Raneem Oudeh and Khaola Saleem

Louise Hunt 
Senior Coroner 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

19 December 2022 

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.  

Yours sincerely  

Chief Executive Officer 
College of Policing

Home Office 

' 

Direct Communications Unit 
2 Marsham Street 
London 
SW1P4DF 

Tel:  020 7035 4848 
www, ho m c office ,qov. u k 

Mrs  Louise Hunt 
HM  Senior Coroner for Birmingham and Solihull Area 
The Birmingham and Solihull Coroner's Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 
Birmingham City Council 
City Operations Directorate 

2nd  December 2022 

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

CRAIG  GUILDFORD QPM VR DL 
CHIEF CONSTABLE 

POLICE HEADQUARTERS 
PO Box 52 
Colmore Circus Queensway 
BIRMINGHAM 
B46NQ 

Switchboard: 101 

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

CHIEF CONSTABLE 

19th January 2023 

CReerhi 

POLICE HEADQUARTERS 
PO Box 52 
Colmore Circus Queensway 
BIRMINGHAM 
B4 6NQ 

Switchboard: 101 

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

Saint Aignan, 

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

56480 

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. 

Morbihan 

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

Bretagne 

France 

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.  

Yours sincerely 

Chief Constable

Telephone Number: 0121 626 6060 
wmpcc@westmidlands.police.uk 

Sent by email to: Lynne Boyle 

27 January 2023 

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.   

Yours sincerely, 

Police and Crime Commissioner 

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

CRAIG  GUILDFORD QPM VR DL 
CHIEF CONSTABLE 

POLICE HEADQUARTERS 
PO Box 52 
Colmore Circus Queensway 
BIRMINGHAM 
B46NQ 

Switchboard: 101 

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. 

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 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. 

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 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. 

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 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 

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