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 2025
Year of death: 2021
Extracted: 4 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 highlights fragmented multi-agency responses to the victim's complex vulnerabilities, including enduring mental health issues, substance misuse, and experiences of domestic abuse and exploitation, exacerbated by cross-border care challenges and missed opportunities for safeguarding referrals.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | The Manchester Community Safety Partnership works with the Manchester Safeguarding Partnership, the Manchester Integrated Care Board, IRIS Manchester and the Betsi Cadwaladr University Health Board to seek assurance that all independent practitioners (General Practitioners and other independent contractors) are aware of their safeguarding duties and receive training and support to deliver these duties; The Manchester CSP seeks assurance from GMICS that the IRIS training that they commission contains reference to: Trauma informed Care Referral pathways for perpetrators of domestic abuse The link between domestic abuse and suicide. Same sex partner intimate violence. Poly substance abuse The Manchester CSP, with the support of Adult Social Care, should ensure that all partners are aware of the national framework for what constitutes a safeguarding concern, which includes domestic abuse, and how to respond to such concerns. The Manchester Community Safety Partnership works with the aforementioned organisations and other secondary care providers involved in the care of the subjects of this Review, to 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 the training programme: o Raises awareness of ‘Chem-sex’ parties and their impact upon vulnerable adults (they can be considered as a form of potential exploitation); o Raises awareness so staff are mindful of any coercion or exploitation and if these issues are identified, to make a child or adult safeguarding referral (as appropriate) and to seek advice from the specialist advice that is available. | Manchester Community Safety Partnership | Manchester Safeguarding Partnership | Manchester Integrated Care Board | Betsi Cadwaladr University Health Board | GMICS | Adult Social Care |
| 2 | That the Manchester CSP share the learning from this DHR with the Greater Manchester Bereavement Service; That the Manchester CSP share the learning from this DHR with the National Suicide Prevention Group in Wales and with the Mental Health Division within the BCUHB; That the Manchester CSP supports the recommendations from the National Confidential Inquiry into Suicide and mental Health (NCISH) research findings and works with the Suicide Prevention Partnership, the Public Health Leads for suicide prevention and others to raise awareness of these findings. | Manchester Community Safety Partnership | Greater Manchester Bereavement Service | National Suicide Prevention Group in Wales | Mental Health Division within the BCUHB | Suicide Prevention Partnership | Public Health Leads for suicide prevention |
| 3 | The Manchester Community Safety Partnership, supported by the Integrated Care Board, seeks assurance that the IRIS training made available to General Practitioners is reviewed in light of the themes identified in this and other DHRs and that: An update is provided to GP Safeguarding Leads to reinforce the point that the risk of domestic abuse does not diminish when a relationship is over (it can increase) so an IRIS referral should still be offered when DVA is disclosed. This is in the context of historic relationships not just recently ended ones. An update is provided to GP Safeguarding Leads to reinforce the point that male victims of DVA can, of course, be as vulnerable as female victims and professionals should be ‘professionally curious’, enquire about DVA and refer appropriately. | Manchester Community Safety Partnership | Integrated Care Board |
| 4 | The Manchester CSP, supported by the LGBT+ Foundation and the Northern Centre for Sexual Health, should: Develop a programme to determine the most effective way to promote the service and raise awareness of the pathways to access the service; Encourage partners on the CSP to reflect in their safeguarding updates that chem-sex parties are recognised as a potential form of sexual exploitation that, coupled with other co-existing risks, may warra | Manchester Community Safety Partnership | LGBT+ Foundation | Northern Centre for Sexual Health |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||