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

Salford review

CSP: Salford Published: June 2025 Year of death: 2020 Extracted: 18 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
The review identified inconsistent and uncoordinated agency responses to domestic abuse, including a failure to conduct risk assessments and refer to specialist services. It also highlighted missed opportunities to assess the victim's complex care needs and a lack of understanding of the links between domestic abuse, mental health, and suicidality, exacerbated by cross-border information sharing issues.

Home Office classifications

40 tags

Source-supplied classifications used by the Home Office to catalogue this review.

  • Victim - died by suicide
  • Victim - alcohol misuse
  • Victim - substance misuse
  • Victim - housing issues
  • Victim - pregnancy
  • Victim - mental ill health
  • Victim - anxiety
  • Victim - depression
  • Victim - self harm
  • Victim - suicidal thoughts
  • Victim - suicide attempts
  • Victim - had been a victim of an abuser before
  • Children - under 18 shared parental responsibility (victim and perpetrator)
  • Children - under 18 shared parental responsibility (between victims)
  • Children - under 18 shared parental responsibility (between perpetrators)
  • Children - living with victim (including adult children)
  • Children - living with perpetrator (including adult children)
  • Children - subject to child protection or domestic abuse prior to homicide
  • Children - removed into care
  • Child - primary address same as victim
  • Perpetrator - alcohol misuse
  • Perpetrator - substance misuse
  • Perpetrator - known to agencies as a domestic abuse perpetrator
  • Perpetrator - known to police as a domestic abuse perpetrator
  • Perpetrator - known to social services as a domestic abuse perpetrator
  • Perpetrator - known to health services as a domestic abuse perpetrator
  • Perpetrator - known to mental health services as a domestic abuse perpetrator
  • Perpetrator - known to idva or other domestic abuse support service as a domestic abuse perpetrator
  • Aggravating factors - separation
  • Aggravating factors - sexual abuse
  • Aggravating factors - psychological or emotional abuse
  • Aggravating factors - physical abuse
  • DHR process - family supported by expert specialist advocate
  • DHR process - family received draft report
  • DHR process - community safety partnership recommendations
  • DHR process - training recommendation themes
  • DHR process - policy recommendation themes
  • DHR process - multi agency working recommendation themes
  • DHR process - awareness raising recommendation themes
  • DHR process - other recommendation themes

Extracted recommendations

18 recommendations pulled from the report · 6 matched to organisations in the index

Recommendation 1

Addressed to Salford Community Safety Partnership | Salford Safeguarding Adults Board

The Chairs of the Salford Community Safety Partnership and Safeguarding Adults Board should formally write to the Home Office setting out the difficulties experienced by this review in relation to different legislative processes pertaining in the two countries.

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

Recommendation 1

Addressed to Health and Social Care Partnership in Scotland

The Health and Social Care Partnership in Scotland should seek to review policies and practice in relation to referring to adult services.

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

Recommendation 2

Addressed to Salford Safeguarding Adults Board

Salford Safeguarding Adults Board should review and enhance the multi-agency policy and procedures to reflect the importance of Think Family which will enable parents with care and support to be identified under the Care Act safeguarding duties.

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

Recommendation 2

Addressed to Health and Social Care Partnership | Information Governance | NHS agencies in Scotland

The Health and Social Care Partnership, together with Information Governance and NHS agencies in Scotland should urgently review their processes and procedures to ensure that case transfer and information sharing across all agency’s procedures are fit for purpose. This should include the transfer of all relevant current and historical information and should ensure that differences in policy, practice and terminology are understood when transferring cases.

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

Recommendation 3

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should seek assurance from relevant agencies involved in this review that their local policy and procedures are clear and robust to ensure a timely and effective handover of information when an adult moves from one area to another.

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

Recommendation 3a

Addressed to Adult Protection Committee in Scotland

The Adult Protection Committee in Scotland should oversee the development and facilitation of a series of Learning Reviews to be delivered to a wide range of staff across the Health and Social Care Partnership and the NHS.

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

Recommendation 3b

Addressed to Children’s Services in Scotland

Children’s Services in Scotland should review their practice in relation to transfer of cases across national boundaries.

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

Recommendation 4a

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should ensure that there is a clear expectation of collaborative working with non-commissioned services.

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

Recommendation 4a

Addressed to Health and Social Care Partnership Scotland

The Health and Social Care Partnership Scotland should take action to ensure that disclosures of domestic abuse are recorded, responded to, and acted upon (i.e. enabling the victim an opportunity for safety assessment and follow up, including referral to specialist services).

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

Recommendation 4b

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should ensure that information regarding referral pathways is widely disseminated and understood.

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

Recommendation 4b

Addressed to Health and Social Care Partnership in Scotland

The Health and Social Care Partnership in Scotland should ensure that practitioners know about post-separation abuse and recognise it as a risk factor for victims who have separated from perpetrators.

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

Recommendation 5a

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should ensure that services develop and adopt trauma informed approaches to mental health interventions.

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

Recommendation 5a

Addressed to NHS agencies in Scotland | Health and Social Care Partnership in Scotland

NHS agencies and Health and Social Care Partnership in Scotland should ensure that services develop and adopt trauma informed approaches to mental health interventions.

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

Recommendation 5b

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should ensure that all services are fully informed about the impact of domestic abuse on mental health and links to self-harm and suicide.

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

Recommendation 5b

Addressed to Health and Social Care Partnership in Scotland

Health and Social Care Partnership in Scotland should ensure that mental health services are fully informed about the impact of domestic abuse on mental health and links to self-harm and suicide.

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

Recommendation 5c

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should ensure that practitioners know about post-separation abuse and recognise it as a risk factor for victims who have separated from perpetrators and that this is reflected in practice.

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

Recommendation 5d

Addressed to Salford Community Safety Partnership

The GM Suicide Prevention Strategy training programme should continue to be implemented and evaluated.

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

Recommendation 6

Addressed to Salford Community Safety Partnership

Salford Community Safety Partnership should seek assurance from the Salford Safeguarding Children Partnership that all learning from the Children’s Safeguarding case review has been acted on.

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