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: October 2024 Year of death: 2021 Extracted: 22 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 review identified concerns regarding the victim's long history of domestic abuse and complex needs, including mental health issues and alcohol dependence, which were not consistently identified or addressed by agencies. There were also missed opportunities for effective multi-agency information sharing and intervention, despite repeated referrals.

Extracted recommendations

22 recommendations pulled from the report

#	Recommendation	Addressed to
1	Improved responses to ensure Domestic Abuse cases are dealt with efficiently and timely from the initial receipt of them.	Rochdale Borough Council – Adult Care
1.	That training delivered by HMR CCG to all GP Practices across the borough is updated to include learning from this review.	HMR CCG \| GM ICS \| GP Practices
1.	Quality assurance of safeguarding cases.	Rochdale Borough-Wide Housing Services
1.	Alcohol Treatment	Probation Service \| Turning Point
1.	GMP to reinforce safeguarding training	Greater Manchester Police
10.1	That the Rochdale Safer Communities Partnership (SCP) is assured that a process is in place to identify “domestic abuse victim suicides”; That the Rochdale Safer Communities Partnership (SCP) share the learning from this DHR with the Greater Manchester Bereavement Service; That the Rochdale Safer Communities Partnership (SCP) supports the recommendations from the National Confidential Inquiry into Suicide and Mental Health (NCISH) research findings and works with the local Suicide Prevention service, the GM Bereavement Service and the local Public Health lead for suicide prevention to raise awareness of these findings. The Panel encourages the SCP to support the local delivery of the following elements from the NCISH research: o That clinicians become aware of the suicide risk of patients living with domestic abuse/violence; o That any assessments of suicide risk undertaken by the commissioned mental health services should include direct and sensitive professional curiosity about violence in the home; o GPs should be encouraged to consider violence in the home when engaging in consultations concerning suicidal ideation; o That the family of the person who has taken their own life is identified and bereavement support is offered to the family of the victim as soon as practicable. That the Rochdale Safer Communities Partnership (SCP) identify examples of other statutory Reviews where residents have taken their own life and note the recommendations made by these Reviews and aim to make the Recommendations from both Reviews inter-operable	Rochdale Safer Communities Partnership (SCP)
10.2	That the Rochdale Safer Communities Partnership (SCP), with support from the Adult Social Care Service, ensures: o That in all domestic abuse cases, where the victim has care and support needs, to refer the client directly to Adult Care for a needs assessment; o That Rochdale Adult Care, as part of their front door/duty review, to consider promptly allocating such cases to a named worker when safeguarding concerns are indicated within the referral to the service; o Adult Care workers record domestic abuse reports received from GMP or NWAS on the adult care management system as a safeguarding concern. This will ensure that the Care Act s42(1) criteria can be applied. A “Responding to Domestic Abuse” procedure will help cement this expectation.	Rochdale Safer Communities Partnership (SCP) \| Rochdale Adult Social Care Service
10.3	That the Rochdale Safer Communities Partnership (SCP), with the support of Adult Social Care, should ensure that all partners are aware of the national framework for what constitutes a safeguarding concern (where there are concerns about abuse and neglect, which includes domestic abuse). This can be located at: Understanding what constitutes a safeguarding concern and how to support effective outcomes (local.gov.uk) That the Rochdale Safer Communities Partnership (SCP), with the support of Adult Social Care, should be assured that procedures are in place to assess the risk caused by incidents of domestic abuse, and that any actions are clearly articulated. The Rochdale Safer Communities Partnership (SCP) should be assured that the ASC Manager holds the responsibility to ensure that actions are followed up in a timely manner and can escalate concerns where there are difficulties with delivery of those actions. That the Rochdale Safer Communities Partnership (SCP) is assured that there is a clear procedure for recording expectations following an officer’s attendance at meetings such as the MARAC, MAAST, HRDM, etc. This procedure should be shared with assessment staff and their managers. That the Rochdale Safer Communities Partnership (SCP), with the support of the Safeguarding Board(s) and Adult Social Care, review the content of the safeguarding training – and other forms of awareness raising for staff – that is currently provided and aim to encourage providers to ensure that their training programme includes: o The utilisation of the Rochdale Council Intranet resources concerning Domestic Abuse; o The Domestic Abuse Strategy, and guidance aimed at ‘Understanding Risk In the context of Domestic Abuse’; o Identifying perpetrators of domestic abuse and the management of risk; o Proactively addressing the link between domestic abuse and suicide The Rochdale Safer Communities Partnership (SCP) should seek assurance from the Greater Manchester Domestic Abuse Board that the mapping exercise undertaken in June 2021 to identify the application of NICE Guidance PH50 and Quality Standard 116 contains no outstanding concerns or gaps. Taking account of the learning from this specific Review, the Rochdale Safer Communities Partnership should work with the Safeguarding Board(s) and explore the possibility of providing safeguarding training – as an enhancement to their Level 3 Safeguarding training programme – to include staff from both Adult Social Care and Children’s Social care	Rochdale Safer Communities Partnership (SCP) \| Adult Social Care \| Safeguarding Board(s) \| Greater Manchester Domestic Abuse Board
10.4	That the Rochdale Safer Communities Partnership (SCP) works with HM&R Integrated Care and seeks assurance that: o The Local Care Organisation (LCO) can ensure that all practitioners, including those within the Primary Care Networks, can fulfil their statutory safeguarding duties; and o That the Rochdale Safer Communities Partnership seeks assurance from the LCO that the learning and recommendations from this review will be embedded into practice	Rochdale Safer Communities Partnership (SCP) \| HM&R Integrated Care \| Local Care Organisation (LCO)
10.5	That the Rochdale Safer Communities Partnership (SCP), with the support of the ICB, ensures that independent practitioners (i.e., General Practitioners and other independent contactors) are aware of their safeguarding duties; That the Rochdale Safer Communities Partnership (SCP), together with the NHS Greater Manchester Integrated Care (HMR), emphasise and promote awareness and application of NICE Quality Standard 116 and NICE Guidance PH50 within all primary and NHS secondary care settings in Rochdale That the Rochdale Safer Communities Partnership (SCP) supports the NCA to assess the impact of the bespoke Domestic Abuse training sessions across the NCA being delivered by the lead officer for domestic abuse in that NHS Trust	Rochdale Safer Communities Partnership (SCP) \| NHS Greater Manchester Integrated Care (HMR) \| Northern Care Alliance NHS Foundation Trust (NCA)
10.6	That the Rochdale Safer Communities Partnership (SCP) supports the NCA to assess the impact of the following training programmes: o The Adult and Children Level 1/2 safeguarding training programme being undertaken by all staff across the NCA. This programme of training includes reference to domestic abuse and advises front line staff on internal policies and procedures, and response/referral processes to multi-agency partners when Domestic Abuse has been identified o The Adult and Children Level 3 Safeguarding training will be extended. From November 2022 all registered staff members will have the Level 3 adult and children training attached to their mandated training matrix. Additionally, the adult and children Level 3 training is aligned with Health Education England Core Skills Framework offering a consistent training programme aligned nationally across the NHS. That the Rochdale Safer Communities Partnership (SCP) supports the NCA to assess the impact of the recently recruited hospital based IDVA which is to be piloted across the estate for a 12-month period. Early indications offer a positive response from A&E with a number of enquiries referred to this service. It is recommended that the evaluation of this service should be coupled with the evaluation of the Hospital IDVA service provided for the Wigan, Wrightington and Leigh NHS Foundation Trust by Manchester University	Rochdale Safer Communities Partnership (SCP) \| Northern Care Alliance NHS Foundation Trust (NCA) \| Wigan, Wrightington and Leigh NHS Foundation Trust \| Manchester University
10.7	That the Rochdale Safer Communities Partnership (SCP) seek assurance that trauma informed training is rolled out across the Borough of Rochdale and that trauma informed practice is embedded within all commissioned services. That the Rochdale Safer Communities Partnership (SCP): o Notes the outcome of the Trauma informed Practice (TiP) launch event that occurred on the 18th of May 2023 and the pledge made by key stakeholders to become ‘Trauma Informed Rochdale’; o Ensure that the TiP training provided across the key stakeholder system is consistent and accords with an agreed set of service standards; o Review the current provision of TiP training being provided by the Mental Health Team and evaluate the impact of the training on the practice of the cohort of staff who have received the training to date; o Considers the available evidence from other Districts and proposes the most effective and efficient model for the provision of TiP training to satisfy the pledge made by key stakeholders.	Rochdale Safer Communities Partnership (SCP) \| Mental Health Team
2.	Administrative staff in primary care should receive domestic abuse training which is appropriate to their role, including recognition of risk indicators in third party information, coding and flagging, MARAC pathways and electronic access to records.	HMR CCG \| GM ICS \| GP Practices
2.	Make different attempts and communication approaches to engage tenants	Rochdale Borough-Wide Housing Services
2.	Liaison with specialist provision within the risk management plan to address specific vulnerabilities or risk	Probation Service
3	An assessment of risk should take place in all situations relating to domestic abuse and actions with associated appropriate timescales commensurate to the level of risk should be clearly articulated.	Rochdale Borough Council – Adult Care
3.	That a domestic abuse policy template is included within the HMR CCG Domestic Abuse Toolkit for primary care.	HMR CCG \| GM ICS \| GP Practices
3.	Training for all front line staff in awareness of domestic abuse	Rochdale Borough-Wide Housing Services
4	To improve recording on ALLIS following a practitioner’s attendance at MARAC and High Risk Domestic Abuse panel meetings	Rochdale Borough Council – Adult Care
4.	Ongoing work is needed to embed and evaluate the effectiveness of the HMR CCG MARAC information sharing pathway, which commenced from 01.10.21.	HMR CCG \| GM ICS \| GP Practices
5	Improved knowledge amongst Adult Care staff regarding domestic abuse.	Rochdale Borough Council – Adult Care
6	Improved consistency of response for victims of Domestic Abuse.	Rochdale Borough Council – Adult Care
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗