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

Rochdale review

CSP: Rochdale Published: August 2023 Year of death: 2019 Extracted: 18 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 highlights missed opportunities by agencies to identify and respond to domestic abuse, including coercive control and potential forced marriage, experienced by the victim from her father and brother. It notes inconsistent risk assessment, poor information sharing, and a failure to fully explore the victim's capacity to make decisions free from undue influence.

Home Office classifications

40 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - died by suicide
  • Victim - housing issues
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - serious or life limiting illness
  • Victim - had been a victim of an abuser before
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - physical disability
  • Perpetrator - mental ill health
  • Perpetrator - self harm
  • Perpetrator - suicidal thoughts
  • 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 mental health services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - forced marriage
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • Aggravating factors - economic abuse
  • DHR process - family contributed to dhr
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - health services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - identification of risk recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

18 recommendations pulled from the report · 4 matched to organisations in the index

Recommendation 1

Addressed to Rochdale Safer Communities Partnership

That Rochdale Safer Communities Partnership obtains assurance from Greater Manchester Police on the steps taken to raise and maintain awareness of forced marriage and forced marriage procedures.

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

Recommendation 2

Addressed to Rochdale Borough Safeguarding Adults Board | Rochdale Safer Communities Partnership

That Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership initiate a campaign to raise awareness of forced marriage and the action to take in response to suspicions that a person may be at risk of forced marriage, possibly in conjunction with the Safeguarding Children Partnership.

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

Recommendation 3

Addressed to Rochdale Borough Safeguarding Adults Board | Rochdale Safer Communities Partnership

When learning from this review is disseminated, that Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership utilise the learning from this case to further reinforce their efforts to raise awareness of forced marriage and the action to take in response to suspicions that a person may be at risk of forced marriage.

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

Recommendation 4

Addressed to Rochdale Safer Communities Partnership

That when the learning from this review is disseminated, Rochdale Safer Communities Partnership takes the opportunity to use the indications of coercion and control present in this case to further raise professional awareness of how to recognise coercion and control.

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

Recommendation 5

Addressed to Rochdale Safer Communities Partnership

That Rochdale Safer Communities Partnership works with partner agencies to engage with banks and financial services providers in the Rochdale area to support them in their efforts to prevent economic abuse of customers. This process of engagement will also provide an opportunity for banks and building societies to advise on their progress in implementing UK Finance’s Financial Abuse Code of Practice.

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

Recommendation 6

Addressed to Rochdale Safer Communities Partnership

That Rochdale Safer Communities Partnership obtains assurance that familial domestic abuse is regarded as an issue which merits an appropriate response including referrals for domestic abuse support and escalation to MARAC where appropriate.

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

Recommendation 7

Addressed to Rochdale Safer Communities Partnership

That Rochdale Safer Communities Partnership seeks assurance from the CCG that the issue of sharing of information with MARAC by GPs in cases in which there are no children involved has been resolved.

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

Recommendation 8

Addressed to Rochdale Borough Safeguarding Adults Board

That Rochdale Borough Safeguarding Adults Board shares this report with those responsible for overseeing the work of the MAAST so that the learning from this case informs further development of the MAAST process including the clarification of governance arrangements.

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

Recommendation 9

Addressed to Rochdale Safer Communities Partnership

That Rochdale Safer Communities Partnership raises awareness of the need for non-police practitioners to conduct DASH risk assessments and encourage them to do so.

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

Recommendation 10

Addressed to Rochdale Borough Safeguarding Adults Board

That Rochdale Borough Safeguarding Adults Board obtains assurance from Adult Care in respect of the process for assessing safeguarding referrals and screening for consideration of Section 42 or ‘other’ safeguarding enquiries.

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

Recommendation 11

Addressed to Rochdale Borough Safeguarding Adults Board | Rochdale Safer Communities Partnership

That Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership ensure that the learning from this case in respect of the antecedents of suicide and the links between domestic abuse and risk of suicide are shared with practitioners involved in safeguarding adults and in supporting the victims of domestic abuse.

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

Recommendation 12

Addressed to Rochdale Borough Safeguarding Adults Board | Rochdale Safer Communities Partnership

That Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership shares this report with those responsible for Rochdale’s Suicide and Self-Harm Prevention Strategy so that the learning from this review can inform future suicide prevention measures.

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

Recommendation 13

Addressed to Rochdale Borough Safeguarding Adults Board | Rochdale Safer Communities Partnership

When the learning from this case is disseminated, that Rochdale Borough Safeguarding Adults Board and Rochdale Safer Communities Partnership arrange to further promote awareness of the service provided by the Coronial Bereavement Nurse.

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

Recommendation 14

Addressed to Rochdale Borough Safeguarding Adults Board

When the learning from this review is disseminated, that Rochdale Borough Safeguarding Adults Board highlights the complex issue of mental capacity and coercive control and the need to enquire into cases in which a person with capacity repeatedly makes decisions which could be construed as unwise.

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

Recommendation PCFT_1

Addressed to Pennine Care NHS Foundation Trust

To complement PCFT mandatory safeguarding training develop staff support package to raise knowledge and awareness in relation to domestic abuse, so-called honour based violence and forced marriage.

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

Recommendation PCFT_2

Addressed to Pennine Care NHS Foundation Trust

Review of PARIS guidance section in relation to trust approved documentation including mental health and risk assessment. Particular risks around domestic abuse and the consideration of forced marriage and honour based violence

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

Recommendation RBCAC_1

Addressed to Rochdale Borough Council Adult Care

Improvement is required in relation to knowledge and awareness of the Domestic Abuse, Stalking and Harassment (DASH) risk assessment and Multi Agency Risk Assessment Conference (MARAC). Action: Dissemination of a briefing to raise awareness and detail how to how to refer

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

Recommendation RBCAC_2

Addressed to Rochdale Borough Council Adult Care

Improvement is required in an understanding of the indictors of coercive and controlling behaviour as this relates to adult safeguarding and of resources available that are specific to domestic violence. Action: Dissemination of a briefing to raise specific awareness of coercion and control and domestic violence, including the Agency training offer

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