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: 2017 Extracted: 7 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
Key concerns include inadequate multi-agency response to domestic abuse, poor information sharing, insufficient consideration of the victim's and perpetrator's complex needs (mental health, substance misuse, self-neglect), and difficulties in engaging vulnerable individuals with services. Police response to a critical 999 call was also delayed.

Home Office classifications

32 tags

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

  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - mental ill health
  • Perpetrator - case heard in court
  • Perpetrator - alcohol misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - panic attacks
  • Perpetrator - psychosis
  • Perpetrator - self harm
  • Perpetrator - suicide attempts
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - supervised by mental health services
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - sexual abuse
  • Aggravating factors - physical abuse
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - housing services 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 - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - record keeping recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

7 recommendations pulled from the report · 2 matched to organisations in the index

Recommendation 1

Addressed to Manchester Community Safety Partnership | Manchester Housing Providers Partnership

That Manchester Community Safety Partnership shares this DHR overview report with the Manchester Housing Providers Partnership and seeks assurance from the latter partnership that social housing providers have the policies in place, supported by training, which equip their staff to respond with confidence to domestic violence and abuse.

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

Recommendation 2

Addressed to Manchester Community Safety Partnership | Greater Manchester Police

That Manchester Community Safety Partnership seek assurance from GMP that the policy of escalating incidents where the unavailability of resources would have the most detrimental effect is now fully embedded in practice.

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

Recommendation 3

Addressed to Manchester Community Safety Partnership | Greater Manchester MAPPA Strategic Management Board | National Police Chiefs’ Council

That Manchester Community Safety Partnership shares this DHR overview report with the Greater Manchester MAPPA Strategic Management Board so that the latter partnership may consider whether any changes are necessary to the way that the risks presented by registered sex offenders to intimate partners are assessed and managed and refer the case to the National Police Chiefs’ Council if appropriate.

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

Recommendation 4

Addressed to Manchester Community Safety Partnership | Manchester Health and Care Commissioning

That Manchester Community Safety Partnership request Manchester Health and Care Commissioning to address the issues emerging from this DHR, in particular:
 The findings from the review are shared with Primary Care with the expectation that all presenting needs of patients are considered and that professional curiosity is exercised to contribute to risk assessment.
 Ensure that GPs inform patients of services they can access during the period they are waiting for a mental health outpatient appointment.
 Review how GP practices can engage with those patients that are traditionally difficult to engage including review areas of best practice and consider how an outreach approach may be implemented.
 Primary Care to be updated on self-neglect as a safeguarding issue and equipped to make a social care referral for self-neglect/vulnerability rather than only considering a mental health referral.
Manchester Health and Care Commissioning should share the outcome of this recommendation Manchester Community Safety Partnership in due course.

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

Recommendation 5

Addressed to Manchester Community Safety Partnership | Manchester Safeguarding Adults Board

That Manchester Community Safety Partnership shares this DHR overview report with Manchester Safeguarding Adults Board so that the latter Board can consider what action to take to enhance the multi-agency approach to self-neglect in Manchester.

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

Recommendation 6

Addressed to Manchester Community Safety Partnership

That Manchester Community Safety Partnership seeks assurance that partner agencies have policies in place to engage with ‘difficult to engage’ service users, particularly those abusing alcohol and/or drugs and/or experiencing mental health issues, who may be at risk of domestic abuse.

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

Recommendation 7

Addressed to Manchester Community Safety Partnership

That Manchester Community Safety Partnership widely disseminate the learning from this DHR.

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