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: 2011 Extracted: 14 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 missed opportunities by agencies to assess and respond to domestic abuse disclosures, particularly regarding risk at separation and the significance of specific injuries. It highlights gaps in inter-agency information sharing, risk assessment tools, and staff training for both victims and perpetrators.

Extracted recommendations

14 recommendations pulled from the report

#	Recommendation	Addressed to
1	GP practice, with the support of NHS Manchester, to identify a Safeguarding Lead and for the Lead to complete duties according to the Safeguarding Children Toolkit.	GP Practice \| NHS Manchester
1	Introduce steps in procedure to review perpetrator management	The Housing Provider
1	That MSCB and MSAB develop a Domestic Abuse Protocol to promote the referral pathway for victims of domestic abuse, including sexual violence and recommendations on best practice for those who work with perpetrators of domestic abuse including sexual violence. All agencies likely to identify victims and perpetrators of domestic violence, including GP practices and housing associations, should be included.	Manchester Safeguarding Children Board (MSCB) \| Manchester Safeguarding Adults Board (MSAB)
2	Ensure all staff are aware who the Safeguarding Lead is and of their own role in respect to Safeguarding Children, Adults including Domestic Violence.	GP Practice
2	Introduce steps in procedure to evaluate risk to victim	The Housing Provider
2	That all agencies should promote the take up of domestic abuse training for their front line staff to ensure that they recognise risk, [including the significance of bite marks as a possible indicator of sexual abuse] assess risk and respond appropriately to disclosures of domestic abuse. Training should also be offered in how best to work with perpetrators of domestic abuse.	GP Practices \| Housing Providers \| Police Forces \| NHS Trusts \| Domestic Abuse Support Services
3	Improve record keeping in the practice. Guidelines to be produced to include when to record and when more detail is essential.	GP Practice
3	Introduce steps in procedure to make victim aware of crisis points	The Housing Provider
3	That the Manchester Domestic Abuse Forum should consider a publicity campaign to target family and friends of victims of domestic abuse to direct them to support services and enable them to know how to support those who confide in them.	Manchester Domestic Abuse Forum
4	GP Practice to undertake a Significant Event Analysis (SEA) to enhance learning.	GP Practice
4	That MSAB and MSCB consider whether all employers should have domestic abuse policies.	Manchester Safeguarding Adults Board (MSAB) \| Manchester Safeguarding Children Board (MSCB)
5	Safeguarding Lead to ensure the practice is fully compliant with children and adult including domestic violence safeguarding training.	GP Practice
6	Share findings of the Serious Case Review report with: NHS Manchester/ Clinical Commissioning Group (CCGs), Mental Health commissioning colleagues Child and Adult Safeguarding colleagues	GP Practice
7	Generic competencies in GP Training that relate to risk assessment and management are applied in safeguarding situations and demonstrated to their supervisors	GP Practice
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗