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: July 2023Year of death: 2016Extracted: 12 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
The report identifies a failure in agencies to holistically assess the perpetrator's risk across multiple incidents and complex relationships, compounded by victims' reluctance to cooperate. It highlights the absence of a multi-agency forum for cases not meeting MARAC thresholds and issues with information sharing. Cultural factors and GP awareness were also noted as concerns.
Home Office classifications
41 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - mental ill health
Victim - depression
Victim - panic attacks
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Children - under 18 shared parental responsibility (between victims)
Children - living with victim (including adult children)
Children - subject to child protection or domestic abuse prior to homicide
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - substance misuse
Perpetrator - depression
Perpetrator - post traumatic stress disorder (ptsd)
Perpetrator - known to agencies as a domestic abuse perpetrator
Perpetrator - known to police as a domestic abuse perpetrator
Perpetrator - known to social services as a domestic abuse perpetrator
Perpetrator - known to health services as a domestic abuse perpetrator
Perpetrator - known to housing services as a domestic abuse perpetrator
Perpetrator - known to school as a domestic abuse perpetrator
Perpetrator - known to others as a domestic abuse perpetrator
Perpetrator - known to family as a domestic abuse perpetrator
Perpetrator - immigration involvement
Aggravating factors - separation
Aggravating factors - coercive or controlling behaviour
Aggravating factors - stalking
Aggravating factors - sexual abuse
Aggravating factors - psychological or emotional abuse
Aggravating factors - physical abuse
Aggravating factors - economic abuse
DHR process - family contributed to dhr
DHR process - health 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
DHR process - other recommendation themes
Extracted recommendations
12 recommendations pulled from the report · 6 matched to organisations in the index
Addressed to
NHS England Greater Manchester Clinical Commissioning Group
There is a need to ensure that GP practices are aware of risk factors relating to domestic violence and abuse and to know what to do if a concern arises. This has been a previous recommendation and an IRIS training plan is in place, therefore the recommendations will reflect this.
Addressed to
NHS England Greater Manchester Clinical Commissioning Group
There is a need for all GP practices to establish a domestic violence and abuse policy and procedure. This has been a previous recommendation and needs to be audited to assess compliance. This needs to include a system for recording health indicators for domestic abuse in line with the Guidance for responding to domestic abuse published by RCGP, IRIS, CAADA (2012)
Provide guidance to Public Protection Investigation Unit (PPIU) Detective Sergeants and PPIU safeguarding practitioners involved in researching and risk assessing domestic abuse referrals, of the need to apply holistic research and assessment principles into the background and circumstances of individuals involved in domestic abuse incidents in order to identify relevant issues. For example, issues such as repeat victimisation, serial offending behaviour, patterns of under reporting or lack of support for prosecutions are often revealed by this process. Identifying these and other historic issues can assist in informing enhanced risk assessments and the formulation of appropriate safety plans.
Consider the introduction of training for all immigration casework staff in MAPPA (Multi Agency Public Protection Arrangements) & MARAC (Multi-Agency Risk Assessment Conference) processes/procedures.
Manchester Community Safety Partnership (MSCP) request partner agencies review their domestic violence policies and programmes, and identify if they include reference to cultural differences. Agencies should consider including such reference where none exists and to ensuring existing references are updated to reflect the learning from this review. Agencies to report to MSCP the outcomes of their reviews;
Addressed to
Manchester Community Safety Partnership (MSCP)
That MSCP ensures a member from domestic violence services works with agencies to review changes to their processes put in place since 2012. This review should ensure that processes are now in place to capture and evaluate intelligence and information, identify risk and ensure the early identification of a perpetrator such as the perpetrator.
Addressed to
Delivering Differently Senior Project Team
To notify the Delivering Differently Senior Project Team of the learning from this case. Particularly that there is currently no information system to identify people/properties that have been subjected to multiple incidents of domestic that have been reported to different agencies none of which, on their own, would have led to a MARAC being held. The project team to be asked to consider the problem and a potential solution as part of the new model of delivery they are developing.
The Home Office are requested to consider the issue that the Borders Act 2009 only allows automatic consideration of deportation of a foreign national when they have been sentenced to a term of imprisonment of 12 months or more. The panel believe that some weight should be attached to cases such as this in which there was substantial intelligence that a perpetrator has been involved in multiple acts. While these did not result in imprisonment, nonetheless they presented a risk to other persons resident in the UK.
Addressed to
Manchester Community Safety Partnership (MSCP)
MSCP takes steps to promote to all agencies the availability and capability of the UK Visas and Immigration Safeguarding ‘in box’ as a means of sharing information about any risks of domestic abuse involving none UK nationals either as victims or perpetrators.