About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review
Sefton review
CSP: SeftonPublished: April 2023Extracted: 10 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The review identified failures in mental health care coordination and information sharing for the perpetrator post-prison release, leading to inadequate risk management. Agencies also missed opportunities to identify domestic abuse indicators for the victims and to arrest the perpetrator for a restraining order breach.
Home Office classifications
39 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - substance misuse
Victim - mental ill health
Victim - had been a victim of an abuser before
Children - living with victim (including adult children)
Children - living with perpetrator (including adult children)
Children - present at homicide (including adult children)
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - psychosis
Perpetrator - suicidal thoughts
Perpetrator - suicide attempts
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to friends as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - managed by mappa
Perpetrator - supervised by mental health services
Perpetrator - supervised by probation services
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - physical stalking
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - family supported by expert specialist advocate
DHR process - family received draft report
DHR process - police recommendations
DHR process - social services recommendations
DHR process - health services recommendations
DHR process - housing services recommendations
DHR process - technology systems recommendation themes
DHR process - identification of risk recommendation themes
DHR process - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - other recommendation themes
Extracted recommendations
10 recommendations pulled from the report · 5 matched to organisations in the index
Addressed to
Manchester Mental Health and Social Care Trust (HMP Manchester) | Mersey Care NHS Trust | Sefton Safer Communities Partnership
That Manchester Mental Health and Social Care Trust (HMP Manchester) and Mersey Care NHS Trust confirm in writing to Sefton Safer Communities Partnership what actions have been taken to remedy the identified weaknesses when releasing prisoners who are entitled to Section 117 services.
That in cases in which prison mental health services have identified that a mental health assessment is needed, the National Offender Management Service ensures that when decisions are taken to move offenders between prisons, the assessment is completed prior to that move. If the prisoner is to be released before the assessment is completed, the National Offender Management Service should ensure there is a process in place to highlight the incomplete assessment to the offender’s current or last known GP, and request the GP to refer the offender to the nearest secondary mental health provider to the area in which they are released.
Furthermore, that where a prisoner is already being assessed by specialist mental health services, the National Offender Management Service is asked to determine the risks to that individual, and of the individual reoffending, if a complete mental health assessment cannot be achieved as a direct consequence of the prisoner being moved or released.
Addressed to
Your Housing Group | Sefton Safer Communities Partnership
That Your Housing Group reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that it minimises the risks of domestic abuse to its tenants. This must include commentary on how it ensures that the risk of domestic abuse is assessed for all new tenants, and how its staff are trained to respond to information that raises a domestic abuse concern.
That Sefton Safer Communities Partnership undertakes research within its local communities about barriers to reporting domestic abuse and how the community can be empowered to ‘speak out’. Furthermore, Sefton Safer Communities Partnership is asked to develop, publish and publicise advice for family and friends on what to do [or not to do] when they receive disclosures of domestic abuse and to ensure that this information is always available in places frequented by the public.
That Merseyside MAPPA Strategic Management Board reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that Section 6.15 of the MAPPA Guidance 2012 [Identifying MAPPA offenders] is adhered to.
Addressed to
Merseyside MAPPA Strategic Management Board
That MAPPA-managed offenders are managed at the appropriate level and that any substantial disagreement between agencies on which level a person should be managed at has a resolution pathway.
Addressed to
Merseyside MAPPA Strategic Management Board
That disclosure is always considered when there is a risk to others. Disclosure to a third party (Your Housing Group) was considered but not felt necessary when the perpetrator was assessed as presenting a risk to the public at the MAPPA meeting on 12 August 2014. While full disclosure to all residents was unlikely, this should have been discussed and clarified in the minutes, as should discussion and clarification of disclosure to Your Housing Group. The learning from this event is that disclosure should always be considered when there is a risk to others. This learning should be fed back to those who chair MAPPA meetings.
Addressed to
Merseyside Police | Sefton Safer Communities Partnership
That Merseyside Police reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that its policies and practices for circulating wanted people are appropriate and followed.
That the pan-Merseyside MARAC steering group considers the way in which the recording of MARAC meetings can be improved, how actions are recorded and allocated, and how agencies are held to account for their delivery. The steering group should consider whether meetings should be voice recorded.