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: February 2024 Year of death: 2021 Extracted: 10 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
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

Recommendation 1

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.

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

Recommendation 2

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.

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

Recommendation 3

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’.

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

Recommendation 4

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.

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

Recommendation 5

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.

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

Recommendation 6

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.

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

Recommendation 7

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.

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

Recommendation 8

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.

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

Recommendation 9

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.

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

Recommendation 10

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.

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