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
Stockport review
CSP: Stockport
Published: April 2023
Year of death: 2014
Extracted: 22 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review identified that the perpetrator's inadequately treated psychosis was the root cause of the homicide, exacerbated by a lack of information sharing across services and within the family. Inadequate risk assessments, care planning, and missed opportunities for intervention were also significant concerns.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Pennine Care NHS Foundation Trust : should ensure that the quality of care and contingency plans is audited, including the checking of plans against identified needs | Pennine Care NHS Foundation Trust |
| 10 | Pennine Care NHS Foundation Trust & Stockport Metropolitan Borough Council : should have triggers for responding to crisis calls and an escalation process in place | Pennine Care NHS Foundation Trust | Stockport Metropolitan Borough Council |
| 11 | Stockport NHS Foundation Trust : should set a clear strategy for the recognition of domestic abuse, with up to date policy guidance and a programme of staff training | Stockport NHS Foundation Trust |
| 12 | Stockport Community Safety Partnership : should assess the results of the Domestic Abuse strategy thus far, with emphasis on increasing the access to training to frontline healthcare staff, and ensuring that child to parent violence is included | Stockport Community Safety Partnership |
| 13 | Stockport NHS Foundation Trust : should ensure the lessons learned from this incident with specific regard to domestic abuse and violence are conveyed across the Trust, and particularly in the Emergency Department | Stockport NHS Foundation Trust |
| 14 | Stockport NHS Foundation Trust : should revise its admission and discharge documentation to include a prompt regarding carers needs and signposting to a plan of care and an assessment before discharge | Stockport NHS Foundation Trust |
| 15 | Stockport Metropolitan Borough Council : should assess the efficacy of the current multi-agency approach to carers needs, along with partner organisations, and implement a strategy to ensure the aims of the position statement are carried out | Stockport Metropolitan Borough Council |
| 16 | Stockport NHS Foundation Trust : should revise the recording systems to ensure a complete and contemporaneous record is maintained of all clinical encounters | Stockport NHS Foundation Trust |
| 17 | Stockport CCG : formal processes must be in place so that multiagency risk assessments are carried out for all vulnerable children and their carers on transition from children to adult services | Stockport CCG |
| 18 | Stockport CCG: GP practice staff must undertake adult safeguarding and domestic abuse training. | Stockport CCG |
| 19 | Pennine Care NHS Foundation Trust and Stockport NHS Foundation Trust : Domestic abuse training material should be reviewed to ensure that it includes domestic abuse in both children and adults safeguarding; including that any individual in a domestic arrangement may abuse anyone else in that setting | Pennine Care NHS Foundation Trust | Stockport NHS Foundation Trust |
| 2 | Pennine Care NHS Foundation Trust : should amend the CPA policy to describe the role of the psychiatrist with regard to the CPA policy and care planning | Pennine Care NHS Foundation Trust |
| 20 | Stockport NHS Foundation Trust : Fully implement NICE guidance ‘Domestic violence and abuse: multi-agency working’ (PH50) recommendation 5: ‘Create an environment for disclosing domestic violence and abuse’ with particular emphasis on consistent implementation of policy, and recording of information | Stockport NHS Foundation Trust |
| 21 | Pennine Care NHS Foundation Trust : change incident reporting and management policy to implement structures and processes as described in NHS Serious Incident Framework March 2015 | Pennine Care NHS Foundation Trust |
| 22 | Stockport Community Safety Partnership : guidance on domestic abuse by children to parents should be included in domestic abuse strategies | Stockport Community Safety Partnership |
| 3 | Pennine Care NHS Foundation Trust : CPA policy should provide guidance on assessment and CPA care planning to clarify responsibilities and requirements where there are carers funded by direct payments | Pennine Care NHS Foundation Trust |
| 4 | Stockport Metropolitan Borough Council should develop a system to follow up on plans and interventions after carers assessments and co-ordinate interventions with Pennine Care NHS Foundation Trust where the carer is caring for a mental health service user | Stockport Metropolitan Borough Council |
| 5 | Pennine Care NHS Foundation Trust : should ensure that NICE CG178 ( Psychosis and schizophrenia in adults: prevention and management) is implemented and monitored | Pennine Care NHS Foundation Trust |
| 6 | For Pennine Care NHS Foundation Trust, Stockport CCG : implement a system for follow up and monitoring of GP physical health checks re psychiatric medication | Pennine Care NHS Foundation Trust | Stockport CCG |
| 7 | For Pennine Care NHS Foundation Trust, Stockport CCG & Stockport Metropolitan Borough Council : audit of implementation of the autism strategy, and resources to support staff & patients who are diagnosed with Autistic Spectrum Disorder | Pennine Care NHS Foundation Trust | Stockport CCG | Stockport Metropolitan Borough Council |
| 8 | Pennine Care NHS Foundation Trust : Ensure that clinical decisions about changes to pathways or services should include the care team, and there is evidence that the perspectives of patient and carers have been considered, taken into account and documented | Pennine Care NHS Foundation Trust |
| 9 | Pennine Care NHS Foundation Trust : change approach to Risk Assessment training, to focus on formulations; and implement a quality assurance process for Risk Assessments | Pennine Care NHS Foundation Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||