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: ManchesterPublished: June 2023Year of death: 2016Extracted: 4 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 systemic failures in the management of severe and enduring mental health conditions for both the victim and the perpetrator, including non-adherence to clinical guidelines, missed opportunities for specialist engagement, and inadequate information sharing across health and offender management services. There were also shortcomings in safeguarding responses to disclosures of domestic abuse.
Home Office classifications
17 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - alcohol misuse
Victim - mental ill health
Victim - psychosis
Children - living with victim (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 - housing issues
Perpetrator - mental ill health
Perpetrator - psychosis
Perpetrator - managed by mappa
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
DHR process - community safety partnership recommendations
DHR process - technology systems recommendation themes
DHR process - multi agency working recommendation themes
The CSP should seek assurance from the CCGs and their respective providers of mental health services that the management of severe and enduring mental health problems is in line with clinical practice guidance. This should include support for families and psychosocial supports as set out in the NICE guidance.
The CSP should seek assurance from the CCGs that GPs are aware of and implementing the mental health toolkit set out by the Royal College of General Practitioners in relation to the management of mental health issues in primary care.
The CSP should seek assurance that multi-agency systems for sharing information in relation to risk of self-harm and harm to others are in place across the Partnership area, including information sharing between health services and offender management services.
The CSP should make representation to NHS England regarding the criteria for Mental Health Homicide reviews. The panel believes that this case would have benefited from such a review