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
Salford review
CSP: Salford
Published: June 2023
Year of death: 2018
Extracted: 24 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 differing understandings of domestic abuse, leading to missed opportunities for safeguarding interventions despite clear signs of the victim's vulnerability, self-neglect, and exploitation by the perpetrator. There were also concerns regarding multi-agency coordination and mental capacity assessments.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | Initial learning from the joint DHR/SAR is shared in an agreed format from this case and will be disseminated to all CMHTs, Early Intervention, Home Based Treatment, Liaison, in-patient wards. | Greater Manchester Mental Health NHS Foundation Trust Mental Health Services |
| 1 | Adult safeguarding referrals should always be made when there is a concern a person may be at risk of harm from abuse or neglect. This promotes wider multi-agency involvement and information exchange between partner agencies, and may open up options that further inform decision-making and practice. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 10 | Training/awareness raising on how to access/navigate the system for applying for housing and on what housing options are available. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 11 | The key learning points from this case to be incorporated into existing training packages at each partner agency. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 12 | Mental Capacity Act training to include how excessive alcohol use and withdrawal from alcohol may impact upon mental capacity; the likelihood of fluctuating capacity in relation to key decisions such as care, treatment, residence etc in these situations; and how coercion and control might influence decision-making. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 13 | Salford Safeguarding Adult Board to ensure local adult safeguarding policy, procedures and guidance incorporate the key learning points so staff can be fully supported in their practice. | Salford Safeguarding Adult Board |
| 14 | Ensure that staff are fully aware of the different ways that formal appointeeship can be implemented in order to protect a person’s finances. This may include consideration of a commissioned package of care to ensure essential items are bought. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 2 | The key learning points identified in this document to be disseminated in the form of interim guidance to all qualified staff at GMMH | Greater Manchester Mental Health NHS Foundation Trust Mental Health Services |
| 2 | Agencies to review no reply policies and ensure that they are fit for purpose and include escalation routes. This aims to address the importance of regular and timely care coordination visits in accordance with the presenting needs of service users. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 3 | That GMMH explores how information may be better shared between GMMH Mental Health Services and the HISMT. | Greater Manchester Mental Health NHS Foundation Trust Mental Health Services |
| 3 | To investigate with housing providers what housing options are available in these circumstances and what the process is to apply. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 4 | That GMMH investigates how relevant information could be entered on Paris when clients attend to collect money. This might include who they are accompanied by. | Greater Manchester Mental Health NHS Foundation Trust Mental Health Services |
| 4 | To investigate how practitioners working long-term with people with ongoing established risk might have access to a forum where they might draw on other perspectives and expertise if clients do not meet the threshold for a Section 42 enquiry. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 5 | The frequent attenders’ process should be reviewed and promoted within the Trust to highlight the referral process to the community based Multi-Disciplinary Group. | Salford Royal Hospitals NHS Foundation Trust |
| 5 | Practitioners to be reminded to ask about the tenure of service users and to involve social landlords where possible: if it is a social landlord there are a range of people, services and expertise that can add value in terms of solving issues and taking remedial action. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 6 | Frequent attenders with substance misuse and mental health problems should have a safeguarding referral where appropriate. | Salford Royal Hospitals NHS Foundation Trust |
| 6 | Salford Safeguarding Adult Board to formulate a Seven Minute Briefing (or similar) to concentrate the key learning points into an accessible format. This should be disseminated to all qualified staff at each partner agency. | Salford Safeguarding Adult Board |
| 7 | There is a need for regular mental capacity assessments when patients present with fluctuating capacity | Salford Royal Hospitals NHS Foundation Trust |
| 7a | Understand when abuse and / or neglect may result in the need to consider urgent interventions such as a change of accommodation, | Community Safety Partnership | Salford Safeguarding Adult Board |
| 7b | Be able to identify potential options in the context of relevant legal frameworks, | Community Safety Partnership | Salford Safeguarding Adult Board |
| 7c | Understand the importance of promptly formulating and implementing an appropriate interim protection plan once an adult safeguarding referral has been raised. | Community Safety Partnership | Salford Safeguarding Adult Board |
| 8 | A schedule of regular replenishment of domestic abuse signposting posters needs to be developed to ensure patients and relatives have access to contact numbers. | Salford Royal Hospitals NHS Foundation Trust |
| 8 | SSAB website to be updated to include more information about different services, tools, and raising awareness of legal powers partners may have when dealing with different situations. | Salford Safeguarding Adult Board |
| 9 | The delivery of a be-spoke training package to key staff across partner agencies aiming to address the agreed learning points from this case in relation to: the operation of adult safeguarding procedures, risk assessment / management and mental capacity issues with specific reference to those people presenting with alcohol addiction and/or subject to exploitation and/or coercion and control, and including when Police should be consulted in relation to a crime. | Community Safety Partnership | Salford Safeguarding Adult Board |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||