This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 30 August 2018 I commenced investigations into the death of Raneem Oudeh and Khaola Saleem. The investigations continue and inquests were resumed before a jury on 31/10/22. The inquests have not yet concluded, however, I heard evidence that raises a significant concern about the risk of future fatalities to a particularly vulnerable group that I am sending this report before the conclusion of the inquest. As the inquests are yet to conclude I will only provide a summary of the factual circumstances.
Circumstances of the death
Raneem Oudeh was originally from Syria. She came to the UK in 2014 to be with her mother Khaola Saleem who had two other daughters. They both lived in Solihull. Khaola had come to the UK several years earlier joining her sister. Khaola met her husband in 2002 and they got married and had 3 children. Raneem attended Solihull College and it was there that she met a man ████████ they became friends. ████████ started to hassle Raneem at college, and he was suspended from the college as a result of this and poor attendance. In 2015 Raneem married another man but that relationship broke down due to relationship issues when she was pregnant, and she moved back to live with her mother. Raneem had a little boy ████████ Raneem reformed a relationship with ████████ in 2017 and they married on 02/04/17. Raneem found out that ████████ was in fact married to another woman ████████ with whom he had children and ended the relationship in April 2018. At this time Raneem revealed to her family that she was subject to domestic abuse and coercive and controlling behaviour ████████. From April 2018 Raneem contacted WMP on a number of occasions as follows:
02/04/18 - she called 999 ████████ made threats ████████
████████ Police attended however no effective investigation was undertaken and the case was closed.
27/04/18 - Raneem called an ambulance as she was suffering from Chest pain. The ambulance crew took her to hospital and during the journey she revealed her partner was volatile and had been violent towards her causing severe bruising to her shoulder. A nurse from the hospital called 999 to report that Raneem was a victim of domestic violence. Police attended but no effective investigation was undertaken, and the file was closed.
27/05/18 - Raneem called 999 in a distressed state ████████████████████
████████ - Police attended however no effective investigation was conducted.
There were other calls made to the police on 29/05/18, 30/05/18, 31/05/18 and 11/08/18 relating to further incidents of domestic abuse.
16/08/18 Raneem obtained a non-molestation order ████████████████████████████████████████ ██████████████████
26/08/18 Raneem and Khaola attended the Rotana Shisha Lounge in Birmingham where Raneem was meeting a potential new partner. ████████ turned up and an altercation ensued where he slapped Khaola. The police were called but their response was delayed by a firearms incident. Raneem updated the police that she and her mother had left the location to travel home. At just after midnight ████████ murdered Raneem and Khaola outside Khaola’s home address █ He was subsequently convicted of both murders. The inquest will be focusing on the events from April 2018 and the contacts Raneem had with various agencies.
Following forensic post mortems, the medical cause of death for each woman was determined to be:
1a MULTIPLE STAB WOUNDS
1b
1c
II
Coroner’s concerns
1. The inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed. The inquest was told that in Raneem's case the officer reviewing her case on 28/04/18 understood that more needed to be done however he filed the report due to having no staff to investigate the case. The officer stated that this problem continues. The inquest was told that cases are not being investigated due to lack of resources in the department. This leaves a very real and immediate concern that women like Raneem, who was a repeat victim of domestic violence and controlling and coercive control from a man who had made threats to kill her, are at serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised1
Insufficient staffing and resources for domestic abuse investigations
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6
Action
Recruit an additional 20,000 police officers through the Police Uplift Programme by March 2023.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
Action
Maintain the restructured investigation arrangements, including Review and Allocation Team processing, Adult Complex teams and dedicated supervisory responsibilities.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Action
Operate a Review and Allocation Team to assess domestic abuse reports, verify risk grading, and allocate cases for investigation.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Action
Require Adult Investigation Team Sergeants to review, triage, set actions for, and allocate incoming crime reports each shift.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Action
Increase staffing allocated to domestic abuse management and investigation across the West Midlands and Eastern area.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Action
Restructure domestic abuse investigations into Adult Investigation Teams and Adult Complex Investigation Teams.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5
Position
Insufficient police staffing and funding prevent West Midlands Police from fully addressing domestic abuse demand and improving operational practice.
Stated byPolice and Crime CommissionerUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Officer deployment, including staffing decisions, is a local responsibility for Chief Constables because police forces are operationally independent.
Stated byHome OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The new structure, resourcing, information technology and organisational processes manage domestic abuse demand in a controlled and safe manner.
Stated byWest Midlands PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Current domestic abuse investigation staffing has increased substantially, and the relevant team’s workload is considered manageable.
Stated byWest Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Investigation team staffing capacity is not a determining factor in decisions to file domestic abuse reports or pursue further action.
Stated byWest Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.52
1
Select a partner for the refreshed Domestic Violence Perpetrator Programme.
Stated byPolice and Crime CommissionerStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
2
Commission innovative programmes providing specialist advocacy and support to help domestic abuse survivors return to work.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
3
Commission specialist support services for older domestic abuse victims and LGBTQ+ victims.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
4
Establish an Ending Male Violence Against Women and Girls Alliance bringing together relevant stakeholders.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
5
Invest in support so domestic abuse victims can access appropriate services at the right time and place.
Stated byPolice and Crime CommissionerStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
6
Work with West Midlands Police to improve training and awareness for officers on violence against women and girls and domestic abuse.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
7
Work with West Midlands Police to extend independent advocacy and specialist advocate training, including support for LGBT+ victims.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
8
Initiate and support publicity campaigns to reinforce the unacceptability of violence against women and girls.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
9
Work with West Midlands Police to address the Coroner’s conclusions and prevent recurrence of the identified failings.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
10
Work with partners to support robust domestic abuse perpetrator programmes that challenge and change behaviour.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
11
Report performance measures quarterly publicly and monthly through meetings with the Chief Constable.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
12
Appoint a West Midlands Victims Commissioner to work with third-sector and criminal-justice partners.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
13
Increase the number of Domestic Abuse and Sexual Violence Advocates from 31 to 82.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
14
Launch and expand public campaigns addressing violence against women and girls and domestic abuse.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
15
Commission and publish research on the cost-of-living crisis impacts on domestic abuse victims.
Stated byPolice and Crime CommissionerStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
16
Champion legislative change to record misogyny as a hate crime.
Stated byPolice and Crime CommissionerStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
17
Extend the controlling or coercive behaviour offence to intimate partners, former partners and family members regardless of cohabitation.
Stated byHome OfficeStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
18
Continue funding the Domestic Homicide and Suspected Victim Suicides Project.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
19
Update and publish statutory guidance on controlling or coercive behaviour to support frontline identification, investigation and evidencing.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
20
Assist funding the rollout of Domestic Abuse Matters training to police forces lacking equivalent domestic abuse training.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
21
Fund the College of Policing to develop a domestic abuse investigation module.
Stated byHome OfficeStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
22
Use investigation checklists directing officers to review 999 calls, body-worn video and available investigative opportunities.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
23
Use Connect supervisory reminders, DARA review templates, investigative tasking and three-month manager reviews to scrutinise ongoing investigations.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
24
Operate Log Closure, Crime Services and Review and Allocation Teams to quality-check domestic abuse recording and risk grading.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
25
Use Connect’s mandatory question sets, linked records and investigation prompts to capture and review key domestic abuse information.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
26
Increase Learning and Development evaluation capacity, including three research officers, to assess learning and organisational impact.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
27
Continue seeking funding for further SafeLives domestic abuse training for frontline uniformed and investigation staff.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
28
Operate a dedicated civil-orders team to identify and support DVPN and DVPO opportunities.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
29
Establish a commissioning governance process to track and escalate training-evaluation outcomes.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
30
Deliver tailored staff communications and briefings when the revised Domestic Abuse policy is launched.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
31
Use the DARA tool instead of DASH to assess domestic abuse risk, including coercive and controlling behaviour.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
32
Complete consultation, approval and publication of the revised Domestic Abuse policy and its procedural guidance, including an initial-response action checklist.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
33
Audit and review adherence to the Domestic Abuse policy quarterly and through HMICFRS inspections.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
34
Pilot the benefits and evaluation calculator for two courses and extend the methodology to further courses.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
35
Track nine recommendations and 27 associated actions through the Vulnerability and Improvement Board.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
36
Use Control Works with its integrated intelligence and call-handler risk-assessment template to record and inform responses to incidents.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
37
Provide domestic abuse learning through the PEQF student-officer curriculum and investigative rotations, with assessed progression to accreditation.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
38
Implement and track the domestic abuse civil-orders improvement plan, including training, awareness and application support.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
39
Roll out the Operation Sentinel vulnerability training programme to WMP operational staff and complete it for every officer.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
40
Continue rolling out the DA Matters national training package to additional police forces.
Stated byCollege of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
41
Create and establish the DA Matters training package for police responders, delivered by licensed domestic-abuse charities using the prescribed course method.
Stated byCollege of PolicingStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
42
Develop and establish the DARA risk-assessment tool focused on identifying coercive control and other domestic-abuse risks.
Stated byCollege of PolicingStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
43
Roll out DARA as the domestic-abuse risk-assessment tool to every force in England and Wales.
Stated byCollege of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
44
Hold a monthly domestic abuse Performance meeting chaired by the domestic abuse Superintendent to monitor and manage departmental performance.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
45
Operate a joint CPS and Public Protection Unit scrutiny panel to review no-further-action decisions and identify learning and best practice.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
46
Screen domestic abuse reports each morning to identify whether immediate suspect arrest is required.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
47
Require Sergeants to review ongoing investigations at least every 28 days, monitor progress, and set further investigative actions where necessary.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
48
Audit supervisory reviews, action-setting, and allocations quarterly, including dip-sample quality reviews and use of the supervisor template linked to THRIVE+.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
49
Track non-arrested suspects through local documents, management scrutiny, neighbourhood intervention, and force-wide performance review.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
50
Conduct quarterly supervisory sampling of Review and Allocation Team decisions and provide feedback to promote consistent filing and allocation.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
51
Operate an external Scrutiny Panel to review crime-review decisions, disseminate feedback, and identify learning for wider practice.
Stated byWest Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
52
Use investigation and filing checklists, quarterly audits, and consideration of evidence-led prosecutions and civil orders when determining whether to file reports.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 7 November 2022.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2
1
Criminal justice funding cuts and Crown Court backlogs make domestic abuse cases harder to bring to trial and increase victim and witness attrition.
Stated byPolice and Crime CommissionerUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
2
DVPN suitability cannot be inferred from incident totals because multiple crimes may involve one victim and some circumstances make DVPNs unsuitable.
Stated byWest Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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