Recurring concern

Unreliable notification of domestic abuse victims about bail and protective-order decisions

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First reported 25 Jan 2019•Latest report 18 Nov 2020

Definition

What this concern includes

Includes failures of police processes dedicated to notifying domestic abuse victims about suspect release on bail, conditional bail arrangements, DVPNs, DVPOs or materially related protective-order decisions, including failures of timeliness, system effectiveness, follow-up or maintaining appropriate post-charge contact when that contact is part of the notification safeguard.

Not included

Excludes generic police communication or victim-support deficiencies that are not specifically tied to bail, protective-order or post-charge safety notification.
Excludes failures concerning notification to suspects, prisoners, probation services or other recipients where domestic abuse victim notification is not the shared concern.
Excludes failures in making or assessing bail or protective-order decisions when the notification process itself is not deficient.
Excludes general domestic abuse investigation, safeguarding or risk-assessment failures that do not concern communicating bail or protective-order information to victims.

Reports: 2
Individual concerns: 2
Date range: 2019–2020
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Greater Manchester Police2

Crown Prosecution Service1

Department of Health and Social Care1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Home Office1

Pennine Care NHS Foundation Trust1

Trafford Borough Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Nov2020
Manchester South
Concerns raised1
1. Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Recruit dedicated DVPO officers and operate a process for prompt victim contact, support, district follow-up and compliance checks.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Implement the revised force-wide DVPN/DVPO policy and training package, including inspector review, documented refusal rationales and visit timescales.
  Stated by Greater Manchester PoliceStated completed
Respondent positions 1
1. Position
  Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Alfie Gildea · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report
“11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP. ”
Source location
Alfie Gildea · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recruit dedicated DVPO officers and operate a process for prompt victim contact, support, district follow-up and compliance checks.

Verbatim wording from the response
“Since the death of Alfie, GMP has recruited two police staff to permanently and solely perform the role of DVPO officers. This has enabled a new process whereby the team now has extra flexibility to contact the victim as soon as the DVPO has been granted and offer additional support. If this contact fails, then the new process outlines the clear responsibilities for districts to make contact with the victim and conduct compliance checks within specified timeframes.”

Source location
2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Page 7 · response
Published 24 December 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the revised force-wide DVPN/DVPO policy and training package, including inspector review, documented refusal rationales and visit timescales.

Verbatim wording from the response
“A revised DVPN/DVPO policy has been signed-off and launched alongside an accompanying training package to reflect the changes to the process. The following changes to the DVPN/DVPO process have now been implemented force wide:”

Source location
2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Page 7 · response
Published 24 December 2020
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

Verbatim wording from the response
“I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

Source location
2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
Page 1 · response
Published 24 December 2020
Open published response
25 Jan2019
Manchester North
Concerns raised1
1. Failure to maintain contact with domestic abuse victims after an alleged perpetrator is charged and granted conditional bail
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Anne-Marie Nield · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain contact with domestic abuse victims after an alleged perpetrator is charged and granted conditional bail
Wider context from the report
“4. There was little, if any, contact made with the deceased after her partner was charged and granted conditional bail by the Court following the allegation made on the 11th March 2016. Policy and Code were not followed. ”
Source location
Anne-Marie Nield · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to maintain contact with domestic abuse victims after an alleged perpetrator is charged and granted conditional bail

Actions described in response 2

Respondent positions 1