Independent investigation: Bernadette FoxSarah Fox, Bootle (2015)

The Sefton Safer Communities Partnership should ensure that all agencies within the partnership have a clear and consistent understanding of the definition of domestic abuse and the range of behaviours it encompasses, including coercive control and financial abuse. This understanding should be embedded in training, policies, and procedures across all relevant agencies.

Sefton Safer Communities Partnership should review and update its multi-agency information sharing protocols to ensure that all relevant information, particularly concerning individuals with complex needs (such as mental health issues and a history of offending), is effectively shared between agencies, including prison mental health services, community mental health teams, probation, police, and housing providers. This should include clear guidelines on when and how to share information, even in the absence of explicit consent, where there is a risk of serious harm.

Mersey Care NHS Trust, in conjunction with NHS England, should review its processes for the transfer of care for individuals with complex mental health needs from prison mental health services to community mental health teams. This review should specifically address the issues identified in this report regarding incomplete information transfer (e.g., faxed documents), the need for assertive follow-up when initial contact is not made, and ensuring that individuals who meet the criteria for Care Programme Approach (CPA) are actively managed under CPA upon release.

NHS England should ensure that all mental health professionals working in Accident and Emergency departments and crisis teams have access to comprehensive patient records, including those held on SystmOne by prison healthcare providers, to enable informed decision-making during mental health assessments. Where direct access is not immediately feasible, clear and rapid protocols for obtaining critical information from other systems must be established and adhered to.

Merseyside Police should review its procedures for circulating individuals as 'wanted' on the Police National Computer (PNC) and the CORVUS briefing system, particularly in cases involving breaches of restraining orders or where there is an identified high risk of harm to victims of domestic abuse. This review should ensure that officers on patrol are consistently aware of individuals wanted for such offences.

Your Housing Group should review and amend its tenancy risk assessment procedures to ensure that direct questions regarding a history of domestic abuse are consistently asked during initial assessments and ongoing reviews for all tenants, particularly those in sheltered housing schemes. Staff should be trained to recognise indicators of domestic abuse and to make safeguarding alerts to the local authority without delay, even in the absence of explicit tenant disclosure.

The National Probation Service, in conjunction with HMP Manchester and other prison establishments, should review the practice of frequently moving prisoners with complex mental health needs between different prison facilities. This review should consider the impact of such moves on the continuity of mental health care, assessment, and treatment, and explore strategies to minimise disruption for vulnerable prisoners.

Sefton Safer Communities Partnership should ensure that all agencies involved in Multi-Agency Risk Assessment Conferences (MARAC) and Multi-Agency Public Protection Arrangements (MAPPA) consistently record detailed notes of discussions and agreed actions, particularly concerning individuals with mental health issues and a history of violence. Clear protocols should be established for sharing these minutes with all relevant mental health professionals, even if they did not attend the meeting, to ensure a comprehensive understanding of risk.

NHS England, in collaboration with the Ministry of Justice, should review the current policy regarding the non-invitation of the 'nearest relative' (Ministry of Justice) to Care Programme Approach (CPA) meetings for patients admitted under Sections 47/49 of the Mental Health Act 1983. This review should consider whether greater involvement of the Ministry of Justice in CPA meetings could enhance discharge planning and aftercare for such patients, particularly when transitioning back to the community.

Sefton Safer Communities Partnership should develop and implement a comprehensive training programme for all frontline staff across partner agencies (including housing, police, probation, and mental health services) on recognising the signs of domestic abuse in older adults and vulnerable individuals, understanding the dynamics of coercive control, and responding effectively to disclosures or suspicions of abuse.

Mersey Care NHS Trust should ensure that when a mental health professional makes a recommendation for follow-up in the community, especially for individuals with a known history of complex mental health needs, the referral includes all available historical information (e.g., previous diagnoses, admissions to secure units) to enable the receiving team to prioritise and plan appropriate and timely interventions.

NHS England should review the current guidance and practice regarding the assessment of individuals under Section 136 of the Mental Health Act, particularly when there is a known complex mental health history. This review should ensure that assessing clinicians have immediate access to all relevant historical mental health information, including prison healthcare records, and that conclusions drawn from single assessments are appropriately contextualised.

Sefton Safer Communities Partnership should establish a clear and robust mechanism for ensuring that recommendations from Domestic Homicide Reviews and NHS Independent Investigations are systematically implemented, monitored, and evaluated across all relevant partner agencies. This should include regular reporting on progress and accountability for actions taken.