Domestic homicide reviews: consultation analysis

D) Information Gathering and Analysis

This section considered how we can make sure that important information can be gathered to inform the review.

In considering how to ensure information is shared on organisations’ involvement with victims and perpetrators at the time of/in the lead up to, a victim’s death, it is essential that those contributing are clear about why their cooperation is essential.

25. Cooperation: What is the best way to ensure co-operation and participation of agencies in the review process?

Professional respondents and those professionals with lived experience were asked about the best way to ensure co-operation and participation of agencies in the review process. A key recommendation was the need for legislation to strengthen information sharing. Respondents also commented that statutory guidance on the aim and remit of Scotland’s Domestic Homicide Review model would provide clear roles, support mechanisms, expectations and realistic outcomes. It was also noted that to support the implementation of legislation, funding would need to be committed to cover the additional workload by various agencies/ sectors.

Respondents also shared the need for flexibility in providing input and attending meetings to fit work patterns. It was also stated that agencies need to take ownership of the process and view reviews as learning opportunities, making it clear that they are not being used to criticise without offering constructive recommendations.

Some respondents cautioned that Domestic Homicide Reviews need to be integrated within existing review processes to avoid duplication and the burden or re-traumatisation of surviving family members, friends and carers. Others suggested that Scotland’s Domestic Homicide Review model could use existing review models as a basis on how it operates.

26. Learning: What is the best way to ensure the Domestic Homicide Review process is about learning lessons?

Professional and professionals with lived experience were asked about the best way to ensure that the Domestic Homicide Review process is about learning lessons. Resoundingly, feedback echoed that the process needs to be supported by clear guidance and avoid blame culture. Respondents also shared that the Domestic Homicide Review needs to have a mechanism to look at this learning through a multi-agency lens to avoid any agency from acting as gatekeeper to the information.

It was also noted that the quality of the review’s leadership, including the knowledge, skills and experience of lead reviewers, is absolutely critical – not just subject-specific, but a wider skill set that allows them to build findings and recommendations that support improvement. Other ways suggested by respondents included:

• Bespoke reviews tailored to the circumstances of the specific case and that are proportionate.
• A clear focus on facts and behaviour, avoiding sensationalism.
• Implement a quality assurance framework to gather feedback and monitor progress on action points.
• Acknowledge that some partners are more dominant than others or respected and valued. This is particularly important relating to the third sector - they hold significant information that’s of importance.
• Role of families need to be given equal space and place in the learning process.
• Ongoing communication throughout the process. People knowing they are valued and that the work they are contributing to is valued.
• Ensure that updates are provided throughout the process.
• Support for professionals to feel comfortable sharing information, avoiding blame culture, encourage learning from the process.
• Tone of communications has to be about learning. Moving from ‘significant case reviews’ to ‘learning reviews’ in social work has helped to change the mind-set of the profession.
• Victims and families need to be clear that reviews are not investigations and not about establishing facts (this can be very challenging for them) – they will not give them all the answers they are looking for and this needs to be clear from the outset.

27. Examples of good practice: Are there any examples of good practice of review processes in and out with Scotland that operate well in relation to sharing sensitive information?

Respondents were asked whether they had any examples of good practice of review processes. Several examples were suggested and are listed below:

• Child Protection Case Conferences
• Domestic homicide review process Cumbria
• Drug Death Reviews in Tayside.
• Learning Reviews
• Multi Agency Risk Assessment Conference
• Risk Management Case Conferences