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: ManchesterPublished: February 2024Year of death: 2021Extracted: 10 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
Agencies missed opportunities to identify and respond to familial domestic abuse, compounded by ineffective information sharing, unconscious bias, and challenges in engaging with the victim and perpetrator. Delays in welfare checks and the perpetrator's lack of GP registration were also noted.
Home Office classifications
39 tags
Source-supplied classifications used by the Home Office to catalogue this review.
Victim - carer assessed
Victim - substance misuse
Victim - mental ill health
Victim - anxiety
Victim - depression
Victim - serious or life limiting illness
Victim - had been a victim of an abuser before
Victim - referred to marac at any time
Children - living with victim (including adult children)
Children - present at homicide (including adult children)
Children - removed into care
Child - primary address same as victim
Perpetrator - case heard in court
Perpetrator - issued life sentence
Perpetrator - substance misuse
Perpetrator - mental ill health
Perpetrator - depression
Perpetrator - panic attacks
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 housing 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 - physical abuse
DHR process - family contributed to dhr
DHR process - family received draft report
DHR process - police recommendations
DHR process - health services recommendations
DHR process - housing 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 - multi agency working recommendation themes
DHR process - record keeping recommendation themes
DHR process - awareness raising recommendation themes
DHR process - other recommendation themes
Extracted recommendations
10 recommendations pulled from the report · 3 matched to organisations in the index
Addressed to
Manchester Community Safety Partnership
That Manchester Community Safety Partnership seeks assurance in respect of the extent to which ‘standard’ risk domestic abuse incidents are referred into the Victim Support arrangements established following cessation of the STRIVE programme.
Addressed to
Manchester Community Safety Partnership | NHS Manchester Clinical Commissioning Group
That the Manchester Community Safety Partnership requests NHS Manchester Clinical Commissioning Group to request GP practices to ensure that HARK templates are activated within their EMIS systems to support their prompt questions about domestic violence and abuse when consulting patients about anxiety and depression. NHS Manchester Clinical Commissioning Group will also request the IRIS service undertake an audit of GP practices to ensure that the HARK template is activated and seek assurance from IRIS that this has been completed.
Addressed to
Manchester Community Safety Partnership
That when the learning from this DHR is disseminated, Manchester Community Safety Partnership will provide training to professionals to identify patterns of behaviour and avoid treating reports of domestic abuse as ‘isolated incidents’.
Addressed to
Manchester Community Safety Partnership
That Manchester Community Safety Partnership obtains assurance that Housing Providers have robust policies, supported by appropriate training to enable staff to recognise and respond effectively to domestic abuse.
Addressed to
Manchester Community Safety Partnership
That when the learning from this DHR is disseminated, Manchester Community Safety Partnerships draws attention to the risk that unconscious bias could lead to a victim of domestic abuse not being believed.
Addressed to
Manchester Community Safety Partnership
That when the learning from this DHR is disseminated, Manchester Community Safety Partnership takes the opportunity to raise professional awareness of the possibility that a history of limited engagement with services may mask indications of coercion and/or control.
Addressed to
Manchester Community Safety Partnership
That when the learning from this DHR is disseminated, Manchester Community Safety Partnership takes the opportunity to draw attention to the various forms that familial domestic abuse can take including daughters as perpetrators and mothers as their victims and also draw attention to the need to consider the risks that a perpetrator of domestic abuse may present in both intimate partner and familial relationships.
Addressed to
Manchester Community Safety Partnership | Manchester City Council
That Manchester Community Safety Partnership request Manchester City Council to make use of the new post of GP & Pharmacy Quality and Governance Team Leader to drive improvement in communication between CGL and pharmacies in respect of patients who collect opiate substitute prescriptions and improvement in record keeping by pharmacies.
Addressed to
Manchester Community Safety Partnership | Manchester Health and Care Commissioning
That Manchester Community Safety Partnership requests that all Community Safety Partnership partners and Manchester Health and Care Commissioning consider how people might be encouraged by all service providers to register with a GP and take into account good practice in this area such as that involving housing providers encouraging tenants to register with a GP.
Addressed to
Manchester Community Safety Partnership | Home Office
That Manchester Community Safety Partnership writes to the Home Office to suggest that follow up interviews with perpetrators should take place outside the DHR process at a time when perpetrators may be better placed to make a more valuable contribution to the aims of DHRs.