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.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

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.

Extracted recommendations

12 recommendations pulled from the report

#	Recommendation	Addressed to
9.1 a	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.	NHS England Greater Manchester Clinical Commissioning Group
9.1 b	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)	NHS England Greater Manchester Clinical Commissioning Group
9.1 c	There is a need to ensure that the management and supervision processes of safeguarding and DVA issues within GP practices are effective.	NHS England Greater Manchester Clinical Commissioning Group
9.1 d	There is a need to raise awareness of domestic violence and abuse and help and support services available, within GP practices to their patients.	NHS England Greater Manchester Clinical Commissioning Group
9.1 e	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.	Greater Manchester Police
9.1 f	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.	UK Visas and Immigration
9.2 a	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;	Partner Agencies
9.2 b	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.	Manchester Community Safety Partnership (MSCP)
9.2 c	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.	Delivering Differently Senior Project Team
9.2 d	Contact the civil justice group in the Manchester area and request that they are made aware of the learning from this case.	civil justice group in the Manchester area
9.2 e	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.	Home Office
9.2 f	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.	Manchester Community Safety Partnership (MSCP)
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗