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: July 2023 Year of death: 2016 Extracted: 12 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
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

Recommendation 9.1 a

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.

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

Recommendation 9.1 b

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)

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

Recommendation 9.1 c

Addressed to NHS England Greater Manchester Clinical Commissioning Group

There is a need to ensure that the management and supervision processes of safeguarding and DVA issues within GP practices are effective.

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

Recommendation 9.1 d

Addressed to NHS England Greater Manchester Clinical Commissioning Group

There is a need to raise awareness of domestic violence and abuse and help and support services available, within GP practices to their patients.

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

Recommendation 9.1 e

Addressed to Greater Manchester Police

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.

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

Recommendation 9.1 f

Addressed to UK Visas and Immigration

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.

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

Recommendation 9.2 a

Addressed to Partner Agencies

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;

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

Recommendation 9.2 b

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.

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

Recommendation 9.2 c

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.

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

Recommendation 9.2 d

Addressed to civil justice group in the Manchester area

Contact the civil justice group in the Manchester area and request that they are made aware of the learning from this case.

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

Recommendation 9.2 e

Addressed to Home Office

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.

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

Recommendation 9.2 f

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.

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