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

Manchester review

CSP: Manchester Published: May 2023 Year of death: 2015 Extracted: 23 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
Multiple agencies missed opportunities to identify and respond to domestic abuse, including failures in risk assessment, separate interviewing of parties, and information sharing regarding the perpetrator's history. There was also insufficient recognition of the impact on children and potential professional biases.

Home Office classifications

42 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - depression
  • Victim - had been a victim of an abuser before
  • Victim - immigration involvement
  • Children - under 18 shared parental responsibility (between victims)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - immigration involvement
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to military 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 - immigration involvement
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - school recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - identification of risk recommendation themes
  • DHR process - training recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

23 recommendations pulled from the report · 16 matched to organisations in the index

Recommendation 7.1.1

Addressed to National

There should be consideration of developing a process whereby information about high-risk domestic abuse offenders is shared across international boundaries.

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

Recommendation 7.3.1

Addressed to Greater Manchester Police

To ensure that officers probe information provided by victims in relation to previous domestic abuse. This is particularly important in relation to incidents in other areas and the need to complete relevant checks, for example, the Police National Database (PND).

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

Recommendation 7.3.2

Addressed to Greater Manchester Police

To ensure that all officers who have contact with victims of domestic abuse understand the importance of providing relevant helpline and support signposting. When it has been done, a record should be made as to what information has been provided to the victim.

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

Recommendation 7.3.3

Addressed to Greater Manchester Police

To ensure that supervisors make proper use of an up to date induction package for newly appointed domestic abuse specialists when they start in post.

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

Recommendation 7.3.4

Addressed to Greater Manchester Police

To ensure that whenever children are present during incidents of domestic abuse they are communicated with, listened to and their welfare considered.

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

Recommendation 7.4.1

Addressed to Pennine Acute NHS Hospitals Trust

To conduct regular audits to ensure patients identifying signs of domestic abuse are supported appropriately.

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

Recommendation 7.4.2

Addressed to Pennine Acute NHS Hospitals Trust

To ensure that DVA training includes good practice around interviewing the victim and perpetrator separately.

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

Recommendation 7.4.3

Addressed to Pennine Acute NHS Hospitals Trust

To ensure that safe enquiry is conducted in the event of domestic abuse disclosure, regardless of whether the victim is the patient or partner, friend or relative accompanying them.

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

Recommendation 7.4.4

Addressed to Pennine Acute NHS Hospitals Trust

To carry out a risk assessment for any person disclosing domestic abuse in line with MSAB/MSCB guidelines

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

Recommendation 7.5.1

Addressed to Manchester Mental Health & Social Care Trust

To ensure that DVA training includes good practice around interviewing the victim and perpetrator separately.

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

Recommendation 7.5.2

Addressed to Manchester Mental Health & Social Care Trust

To ensure that safe enquiry is conducted in the event of domestic abuse disclosure, regardless of whether the victim is the patient or partner, friend or relative accompanying them.

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

Recommendation 7.5.3

Addressed to Manchester Mental Health & Social Care Trust

To carry out a risk assessment for any person disclosing domestic abuse in line with MSAB/MSCB guidelines

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

Recommendation 7.5.4

Addressed to Manchester Mental Health & Social Care Trust

To cascade lessons learned from this DHR to ensure that clinicians consider the full facts rather than just responding to the presenting issue, e.g. domestic abuse as well as mental health issues.

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

Recommendation 7.6.1

Addressed to Manchester Clinical Commissioning Groups

To improve GP awareness of symptoms and behaviour associated with DVA through IRIS training

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

Recommendation 7.6.2

Addressed to Manchester Clinical Commissioning Groups

To disseminate learning from the DHR via Safeguarding Newsletter, CCG Website.

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

Recommendation 7.7.1

Addressed to North West Ambulance Services

To ensure that awareness raising with staff takes place in relation to the consideration of immigration status and to be curious why a patient may not have a GP.

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

Recommendation 7.8.1

Addressed to Robert’s school

The school should take action to ensure that staff are familiar with the possible indicators of domestic abuse and the impact on the child.

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

Recommendation 7.8.2

Addressed to Robert’s school

The school should consider accessing Healthy Relationships Awareness sessions for pupils, which looks specifically at domestic abuse and relationships.

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

Recommendation 7.8.3

Addressed to Robert’s school

To review the effectiveness of changes to the system where Deputy Head Pastoral reviews all counselling appointments every week to check who has attended and who hasn’t. There should be a system of follow-up as necessary.

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

Recommendation 7.8.4

Addressed to Robert’s school

To ensure that all records relating to children are accurate and visits to the school nurse are included in the Head of House Meeting Minutes

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

Recommendation 7.8.5

Addressed to Robert’s school

To ensure that where children are concerned with their workloads, a referral is made to their personal tutor to discuss and plan support.

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