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: Sefton Published: April 2023 Extracted: 10 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

Original review (PDF) ↗ Source: Home Office DHR Library

Summary AI-generated

Verify against the full report at the source link
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

Recommendation 1

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2 (a)

Addressed to National Offender Management Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 2 (b)

Addressed to National Offender Management Service

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 3

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 4

Addressed to Sefton Safer Communities Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5 (a)

Addressed to Merseyside MAPPA Strategic Management Board | Sefton Safer Communities Partnership

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5 (b)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 5 (c)

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 6

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.

Verified wording from the published review · Original review (PDF) ↗

Recommendation 7

Addressed to pan-Merseyside MARAC steering group

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.

Verified wording from the published review · Original review (PDF) ↗