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: 20 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 care for a vulnerable individual with complex mental health needs, substance misuse, and experience of domestic abuse, exacerbated by cross-border service engagement and missed opportunities for safeguarding referrals, particularly regarding sexual exploitation.

Extracted recommendations

20 recommendations pulled from the report

#	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 victim, 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 \| IRIS Manchester \| 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 warrant a safeguarding referral.	Manchester Community Safety Partnership \| LGBT+ Foundation \| Northern Centre for Sexual Health
5	The Manchester CSP ensures that trauma informed training is rolled out across Manchester City Council, including the promotion of the existing availability of the 7 Minute Briefing on ACEs to all partners.	Manchester Community Safety Partnership \| Manchester City Council
6	The Manchester CSP, supported by the Health and Wellbeing Board, examines if there are any existing communication strategies in place to support the promotion of the safe disposal of unused medication; In the absence of such strategies, Director of Population Health (MCC) to consider developing a public health message to reinforce the need for unused medications to be returned to any dispensing Pharmacy.	Manchester Community Safety Partnership \| Health and Wellbeing Board \| Director of Population Health (MCC)
7	The Manchester CSP, with the support of the ICB, issues a briefing note to all Partners outlining the national policy regarding ‘temporary residence’ when registering with a general practitioner and the implication of temporary residence on the opportunity to receive all commissioned services for that GP catchment; The Manchester CSP invites the GMMH NHS Trust to provide a clear outline for all local agencies and services of i) the structure of the Home-Based Treatment Team (HBTT), ii) the range and nature of provision, and iii) the referral pathways An evaluation of the procedure being developed by the Bridges Domestic Abuse Service is undertaken and shared with all CSP Partners. (Bridges have stated in their submission that, where a client has re-located, a three-way meeting will take place between the client, the Bridges IDVA and the IDVA from the service where the client has moved from, and that this new procedure will be embedded into the process to ensure that transition/continuation of support is achieved and maintained).	Manchester Community Safety Partnership \| Integrated Care Board \| GMMH NHS Trust \| Bridges Domestic Abuse Service
8	The Manchester CSP supports the designated NHS safeguarding teams to liaise with the medicines optimisation teams and GMMH NHS Trust to support best practice across Greater Manchester, and work with MIC to circulate a clear description of best practice to GPs when they are working with patients who transfer from secondary mental health care services into primary care; The Manchester CSP supports the Integrated Care Board, to work with the medicines optimisation teams to support GPs when it is necessary to question mental health service led prescriptions. Additionally, it was noted that all shared care prescribing should adhere to the Greater Manchester Medicines Management Group (GMMMG) policies to ensure safe prescribing for patients who transfer into primary care. Please see: https://gmmmg.nhs.uk/shared-care/gmmmg-approved-shared-care-protocols/ Additionally, where there are mental health initiated prescriptions, GPs should work with the mental health service with CPA responsibility to share oversight of prescribing to, and management of, the patient. GPs should be provided with regular updates on the patient medication reviews carried out by the mental health services and if they do not receive them, they should flag this up on the Datix system; An evaluation of the ICB pilot programme of working with people who are street homeless (whereby the care co-ordinator follows the patient if they remain within the Greater Manchester boundary, regardless of their Borough of residence) is shared with all partners on the CSP.	Manchester Community Safety Partnership \| NHS safeguarding teams \| medicines optimisation teams \| GMMH NHS Trust \| MIC \| Integrated Care Board \| Greater Manchester Medicines Management Group
9	The Manchester Community Safety Partnership: Shares the learning from this DHR with the Greater Manchester Male Victims Working Group and invites the Group to discuss the findings from this DHR and works with the CSP to identify appropriate pathways into support and advice for male victims of domestic abuse and violence; Seeks assurance from GMP that they utilise the D66 recording code for all LGBTQ+ incidents involving domestic abuse; Seeks assurance from all partners that when they refer cases to the MARAC (using SharePoint), they capture the sexual orientation of the victim (this will trigger an automatic alert to the LGBT Foundation IDVA team).	Manchester Community Safety Partnership \| Greater Manchester Male Victims Working Group \| GMP \| LGBT Foundation IDVA team
Bridges 1	All Bridges referrals that disclose low mood/ suicidal ideation will be referred to the Jigsaw Support Wellbeing Navigator team for support and signposting.	Bridges Domestic Abuse Support Services
Bridges 2	Three-way meeting between client, Bridges IDVA and IDVA service where client relocated to will be embedded into process to ensure transition/ continuation of support.	Bridges Domestic Abuse Support Services
GMMH 1	GMMH as an organisation can improve staff awareness and consciousness of the prevalence of domestic abuse. Including increased reference to same sex intimate partner violence and understanding of commonly recognised themes present in these cases.	GMMH
GMMH 2	Robust procedural guidance on the importance of using structure risk assessment tools such as the ‘Domestic Abuse Stalking and Honour Based’ risk assessment checklist (DASH).	GMMH
GMMH 3	Level 3 Safeguarding Adults/Domestic abuse training module to be updated to include specific information on same sex intimate partner violence and other complexity factors such as polysubstance use.	GMMH
GMMH 4	Safeguarding Adults Level 3’ training module to include information on ‘Chemsex’ as a complexity factor to raise staff awareness and to inform them of specialist advice available.	GMMH
GMMH 5	GMMH ‘Safeguarding Adults at Risk’ policy to be updated to include clear guidance on clinical expectations when ‘screening’ safeguarding referrals made by other agencies, including documentation required and professional communication with the referrer.	GMMH
GMP 1	If the victim refuses to answer DASH questions, the officer should apply their professional judgement to make an assessment of risk.	Greater Manchester Police
GMP 2	When officers from GMP attended one particular incident, a DASH assessment was submitted but some of the questions were left blank. According to GMP’s policy and procedure, if a victim refuses to answer DASH questions, the officer responding should apply their professional judgement to make an assessment of risk. Officers should include their assessment of the victim’s demeanour in the DASH	Greater Manchester Police
GMP 3	Officers from GMP attended one particular incident and spoke to the partner. It transpired that the victim and the partner had engaged in an argument and the partner said it was a verbal argument and denied assaulting the victim. A referral was sent to MARAC for this incident. A crime was submitted for Common Assault and it was concluded that there was little prospect of a detection of the crime. A DVPN could have been authorised to safeguard the victim	Greater Manchester Police
GMP 4	GMP has policy and procedures in place when attending domestic incidents and incidents when persons present with mental health related concerns. This dictates how information is recorded so risk can be managed, and the appropriate safeguarding put in place. GMP policy states, at present, that a Domestic Abuse Plan (referred to as a DAB Plan) is to be submitted over a care plan when Mental Health issues are identified during a Domestic Abuse incidents. On police contact with the victim, it is highlighted that these policies were not adhered to.	Greater Manchester Police
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗