sexual abuse. The Home Office continues to fund the Domestic Homicide and Suspected Victim Suicides Project. The project is led by the National Police Chiefs' Council and the Vulnerability and Knowledge and Practice Programme. The project counts all domestic abuse related deaths which, as well as domestic murder by a (current or ex) partner, family member or co-habitee, also counts child deaths in a domestic setting, unexplained or suspicious deaths, and suspected suicides of individuals with a known history of domestic abuse victimisation. Domestic Homicide Reviews must also be considered for all deaths involving a person over the age of 16 where domestic abuse has or appears to have been a factor. This includes deaths by suicides. The Government want to ensure the police response to domestic abuse is consistent across the country, help increase the confidence of victims and survivors in the police and ensure they receive the compassionate treatment we expect. This is why, in the Tackling Domestic Abuse Plan, the Home Office committed to assist funding the rollout of Domestic Abuse Matters training to forces which have yet to deliver it, or do not have their own specific domestic abuse training. The programme aims to improve the police response to domestic abuse, including the investigation of controlling or coercive behaviour offences and to achieve national consistency in the service police forces provide to people experiencing domestic abuse. It seeks to do this by increasing the knowledge and understanding of officers, raising awareness of the varied forms of domestic abuse ­ physical and non-physical - and providing skills that police officers and staff can use to improve outcomes for victims. In addition, the Home Office have also funded the College of Policing to develop a new module aimed at investigators of domestic abuse. Alongside implementing the commitments set out in the Tackling Domestic Abuse Plan, the Government are providing policing and law enforcement agencies with everything they need to bring murderers to justice. The Government is on track to deliver its commitment of recruiting an additional 20,000 police officers by March 2023. As of 30th September 2022, 15,343 additional uplift officers have been recruited in England and Wales through the Police Uplift Programme, 77% of the target of 20,000 additional officers by March
2023. As part of this commitment, West Midlands Police have benefitted from up to £40m of additional funding this year alone. As at the end of September, the force has recruited an additional 944 officers towards its overall Uplift allocation of 1,218. It is important to note, however, that forces are operationally independent, and the deployment of officers .remains a local decision for Chief Constables. P. Patel Head of Domestic Abuse Perpetrators and Homicides Policy Email: Public.Enquiries@homeoffice.qov.uk

Dear Ms Hunt Regarding Raneem Oudeh and Khaola Saleem We were shocked and saddened to read the circumstances of the murders of Raneem Oudeh and Khaola Saleem, on behalf of everyone at the College of Policing, our sympathys and thoughts are with their families and friends. Thank you for your work to ensure lessons are learned and for identifying matters of concern. These incidents took place between 2015 and 2018. The offence of coercive and controlling behaviour was introduced in December 2015 and policing is continuing to make greater use of this law. The College is committed to working with policing to improve responses to domestic abuse.

Following a critical report by Her Majestys Inspectorate of Constabulary (HMIC) in 2014 regarding policing and domestic abuse, the College undertook two key pieces of work. Domestic Abuse (DA) Training The HMIC report had found unacceptable variations across forces in the way that DA training was created and delivered in police forces.The College, as a new organisation, had adopted the approach of its predecessor body, the National Policing Improvement Agency, and set learning objectives for forces to follow. At this time, the College did not create any content for forces to use in their training and did not prescribe or oversee the method for delivering the learning objectives. HMIC found that this led to different levels of service. In response, the College worked with practitioners and DA charities to create a training package for police responders. This package is called ‘DA Matters’. It is a daylong training course, focusing on coercive control. The course features videos of victim/survivors and content from responders’ body worn video at the scenes of DA incidents and crimes. DA Matters is delivered by three DA charities under

licence from the College. No other delivery method is permitted. The course was tested and evaluated during development. It has also been subject to post-delivery evaluation and found to lead to increased arrests for coercive control (Policing a new domestic abuse crime: effects of force-wide training on arrests for coercive control, 2021, Brennan I, Myhill A, Tagliaferri G, Tapley J at Policing a new domestic abuse crime: effects of force-wide training on arrests for coercive control: Policing and Society: Vol 31, No 10 (tandfonline.com) . West Midlands Police received the package from September 2019 – January 2020 and approximately 750 police responders received that first round of training. Thirty forces have received this national training and more are scheduled to receive it over the next few months. The Home Office has made funding available so that outstanding forces are encouraged to do so. Domestic Abuse Risk Assessment tool (DARA) The same HMIC report also raised concerns about the way in which policing carried out DA risk assessments. The College worked with academic institutions to assess the way in which the most prevalent risk assessment tool at the time was used. The research found that the 2009 DASH model (Domestic Abuse, Stalking and Harassment and Honour Based Violence) was inconsistently used and, that the way in which questions in the tool were posed meant that it was not fully effective in eliciting evidence about coercive control. The College worked with academics, DA survivors and practitioners to develop a new risk assessment tool. It is focused on eliciting evidence of coercive control as well as supporting identification of evidence of risk for other types of harm , such as assault. The tool has been piloted and evaluated. It has also been subject to extensive testing in a range of police forces, including West Midlands. West Midlands was one of the pilot forces and continues to use DARA as their risk assessment tool. We are now rolling DARA out to every force in England and Wales.

Much has changed since the tragic murders that were investigated during your Inquests. The College has introduced two far reaching initiatives that support police responders to be better informed when attending DA incidents and crimes. We will continue to look for opportunities to support policing to improve performance in relation to all vulnerable people and our current focus is on violence against women and girls. Work in this area will build on the two initiatives set out above to make women and girls safer.

Dear Mrs Louise Hunt – HM Senior Coroner for Birmingham and Solihull

Regulation 28 Report to Prevent Further Deaths – Raneem Oudeh and Khaola Saleem

I write in response to the Prevention of future death report dated the 24th November 2022 which followed from the inquest of Raneem Oudeh and Khaola Saleem. The report identified six key areas which we are addressing below.

General understanding of the nuances of domestic abuse and the WMP Domestic abuse policy

West Midlands Police (WMP) is due to publish a new Domestic Abuse (DA) policy early this year. The policy has been reviewed and sent out for consultation with key stakeholders across the force. We are in the process of cross referencing the issues highlighted in this preventing future deaths report before further consultation, sign off and then publication. The new policy is in a more accessible format than the previous version, with a shorter core policy document supported by 11 ‘procedural guidance’ documents that cover specific aspects of the policing response to DA, including a document for all key areas i.e. Response Officers and call handlers. Within the policy for the initial response is an `initial response action checklist` that outlines key actions for staff. The launch of the revised policy will be accompanied by a tailored communication and briefing package to ensure that all staff are fully informed of the changes. Through our audit and review processes, undertaken on a quarterly basis, we will ensure that the policy is being adhered to and this is also subject to review during inspections from His Majesty`s Inspectorate of Constabulary and Fire and Rescue Service (HMICFRS).

Since April 2021, crimes have been recorded and managed on the ‘Connect’ system. Connect combines the functions of several systems that were in operation in 2018, including crime recording and investigation, custody and briefing. The Connect system includes built- in mandatory question sets for officers to complete when they record a crime. These question sets help to guide officers through the process, prompting them with questions to capture and consider all of the relevant information.

WMP was a pilot force for the Domestic Abuse Risk Assessment (DARA) tool, which has now replaced the DASH form as the nationally recommended DA risk assessment. The DARA is considered to give an increased focus on coercive and controlling behaviour so that officers consider the offender’s behaviour holistically rather than considering individual incidents in isolation. This improves the risk assessment of DA crime and drives proactive interventions against offenders.

WMP have also introduced Log Closure, Crime Services and Review and Allocation Teams. All of these functions have a role in quality checking our response to DA to ensure that all recordable offences have been recorded as crimes and that the DARA risk grade has been accurately assessed. These checks, alongside frontline supervisory activity, are designed to ensure that our response is in line with the force policy and national guidance so that we investigate offences and safeguard victims effectively.

Recording of key information to ensure there is one version of the truth

In 2020, the force replaced Oasis, the old Command and Control system that was in use in 2018, with the new Control Works system. The command and control system is used across the force to record calls for service, dispatch officers and record attendance and progress at incidents. The Control works system has a risk assessment template built in for the call handler to complete. This risk assessment guides the call handler to consider various aspects of the incident and to include the relevant information to support the attending officers. Unlike the Oasis system, Control works is integrated with our intelligence system and provides a greater amount of information to inform the risk assessment process, without the need to check multiple systems. The system can include details of previous incidents and person details to aid officers in decision making. This ease of operation, better enables the call handlers to accurately capture and record key information to inform the responding officers.

The Connect system links people and locations to offences and allows for much quicker and easier research of previous domestic abuse incidents, listing all of the crimes that the individuals are linked to. The system also displays all of the previous DARA grading relating to the victim, thereby highlighting at a glance if the victim has been subject of repeat abuse. The system uses a series of ‘decision trees’ and ‘question sets’ to assist the officers when they record a crime. An ‘Initial Investigation’ question set is completed for each investigation by the recording officer and prompts them to record detailed information about the incident, for instance the victim’s account, scene management, witness details, house to house enquiries etc. This helps to ensure that all relevant information is recorded to fully inform other staff who may subsequently deal with the investigation. Investigating officers are also directed through a separate ‘investigation checklist’, that is not part of Connect, to listen to the 999 call and watch any available Body Worn Video footage where relevant so that they get a better understanding of what has taken place, the demeanour of the parties and to ensure they explore all available investigative opportunities.

The log closure team was created to ensure that all offences arising out of a domestic incident log are reviewed and accurately recorded in line with Home Office Counting Rules. The Victim Services Assessment team (VSA) conduct audits in various areas of business within WMP. In March 2022 during an audit of violence against women and girls, 20 cases were dip sampled and had the initial call listened to. In 20 (100%) of the cases, the call reflected the initial report correctly. Of the 20 calls listened to a good open style of questioning was used and accurate accounts were recorded in the respective logs.

Work load of supervising sergeants

In our response dated the 28th December 2022, we detailed the work of the Review and Allocation Team (R&A) that was set up in the Public Protection Unit (PPU) department restructure in February 2019. The R&A team removes a significant proportion of the inbox management work that used to be completed by the Domestic Abuse Team supervisors, alongside their other duties. The R&A team currently manage 40-50% of the DA crime that in 2018, the investigation supervisors would have had to review and process.

The restructure also took away complex work that would have been investigated by the Domestic Abuse supervisors in 2018. Rapes, other penetrative sexual offences and honour- based abuse matters are now dealt with by the Adult Complex teams. These offences, by their nature, take a significant amount of time to review and manage effectively. One of the main aims and benefits of the restructure was to separate these offences from the volume of DA reports so that the supervisors were not managing these complex investigations alongside a significant number of other reports and persons in custody.

Nevertheless, the number of Detective Sergeants on the Adult Investigation Teams has been maintained when compared with those on the Domestic Abuse Teams in 2018. Who were not solely managing safeguarding staff, with 36 Sergeants now compared to 37 then. This allows for a daily division of responsibility between the team Sergeants in each area, with one generally managing persons in custody, another reviewing the new recorded offences and, where available, a third reviewing ongoing investigations. The Connect system facilitates the investigative reviews with a designated review section, supervisor review reminder tasks every 28 days for ongoing investigations, and a supervisors’ DARA review template. For more complex investigations an action and tasking facility allows for individual investigative enquiries to be allocated and monitored. The process is further supported by manager review tasks that generate every 3 months on each report and ensure appropriate scrutiny by the first line supervisor’s manager, normally an Inspector, for protracted investigations.

The new DA policy gives guidance to supervisors on what actions are expected for DA investigations and includes the investigative checklist that has already been mentioned. Whilst DA investigation remains a busy and complex area of work, the new structure, additional resourcing, improved IT and daily organisation means that the demand is managed in a controlled and safe manner.

Training, Officers not being aware of key concepts in the WMP domestic abuse policy and/or having specialist training with no accurate list of training received by officers and auditing of its effectiveness

We are continually seeking to improving officer`s awareness of DA and vulnerability. It is a thread that runs through our training with new and current officers. During 2018 and 2019 approximately 900 Response officers were given the one-day DA Matters training course delivered by Safe Lives, who are a nationally recognised DA training provider recommended by the College of Policing. We continue to seek funding for further training by Safe Lives, which we are hoping to deliver to all frontline uniformed staff and investigation staff who deal with DA.

A vulnerability training course was also rolled out for all WMP operational staff in 2021, as part of the Operation Sentinel vulnerability programme, to raise awareness of what constitutes vulnerability and what action should be taken to protect vulnerable people. The programme works through a series of modules and will be completed by every officer.

As part of the Policing Education Qualification Framework (PEQF) curriculum DA is covered in various places throughout Year 1 & 2 of a student officer’s journey. It is covered in detail through the Vulnerability & Risk section as well as the PPU section. The key topic areas covered are:
- Defining 'vulnerability' in the context of operational policing
- The personal aspect of vulnerability and trauma
- Influences of risk factors on those who are vulnerable
- Importance of vulnerable people being appropriately supported by the police
- National drivers for providing a professional and ethical service to individuals who are, or may be, vulnerable, have suffered harm or be at risk of harm
- Understanding the breadth of abuse incidents
- Identify a potential public protection incident when acting as a first responder to an unrelated incident
- Take appropriate initial actions when responding to a public protection incident

Since 2019 WMP have recruited over 2000 new officers under the Police Education Qualification Framework and Degree Holder Entry Programme. The new recruits undertake a 2 or 3 year student officer programme; during which time they complete a number of rotations through Response, Neighbourhood and Investigative departments. This includes a mandatory 10-week tutored period on an investigative department and at least one further investigation rotation lasting between 12 weeks and 12 months, and in some cases two further investigation rotations. In each rotation, one third of the students are posted into the PPU, normally onto the Adult Investigation Teams, where they gain a good understanding of investigating DA offences. They are then able to take this learning with them when they rotate back into uniform roles.

The students are subject of on-going assessment throughout the period of the qualification, comprising both academic assessment by our partner university and work-based assessment, either by their police tutor or a police work based assessor. The students must pass these assessments in order to progress with the programme and ultimately to be accredited as a substantive police officer.

The Learning and Development (L&D) department have increased their resource to drive some fundamental changes to the way they plan and deliver evaluation into the effectiveness of training. This change will see a move from doing basic Level 1 & 2 evaluation (review of environment on the day and trainer delivery etc), to level 3 type evaluation giving better benchmarking data and more robust consideration of how the learning and its impact can be measured. They are setting up a commissioning governance process which will also allow for a more robust tracking and escalation of evaluation outcomes. The number of research officers that undertake evaluation work has also been increased to three, which will not only increase evaluation capacity, but also allow L&D to move forward into analysing behavioural and organisational impact as a result of the learning solutions implemented by WMP. The evaluation of two courses is currently being piloted using the benefits and evaluation calculator with a plan to extend the use of this methodology to further courses. The benefits and evaluation calculator provide a template that captures both tangible and intangible benefits provided by the learning solution.

Training is provided across a number of different platforms, from classroom based delivered by L&D, College learn on line, continued professional development (CPD) sessions, work based and others. An absence of a College of Policing specialist course on Domestic Abuse

All officers receive core training for investigation through the national Professionalising Investigations Programme (PIP) at level 1 for volume and priority crime and level 2 for those investigating more serious and complex crime. There is a national curriculum, which builds on the core skills, for investigating specific crime types including domestic abuse, and supporting resources from the College including: DA Matters for first responders (FR) with a focus on controlling and coercive behaviour and evidencing such cases; DA Matters for Champions/mentors which builds on the FR with enhanced knowledge of the dynamics of DA and risk; Coercive Control video and classroom course; and domestic abuse risk identification, assessment and management training.

Domestic abuse is embedded in other linked programmes including Vulnerability and Risk, Public Protection learning programme, Rape and Sexual offences investigation skills.

The College is currently working with National Police Chiefs Council (NPCC) to identify the underuse of legislation for ‘behavioural ‘type offences such as controlling and coercive behaviour in relationships, with a view to improving investigation and prosecution of such cases and will develop a programme to support forces in this aspect.

WMP use of DVPN (Domestic violence protection notice) and DVPO (Domestic violence protection orders)- Evidence at the inquest that out of 40,000 – 50,000 domestic abuse incidents each year only 400-430 DVPNs or DVPOs were obtained

Within the calendar year of 2022 there were 66,001 recorded DA crimes within WMP. From this 33,445 were within the offence category, violence against the person which are likely to be offences which could meet the DVPN criteria. Due to crime recording in line with home office counting rules there are also multiple crimes often recorded against one victim. It is important to note that a DVPN is not always suitable, for example when the perpetrator has been charged with an offence or on police bail.

In February 2019 WMP created a team of one supervisor and three staff members to focus on DVPN`s. This team work alongside the DA teams to identify and support them with opportunities for DVPN`s. WMP currently have an improvement plan in place with the objective to increase our number of DVPNs across the department. We recognise the value of civil orders and the benefit they can have on victims of DA. The civil orders team are working with DA investigators to identify opportunities to increase our use of the orders. This includes training and awareness, as well as working across the teams to support applications. An improvement plan has been created and is tracked through the PPU management team. Also, this is tracked through department quarterly performance reviews and performance panel meetings to senior leaders. DVPN/Os are one of a range of other civil interventions that can be used to safeguard victims.

Further to the inquest WMP has conducted a review of the issues raised within the PFD`s and conducted a series of workshops with the key departments namely, PPU, Response, Contact and L&D. The focus of the workshops has been to understand the issues raised and set recommendations that can have SMART actions that will improve and address the concerns identified. There are now nine key recommendations supported by 27 actions which will be tracked through the Vulnerability and Improvement Board, chaired by the Assistant Chief Constable (ACC) Crime to ensure progress. I hope that the above response provides you with assurance of the steps taken by the force since 2018 in responding to reports of DA and its continued search for ways to improve the service we offer to our communities.

Dear Ms Hunt,

Regulation 28 Report to Prevent Further Deaths: Raneem Oudeh and Khaola Saleem

I write in response to your Prevention of Future Death Reports dated the 24th November 2022, which followed from the inquest of Raneem Oudeh and Khaola Saleem. The murders of Raneem and Khaola shocked the country. On 22 November 2022, I made the following statement at my public Strategic Policing and Crime Board:

“In August 2018, Raneem Oudeh and Khaola Saleem were brutally murdered. My thoughts are with the victims and their family. In December 2018, Raneem’s estranged husband was convicted of their double murder and jailed for life with a minimum of 32 years.

On 18 November, a Birmingham Coroner’s Court concluded, amongst other matters, that the failings of West Midlands Police “materially contributed to their deaths”; officers breached the Force’s domestic abuse policy on a number of occasions; failed to carry out effective investigations into potential offences; and failed to take sufficient steps to safeguard Raneem.

West Midlands Police have acknowledged the murders were amongst the most shocking and appalling crimes in our region in recent years and have rightly apologised and accepted that more could have been done to protect Raneem from the campaign of domestic abuse that she suffered in the months leading up to her death at the hands of the man who would go on to kill her and her mother.

Since my election in May 2021, the need to prevent and tackle violence against women and girls and domestic abuse has always been a top priority. My Police and Crime Plan makes it clear that West Midlands Police must impose bail conditions on perpetrators, rather than releasing under investigation, make full use of civil protection orders and restraining orders and make arrests for breach of non-molestation orders.

My Victims Commissioner is working tirelessly, as a powerful advocate for the rights and welfare of victims of Domestic Abuse; I have increased the number of Domestic Abuse and Sexual Violence Advocates from 31 to 82; In December 2021, I launched the No Excuse for Abuse campaign; and

Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 0121 626 6060 www.westmidlands-pcc.gov.uk @WestMidsPCC

I continue to invest, to ensure that the victims of domestic abuse have access to the right support, in the right place and at the right time.

In addition to all of this, I will be working with West Midlands Police to address the particular conclusions of the Coroner and to hold West Midlands Police to account, to ensure that everything possible - has been done, is being done and will continue to be done, to ensure that there is no repetition of the failings identified in Raneem and Khaola’s case and to prevent and tackle violence against women and girls and domestic abuse.”

I see it as my responsibility to ensure that, with the resources available, West Midlands Police is as efficient and effective as possible in preventing and tackling domestic abuse and bringing perpetrators to justice. I welcome the response submitted by Chief Constable Craig Guildford, which sets out the improvements to operational practice relating to Domestic Abuse.

I offer the following as evidence of wider efforts to prevent and tackle Violence Against Women and Girls (‘VAWG’) generally, and domestic abuse specifically, focusing on my role as a Police and Crime Commissioner to: a) set the strategic direction for West Midlands Police; b) hold the Chief Constable of West Midlands Police to account; c) work collaboratively with community safety, criminal justice and victim services partners; and d) be a civic leader on matters relating to policing, crime and community safety.

Strategic direction and holding to account

As set out in my Police and Crime Plan 2021-2025, which I launched on 1 November 2021, "Combatting violence against women and girls and domestic abuse is a priority". The Plan includes commitments to work with West Midlands Police to:

• Improve the training and awareness for new and existing officers on violence against women and girls and domestic abuse, to ensure a consistent high-quality response, incorporating feedback from victims;
• Extend the use of independent advocates such as Independent Domestic Violence Advocates’ and Independent Sexual Violence Advocates and increase the number of these advocates with specialist training, for example to support LGBT+ victims;
• Ensure police impose bail conditions on alleged perpetrators of domestic abuse;
• Use all available civil protection orders, ensuring breaches are dealt with proportionately, including use of powers of arrest;
• Support the use of robust domestic abuse perpetrator programmes to challenge and change behaviour;
• Champion a change in legislation to record misogyny as a hate crime as recommended by Citizens UK;
• Ensure good policing plays its part in reducing vulnerability in the night-time economy;
• Increase the proportion of all VAWG crimes where an offender is brought to justice;
• Ensure that officers understand, identify, but never take advantage of vulnerability.
• Commission innovative programmes to support the holistic needs of Domestic Abuse survivors back into work through specialist advocacy and support.

Progress against these objectives is recorded via data, relevant to the following objectives:

• Reduce the number of outstanding suspects for Domestic Abuse offences awaiting investigation
• Reduce the repeat rates for Domestic Abuse offences, both in terms of repeat offenders and victims.
• Reduce the length of time Rape investigations take within West Midlands Police
• Reduce the proportion of DA cases where the suspect is released under investigation rather than being bailed with conditions
• Increase the use of civil protection orders
• Increase the proportion of breaches of civil protection orders which result in an arrest

Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 0121 626 6060 www.westmidlands-pcc.gov.uk @WestMidsPCC

• Increase the number of Domestic Abuse offenders who are managed through IOM/ Community Probation.
• Monitor the number of reports via the National Referral Mechanism which relate to Modern Slavery and work to build a more accurate picture of Modern Slavery within the West Midlands

Furthermore, the Police and Crime Plan commits to reducing the proportion of cases where a perpetrator has been identified, but the victim declines to support the investigation, but also increasing the "positive outcome" rate for Domestic Abuse cases, that is where an offender is charged. As the Plan sets out:

"Improving the response for victims requires action across the criminal justice system. In cases of Domestic Abuse and RASSO, where attrition is particularly high, a more sustained effort is needed. I will ensure West Midlands Police play its part via increased “outcome rates”, meaning that the percentage of recorded cases that lead to a charge or some other positive outcome should increase. I want to see fewer instances where evidential problems prevent a charge being brought, and fewer instances where cases are discontinued because the victim does not support a prosecution. I will work with partners to ensure appropriate use of restraining orders in such cases."

The measures are as follows:

• Identify the reasons for and ultimately reduce the number of investigations which are discontinued due to insufficient evidence where the victim supports police action (Crime Recording Outcome 15) and where victims feel unable to support police action (Crime Recording Outcome 16)
• Increase the positive outcome rates for Domestic Abuse, Rape, and Stalking and Harassment offences above levels where they have typically been historically: o Domestic Abuse > 6% o Rape > 5% o Stalking and Harassment > 8%

Performance against all these measures is reported quarterly, in public reports to the Strategic Policing and Crime Board and monthly, to meetings I hold with the Chief Constable.

A variety of factors, most notably changes to recording practice, have seen rates of recorded Domestic Abuse increase in the West Midlands and elsewhere. In 2018, approximately 500 VAWG offences were recorded per 100,000 of population. This was the lowest rate in the group of police forces similar to the West Midlands. This climbed to approximately 2,400 offences per 100,000 in early 2022, which is more in line with similar increase seen in comparable areas.

Whilst crime recording standards have been maintained, it is notable that rates of recorded VAWG have since fallen to approximately 2,300 offences per 100,000 of population, a rate almost identical to that in Greater Manchester. This suggests that crime recording practices in the West Midlands are aligned to practice elsewhere, particularly given that while the number of recorded crimes pertaining to Domestic Abuse has increased significantly, the number of calls for service relating to Domestic Abuse has not.

Working in partnership and campaigning for change

In order to amplify and reinforce the unacceptability of VAWG, my office has initiated and supported various publicity campaigns in order to drive positive behaviour change. These include, amongst others, the #NoExcuseForAbuse campaign, which started back in 2020 and has recently been expanded and bespoke campaigns during the recent World Cup.

I have appointed as the first West Midlands Victims Commissioner, and works with partners across the third sector and criminal justice, to prevent and effectively respond to these issues. This has included establishing an Ending Male Violence Against Women

Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 0121 626 6060 www.westmidlands-pcc.gov.uk @WestMidsPCC

and Girls Alliance, that brings together a range of stakeholders and will form part of our broader response to the new statutory Serious Violence Duty.

We have recently launched a selection process to find a partner for our refreshed Domestic Violence Perpetrator Programme, which will work to reduce domestic violence reoffending. We have also commissioned and published research, into how the cost of living crisis impacts particularly on victims of domestic abuse. My office has commissioned specialist support services for older victims of DA and victims who are LGBTQ+, and increased the number of Independent Domestic Violence Advocates and Sexual Violence Advocates in the West Midlands from 31 to 82.

As set out in Chief Constable Guildford's response, the influx of new Officers into policing since 2020 is relevant to the ability of West Midlands Police to respond to Domestic Abuse cases. Whilst the increase is welcome, it remains the case that by March 2023, West Midlands Police will have approximately 1,000 fewer Officers than it did in 2010, while forces in lower crime, lower demand areas now have more Officers than at any time in their history. That is entirely perverse and irrational. In addition, flaws in the implementation of the government's police funding formula, mean that West Midlands Police is further disadvantaged and does not receive its full funding allocation, costing our area £40m a year in lost police funding. On 14 December 2022, the government announced that West Midlands is to receive the fifth worst Police Grant Settlement in the country.

This disadvantage is compounded by ill-advised, misconceived and reckless cuts imposed on essential preventative public services and the criminal justice system, which have systematically undermined our criminal justice system and amongst other matters, led to extended backlogs in the Crown Courts, making it harder for cases to come to trial and increasing the risk of victim and witness attrition.

Conclusion

West Midlands Police continues to make significant efforts to improve its response to Domestic Abuse. Improved crime recording practice has significantly increased the number of incidents coming to police attention, also suggesting greater public confidence to report and a wider sense of the unacceptability of violence in relationships. There remains much to do and constant and unremitting action is required.

West Midlands Police lacks the resources it needs, to address the demands it faces and operational practice must continue to improve. Actions to prevent Domestic Abuse, raise public awareness, and work in partnership across community safety, are in place and are progressing.

The incidence of Violence Against Women and Girls and Domestic Abuse in our society remains a cause for constant serious concern and illustrates the need for a comprehensive response, nationally, regionally and locally. As Police and Crime Commissioner, I remain committed to ensuring the effective prevention and tackling of VAWG and Domestic Abuse is a top priority for West Midlands Police and partners.