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

Stockport review

CSP: Stockport Published: September 2023 Year of death: 2012 Extracted: 6 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 concerns regarding inadequate multi-agency information sharing and integrated risk assessment, particularly concerning the impact of parental mental health on children and the needs of young carers. It also highlights missed opportunities in domestic abuse risk assessment and safety planning by police, and follow-up for high-risk self-referrals to alcohol services.

Extracted recommendations

6 recommendations pulled from the report

#	Recommendation	Addressed to
1a	The case highlights a number of missed opportunities in relation to safeguarding the children in this case. The Panel recommends that the Local Safeguarding Children Board should initiate a multi-agency practice review of safeguarding children living in families where there are multiple complex needs and where one or both of the parents have mental health problems.	Local Safeguarding Children Board
1b	The needs of MVD1 were not fully assessed or responded to. Despite her significant responsibilities as a young carer, and the fact that she lived with two vulnerable adults and three siblings with chronic medical conditions, she was not an open case to CSC, having never received a CAF assessment. As recommended in 1a above, the LSCB should ensure that the learning review considers the fitness for purpose of multi-agency policies and procedures in relation to the needs of Young Carers. Following the learning review all agencies should update their policy in relation to supporting young carers, recognising and meeting their specific needs.	Local Safeguarding Children Board \| All Agencies
1c	As part of the LSCB learning review the processes and systems for information sharing with voluntary sector agencies should receive focus. This should ensure that voluntary and third sector agencies have equal access to relevant information to safeguard vulnerable adults and children.	Local Safeguarding Children Board
2	The CCG should be assured, by audit evidence, that the training delivered to and the supervision received by Pennine Care NHS FT (Mental Health) staff thoroughly explores the impact of adult mental health on parenting capacity including staff’s responsibilities if concerns are identified.	CCG
3	The victim was advised to refer to alcohol services and consented to this however, current practice does not require self-referral advice to be followed up by services. The DHR panel recommend that it would be good practice to initiate referrals in cases where the adult is particularly vulnerable or high risk (i.e. where there has been a serious attempt at self-harm). The Drug and Alcohol Joint Commissioning Group should develop the assessment and referral pathways for alcohol misuse where there are co-factors of mental health and domestic abuse. The aim should be to ensure that high risk adults with complex needs are referred to services and that the referral is followed up	Drug and Alcohol Joint Commissioning Group
4	Developing the skills and capacity of the local workforce in relation to identifying, referring and responding to domestic abuse is key to the success of the local domestic abuse strategy. The Safer Stockport Partnership should give specific focus to workforce development in its revised domestic abuse strategy, the focus should be on ensuring that all agencies build confidence amongst their workforce in dealing with domestic abuse.	Safer Stockport Partnership
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗