Home / Sources / Domestic Homicide Reviews / Bury · Sep 2023
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

Bury review

CSP: Bury Published: September 2023 Year of death: 2016 Extracted: 16 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 review identified concerns regarding agencies' under-assessment of the victim's risk, inconsistent information sharing, and delays in referrals. It also highlighted a failure to fully consider the cumulative impact of domestic abuse on the child and to effectively gather information from family and friends.

Home Office classifications

50 tags

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

  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - present at homicide (including adult children)
  • Child - primary address same as victim
  • Perpetrator - case heard in court
  • Perpetrator - issued life sentence
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - housing issues
  • Perpetrator - mental ill health
  • Perpetrator - adjustment disorder
  • Perpetrator - anxiety
  • Perpetrator - depression
  • Perpetrator - suicidal thoughts
  • Perpetrator - suicide attempts
  • 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 probation services as a domestic abuse perpetrator
  • Perpetrator - known to others as a domestic abuse perpetrator
  • Perpetrator - known to friends as a domestic abuse perpetrator
  • Perpetrator - known to family as a domestic abuse perpetrator
  • Perpetrator - attended drug and alcohol services
  • Perpetrator - managed by mappa
  • Perpetrator - supervised by mental health services
  • Perpetrator - supervised by probation services
  • Aggravating factors - separation
  • Aggravating factors - coercive or controlling behaviour
  • Aggravating factors - stalking
  • Aggravating factors - physical stalking
  • Aggravating factors - digital stalking
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family contributed to dhr
  • DHR process - family consulted about terms of reference
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - police recommendations
  • DHR process - social services recommendations
  • DHR process - health services recommendations
  • DHR process - probation services recommendations
  • DHR process - community safety partnership recommendations
  • DHR process - technology systems recommendation themes
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - awareness raising recommendation themes

Extracted recommendations

16 recommendations pulled from the report · 7 matched to organisations in the index

Recommendation 1

Addressed to Team Bury Community Safety Partnership

That Team Bury Community Safety Partnership considers whether its constituent agencies training on assessing risk in domestic abuse cases needs enhancing to ensure all risk factors are identified before setting the final risk level.

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

Recommendation 1

Addressed to Pennine Care NHS Foundation Trust

Develop guidance for health practitioners on responding to domestic abuse notifications

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

Recommendation 1.

Addressed to Greater Manchester Police

The level of knowledge and awareness concerning child safety for all police response staff is reemphasised and reinforced

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

Recommendation 1.

Addressed to Cheshire & Greater Manchester CRC

Line Managers to implement individual actions plans in relations to PK and MM to ensure implementation of learning from this DHR

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

Recommendation 1.

Addressed to North Manchester Clinical Commissioning Group

There is a need to ensure that GP practices are aware of risk factors relating to DVA and to know what to do if a concern arises. This has been a previous recommendation and an IRIS training plan is already in place, together with training by the CCG link nurses.

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

Recommendation 2

Addressed to Team Bury Community Safety Partnership

That Team Bury Community Safety Partnership considers how it can best reinforce the importance of professionals being aware that family and friends very often hold additional information to that which a victim reports, and to determine how such information might be accessed within an agency’s confidentiality framework.

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

Recommendation 2.

Addressed to Greater Manchester Police

The Head of the Public Protection Division to commission work to evaluate the effectiveness of the STRIVE programme, and consider its implementation with a structured and established police input into the process.

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

Recommendation 2.

Addressed to North Manchester Clinical Commissioning Group

There is a need for all GP practices to establish a DVA 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 3

Addressed to Team Bury Community Safety Partnership

That Team Bury Community Safety Partnership reviews whether its advice to family and friends who have knowledge of domestic abuse has penetrated the community effectively.

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

Recommendation 3

Addressed to Pennine Care NHS Foundation Trust

Review the current process for reviewing A&E attendances within health visiting PCFT

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

Recommendation 3.

Addressed to Greater Manchester Police

The Head of the PPD should ensure that awareness around policy and procedure where DV markers are in place be reinforced for all staff throughout the response policing establishment.

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

Recommendation 3.

Addressed to North Manchester Clinical Commissioning Group

GP practices to be encouraged to raise awareness of domestic abuse and support services within their surgeries by the displaying of educational posters and leaflets. This is also included in IRIS training.

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

Recommendation 4

Addressed to Team Bury Community Safety Partnership

That Team Bury Community Safety Partnership considers how it can work together to know when a reconciliation between a victim and perpetrator has, or is thought to have, taken place when separation is seen as a protective factor for a child.

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

Recommendation 4

Addressed to Pennine Care NHS Foundation Trust

 To develop a flow chart for practitioner to use detailing the process of challenge and escalation  To provide training on professional challenge

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

Recommendation 4.

Addressed to North Manchester Clinical Commissioning Group

GP Practice 2 to explore if there are practical ways of maximising relationship continuity using this case as a significant event. The RCGP toolkit for Continuity of Care provides a useful guide of how to do this.

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