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: SalfordPublished: June 2025Year of death: 2020Extracted: 18 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
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
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.