Domestic Homicide Reviews: evidence briefing

Overarching Network was established in 2011

In Australia DHRs are established at state/territory level.

The National Plan to Reduce Violence against Women and their Children 2010–2022 (Strategy 5.2) mandates states and territories to "drive continuous improvement through sharing outcomes of reviews into deaths and homicides related to domestic violence". The Australian Domestic and Family Violence Death Review Network was established to share outcomes.

The goals of the Review Network are to:

Analyse domestic and family violence deaths, the DHR findings and recommendations of all states, and identify practice and system changes that may improve outcomes for people affected by domestic and family violence and reduce these types of deaths

January 2011

No specific legislation, established under coronial mandate. The Office for Women established, in partnership with the South Australian Coroner's Office, the role of senior researcher to research and investigate open and closed deaths related to domestic violence. Depending on the investigation, a coronial inquest may follow.

To research and investigate domestic-violence-related deaths.

July 2012

No specific legislation, embedded in the role of the Ombudsman.

The Ombudsman has all the powers provided for in the Parliamentary Commissioner Act 1971 (WA) (the Act) and all of the powers of a standing Royal Commission.

To identify key learnings that will positively contribute to ways to prevent or reduce family and domestic violence fatalities
The Ombudsman will: 1) review circumstances of deaths; 2) identify patterns and trends; and 3) make recommendations to public authorities.

2010

The Domestic Violence Death Review Team (DVDRT) was established with the Coroners Amendment (Domestic Violence Death Review Team) Act 2010 (NSW), inserting Chapter 9A into the Coroners Act 2009 (NSW) and establishing the Domestic Violence Death Review Team.
Reviews are convened by the coroner, which operates independently within Department of Justice

The DVDRT aims to develop and promote domestic violence intervention and prevention strategies so as to reduce the likelihood of deaths occurring in similar circumstances in the future, and to improve the response to domestic violence more generally.
The functions of the Team are to 1) review and analyse individual closed cases; 2) maintain a database and identify patterns and trends; and 3) develop recommendations

The first Canadian review was established in 2003 in Ontario

Reviews are established at province/territory level but the Canadian Domestic Homicide Prevention Initiative (CDHPI) was developed to share information.

It is a partnership between Western University and the University of Guelph. Funding for the CDHPI was provided by the Canadian Women's Foundation.

The CDHPI hosts information and reports on the reviews as well as provide resources to support implementation

One review conducted in 2010 and one in 2016 (covering the period 2010-2015)

No specific legislation, established under coronial mandate.

The Coroners Act provides the chief coroner with the discretion to establish death review panels to review the facts and circumstances of deaths.

Hosted by British Columbia Coroners Service. Panel members are appointed by the chief coroner under Section 49 of the Coroners Act.

Death reviews are held to provide the chief coroner with advice on medical, legal, social welfare and other matters that may impact public health and safety and prevention of deaths.

A death review panel may review one or more deaths before, during or after a coroner's investigation or inquest.

Established in 2015, as a pilot

No specific legislation, the review was set up as a pilot, to review historical cases.

A steering committee was set up, with representation from ministry divisions that deal with domestic violence situations and the police. This committee oversaw the development of the review process.

Examine specific cases to 1) identify trends, risk factors and patterns, to inform risk management; 2) identify barriers, gaps and points of intervention in community and systemic responses; 3) recommend prevention and intervention strategies; and 4) facilitate systemic and inter-agency communication and coordination

2003

No specific legislation, established under coronial mandate (Section 15(4) of the Coroners Act, R.S.O. 1990, Chapter c. 37, as amended).
The Chief Coroner is authorized, when seen as necessary, to use experts to provide comprehensive examinations and analyses of deaths, to highlight areas for future inquiry, and/or to identify potential recommendations for enhancing prevention

The purpose of the Domestic Violence Death Review Committee (DVDRC) is to assist the Office of the Chief Coroner in the investigation and review of deaths of persons that occur as a result of domestic violence, and to make recommendations to help prevent such deaths in similar circumstances.
Tasks include to maintain a database; to help identify systemic issues, problems or shortcomings; to help identify trends, risk factors and patterns; to conduct research where appropriate; to make recommendations and promote educational activities.

13 April 2011

DHRs were established on a statutory basis under the Domestic Violence, Crime and Victims Act 2004, section 9(3). The Act's provision came into force in 2011.

There is a statutory requirement for local areas to conduct a Domestic Homicide Review (DHR) following a domestic homicide that meets the criteria.

National statutory guidance sets out how DHRs should be conducted and reported on. Guidance and (online) training is produced by the Home Office.

A Domestic Homicide Review (DHR) is a multi-agency review that aims to 1) establish lessons to be learned both within and between agencies; 2) apply these lessons and improve service responses; 3) prevent domestic violence homicide by developing a co-ordinated multi-agency approach; 4) contribute to a better understanding of the nature of domestic violence and abuse; and 5) highlight good practice

2008

As of 2023, the 5 mortality committees, including one with a focus on family deaths will be disestablished, with one committee taking its place

New Zealand Public Health and Disability Act 2000 enables creation of mortality committees.

The New Zealand Family Violence Death Review Committee (FVDRC) established as a ministerial committee in 2008 under this mandate to address family violence.

In April 2011, following the New Zealand Public Health and Disability Amendment Act of 2010, the Committee became the responsibility of the Health Quality and Safety Commission (HQSC).

The focus of the FVDRC is to reduce family violence deaths by 1) reviewing and reporting family violence deaths to the Health Quality & Safety Commission; 2) developing strategies to reduce family violence.

The FVDRC aims to collect a standard set of information on every family violence death. Local and national review of this information helps identify patterns and trends in family violence deaths over time and establish policy and practice improvements that can contribute to the reduction of family violence deaths.

10 December 2020

Legislation: the Domestic Violence, Crime and Victims Act 2004, section 9(3), see England

Guidance was developed by Ministry of Justice, taking into account the UK Home Office Multi-Agency Statutory Guidance, as well as the experiences and learnings in England and the outcomes of a consultation process

See England

The overarching purpose of a review is to prevent future domestic homicides by learning any lessons from the death and improving responses to domestic abuse victims (and their family and children) as a result of lessons learnt.

Established in 2015 and started analysing cases in 2017

Article 4a of the Domestic Violence Act (No. 129/2015) and Ordinance 280/2016 establish and regulate the 'Equipa de Analise Retrospectiva de Homicidio em Violencia Domestica' (Retrospective Analysis Team of Domestic Violence Homicide)

The aim of the EARHVD is the retrospective analysis of domestic violence homicide, to make recommendations on the implementation of new preventative procedures and measures.
The analysis aims to understand the reasons, circumstances and context in which the murder occurred, with a view to improve intervention methodologies, prevent/correct errors and guide the action of public and private agencies.

Domestic Violence Fatality Reviews were established early to mid-1990s.

Fatality reviews are established at a state, regional or local level.

The National Domestic Violence Fatality Review Initiative was established to share information (NDVFRI). It is funded by the Office on Violence Against Women (US Department of Justice), through the Violence Against Women Act. It is housed at Northern Arizona University

The NDVFRI acts as a national repository hosting information and reports and it provides training and technical assistance around implementation and delivery.

The Denver Metro Domestic Violence Fatality Review established in 1996.
In 2017 Colorado Domestic Violence Fatality Review Board was established

Senate Bill 2017-126, created the Domestic Violence Fatality Review Board (DVFRB) chaired by the Colorado Attorney General.

It enables local governments across Colorado to form DVFRTs in order to enhance existing efforts to prevent domestic violence fatalities.

Gain a deeper understanding of the dynamics related to domestic violence fatalities and develop meaningful policy and practice recommendation aimed at improving domestic violence prevention and response services.
The (CDVFRB), is charged to: 1) examine collected data; 2) identify measures to help prevent domestic violence fatalities; 3) establish uniform methods for collecting, analysing, and storing data; and 4) make annual policy recommendations

1996.

It is the first jurisdiction wide review team established in the United States.

By statue: Title 13 Section 2105
It established a permanent Domestic Violence Coordinating Council. The council is given the power to investigate and review domestic homicide deaths, through a review panel, the Fatal Incident Review Team (FIRT)

Primary purpose is to decrease the incidence of domestic violence deaths by reviewing the facts and circumstances of all deaths and near deaths that occur in Delaware as a result of domestic violence.
The reviews focus on 1) identifying trends, patterns and obstacles in services; 2) assessing agency interventions; and 3) developing practical recommendations aimed at improving the system

Local (voluntary) teams established in 2003 and 2004.
In 2005 Local Domestic Violence Fatality Review Teams were signed into law.

Legislation: the Maryland Code of Family Law Section 4-703, which details the purpose and membership of the review teams
Section 4-704 provides the activities the Local Teams should perform

Legislation allowed the two already established review teams to access more information (initially they relied on public records and interviews)

A multifaceted purpose, to prevent domestic violence deaths by:
1) enhancing coordination and cooperation between agencies; 2) deliver crucial services and support to domestic violence victims and their families as well as abusers; and 3) conceive and deliver recommendations for improving investigation and support of domestic violence.

2003.
The Native American fatality review team was added in 2014.

The Fatality Review Commission is described in the Montana Code, Title 2, Chapter 15, Part 20
The commission sits within the Department of Justice.
Next to the Montana Domestic Violence Fatality Review Commission (MDVFRC), there is also the Native American Domestic Violence Fatality Review Team (NADVFRT), focused on domestic homicides in Montana's Indian Country.

The commission seeks to reduce homicides caused by family violence.
The MDVFRC seeks to identify gaps in Montana's system for protecting domestic violence victims and better coordinate multi-agency efforts to protect those most at risk of domestic homicide.
The NADVFRT seeks to deeply understand what leads to domestic violence fatalities in Montana's Indian Country, and to recommend culturally sensitive, proactive changes to prevent them in the future

2002

Legislation: Statue 15 VSA § 1140(b), establishing a Domestic Violence Fatality Review Commission (DVFRC) within the Office of the Attorney General, in consultation with the Council on Domestic Violence

To collect data and conduct in-depth reviews of domestic violence related fatalities to better understand how the fatalities occurred and what can be done to prevent them
The purpose of the DVFRC is to 1) examine trends and patterns; 2) to identify barriers, the strengths and weaknesses in communities and systemic responses; 3) to educate the public, service providers, and policymakers; and 4) to make recommendations

1998

Revised Code of Washington (RCW 43.235.020).

It authorizes the Department of Social and Health Services to make grants available for a DA agency to gather and maintain data and coordinate domestic violence fatality reviews (the Washington State Coalition Against Domestic Violence - WSCADV).

The reviews are carried out by regional panels.

The purpose of the Domestic Violence Fatality Review is to understand how systems and communities are or are not effective in responding to domestic violence victims and abusers.

The Domestic Violence Fatality Review seeks to: 1) increase safety and self-determination for victims and accountability for perpetrators; 2) foster communication and collaboration; 3) identify patterns in and; 4 generate information useful to policy makers, practitioners, advocates and educators.

2011

Legislation: the Domestic Violence, Crime and Victims Act 2004, section 9(3), see England

Next to DHRs, two other types of reviews are established in Welsh law: Child or Adult Practice Reviews (CPRs or APRs) and Mental Health Homicide Reviews (MHHRs)

See England

The DHR will be included in the newly established Single Unified Safeguarding Review (SUSR). This is one single review to include the multiple different reviews in UK and Welsh legislation. The SUSR will allow practitioners to appreciate and address the whole picture and identify key cross cutting areas to learn and develop

In 2021 there were 105 victims of family and domestic violence (FDV) related homicide nationally. The majority of FDV related homicide victims were female (58% or 61 victims).

FDV include (ex)partner, parents, other family members and non-family members that are carer, guardian or kinship relationships

The Network collates information from the DHRs conducted by the different States and Territories and compares reporting.

As such they define minimum case inclusion criteria and developed a standardised minimum data set.

Exact case selection criteria are, however, determined by each state or territory.

In 2021 there were 14 family and domestic violence (FDV) related homicides recorded, including five children (under 18). Ten victims (71%) were female, four victims were male (29%).
Four were intimate partners of the perpetrator, six were other family members. Of four victims relationship was not registered.

The scope of the review includes: single fatality homicide, single fatality suicides and multiple fatality (e.g. homicide–suicide) incidents where there is a context of domestic or family violence.

It includes both child and adult victims.

Open coronial and closed criminal cases are considered.

In 2021 there were 13 family and domestic violence (FDV) related homicides recorded (all adults).
Ten victims were female (77%) and three victims were male (23%).

A FDV fatality is a death that is caused directly or indirectly by a person who was in a family or domestic relationship with the deceased.

This include (ex)partners, parents, children or other relatives.

Both open and closed coronial and criminal cases are considered.

In 2021 there were 26 victims of family and domestic violence (FDV) related homicide, including four children (under 18).

Seven victims were female (27%) and 19 victims were male (73%).

All domestic violence related deaths including intimate partner homicides and adult family homicides as well as domestic violence related suicides and fatal accidents that are caused by domestic violence (e.g. including bystanders)

Review team will only consider closed coronial and criminal cases.

In 2017 there were 76 intimate partner homicides
In total 933 intimate partner homicides occurred between 2007 and 2017, a large majority (79%) involved female victims.

Between 2010 and 2015, 75 fatal intimate partner violence incidents occurred, resulting in 100 deaths (73 IPV victims, 27 IPV perpetrators)
78% of the victims were women, 22% were men.

Almost two-thirds of all IPV victims had a known history of IPV, but fewer than one third of all victims had reported the violence to police.

The 2010 Review covered domestic violence, closed cases that were selected by the chair because the cases were illustrations of the most compelling and significant domestic violence risk factors and systemic gaps.
The 2016 Review covered intimate partner violence related deaths, including victims who were former or current partners, bystanders (e.g. new partners or children) and also perpetrator's suicide

Between 2005-2014 there were 48 domestic homicides (intimate partner violence and parent-child relationships) with nine related suicides.

One third (15) of the victims were under age 21. Of the adult victims 19 were female (58%) and 14 were male (42%).
Of the perpetrators 32 (70%), were male and 14 (30%) were female.

Domestic violence death is defined as a homicide or a related suicide that occurs in circumstances involving persons in an intimate relationship and their families.
It often involves conflict between intimate partners or ex-partners, including situations which lead to the death of a child or familial member.

Quantitative information was gathered on all cases, 6 cases reviewed in-depth (selected to represent diversity of situations)

In 2017 there were 20 victims of domestic violence death (intimate partner violence, including death of any children). It included 17 female adult victims (85%), one male adult victim (5%) and two male children (10%). There were 3 perpetrator suicides related to domestic homicide cases (all adult male).

Domestic violence deaths are defined as "all homicides that involve the death of a person, and/or his or her child(ren) committed by the person's partner or ex-partner from an intimate relationship."

At the discretion of the Chair, review team may also look at near-deaths or cases where there was the possibility that the victim and the perpetrator were involved in an intimate relationship.

In 2020-2021 there were 114 domestic homicides including adults in England and Wales.
Of the 114 domestic homicides, 67 victims were killed by a partner or ex-partner, 27 were killed by a parent, son or daughter and 20 were killed by another family member.
75 (66%) of the victims were female, 39 of the victims were male (34%). Of the 75 female victims, 72 were killed by a male suspect.

Domestic homicide includes intimate partners as well as family relations

A DHR is considered when a case include an adult (aged 16 or over) death that has, or appears to have, resulted from violence, abuse or neglect by (a) a person to whom he was related or with whom he was or had been in an intimate personal relationship, or (b) a member of the same household as himself.
Reviews can be conducted in cases of suicide where "circumstances give rise to concern" (although operationalisation remains somewhat unclear)

A DHR is held when a review may result in identifying lessons to be learnt

In 2018 there were 15 victims killed by their partner, 4 were killed by their child, 5 by their parent and 3 by other family members. Of those 27 victims, 16 were female (59%) and 11 (41%) were male.

Between 2007 and 2018, approximately 136 homicide victims were killed by their partner, of which 74% were female.

A family violence death is defined as: the unnatural death of a person (adult or child) where the suspected offender(s) is a family or extended family member, caregiver, intimate partner, previous partner of the victim, or previous partner of the victim's current partner, and where the death was an episode of family violence and/or there is an identifiable history of family violence.

Excluded from this definition are: non-family member bystanders or interveners, suicides, suicide-assisted deaths, deaths from chronic illness associated with family violence.

In 2020/2021 there were 9 homicides with a domestic abuse motivation (intimate partner violence and incidents between family members).

7 victims were partner or ex-partner of the perpetrator, and 2 victims were other family relations. 8 victims were female (89%), and 1 victim was male (11%).

Between 2010-2021 there were 65 domestic abuse homicides. 36 victims were the partner or ex-partner of the perpetrator, and 29 victims were other family relations. 45 victims (69%) were female, 20 victims were male (31%).

Similar to England, a DHR is considered when:
- the deceased person is aged 16 or over
- the death has or appears to have resulted from violence, abuse or neglect
- the perpetrator was related to the victim, was in an intimate personal relationship with the victim, or lived in the same household as a victim

A DHR is held when a review may result in identifying lessons to be learnt

In 2019 there were 41 homicides in a domestic violence context, of which 26 were intimate partner homicides (22 women and 4 men).

Closed cases of homicides, and near deaths, in a domestic violence context, which includes intentional homicide and attempted homicide, directly or indirectly related to the sociological context and or interpersonal relationships referred to in Article 152 of the Penal Code. It includes intimate partner relations, family members or relatives as well as people co-habiting or being economically dependent of the accused. It also includes death of DA professionals where the crime was motivated by, directly or indirectly, exercising of such functions.

In 2018, 43 individuals were killed as a result of domestic violence (intimate partner homicides and collateral victims in this context). 26 were the primary victim of domestic violence, 2 were collateral children, 4 were collateral adults, and 11 were the primary perpetrator of domestic violence. The largest group (20, or 47%) were women killed by a current or former male partner. 5 men were killed by their female (ex)partner.

Cases that are considered are intimate partner homicide, including near-misses, perpetrator suicide and collateral victims.

Cases for in-depth review are selected based on several factors, including status of the case (must be closed with no civil action pending), availability of records, recommendations by DVFRT members, and incident location.

In 2019 there were 8 domestic violence homicide (intimate partner homicide and homicide between family members) victims and 1 near-death victim.

4 were female and 5 were male. 3 female victims were (ex)partner of the offender. 1 of the victims was a minor child, and 2 were adult children, 1 was an uncle and 1 was the former boyfriend of offender's current partner.

Cases include both homicides and suicides resulting from domestic violence. The victim can be the domestic violence victim, perpetrator, or a by-stander as long as the death or near death (suffered life-threatening injuries) was a result of domestic violence, meaning either intimate partner violence or violence between family members.
The victim must have been a Delaware resident at the time of the incident leading up to the death

In 2020, 56 people lost their lives to domestic violence. This included 38 victims killed by their intimate partner (34 women, one teen girl and three men), 3 bystanders and 4 men lost their life due to DA violence with unknown case details. 11 abusive partners died, nine men and two women in attempted or completed murder-suicides

Local teams review and assess their county data for any domestic violence that resulted in death or near-death (serious physical injury), including suicides.
The local teams may only review criminal cases after conclusion of the court case or suicide investigation.

In 2021 there were 15 domestic homicides (homicide offenses involving partners or family members) in Montana.

The commissions review closed domestic homicide cases selected by the attorney general. The cases that are included are of intimate partner homicide as well as homicide-suicide cases.
The NADVFRT looks at cases of family fatalities related to domestic violence on or near Reservations.

There were 8 domestic violence related homicides in 2020; 5 involved intimate partner relationships, 3 involved family members who lived in the same household. 7 of the deceased were male, 1 was female.

In 2019 there were 8 domestic violence related homicides. 6 involved intimate partner relationships and 2 involved family members. 5 deceased were female and 3 were male.

The (quantitative) data the DVFRC includes only those cases the Office of the Chief Medical Examiner ruled as homicide.

in-depth reviews can be held for any domestic violence related fatality, which can be homicides, murder-suicides, suicides (with a documented history of DA) and substance abuse related deaths (with a history of DA). It includes family members, household member, estranged partner's current household member, or a current partner's or family member's estranged "household member" and bystanders

In 2020 there were 47 domestic homicides (homicides in intimate partner violence context), 18 perpetrator suicides (of abusers in context of intimate partner homicide or assault) and 8 perpetrators killed by police intervention

In 2021 there were 29 domestic homicides, 3 perpetrator suicides (of abusers in context of intimate partner homicide or assault) and 1 perpetrator killed by police intervention

Cases look at intimate partner violence, including: current or former intimate partner; friends, family, new partners, or police officers killed by abusers in the context of intimate partner abuse; abusers killed by victims, police, or someone intervening; and suicides of abusers following a domestic violence homicide or assault.

National statistics are provided by ONS on both England and Wales (see England).

Since 2014, there have been 37 DHRs commissioned

For DHR see England

APRs take place after an 'adult at risk' has died or sustained life threatening injury. An adult at risk is defined as a person who is experiencing or at risk of abuse or neglect, has need for care and support and as a result of those needs is unable to protect themselves against abuse or neglect
MHHRs are carried out after homicides are committed by individuals known to mental health services in Wales. The decision to undertake a review is made on a case by case basis.

The Network comprises of members of each of the death review teams from all of the Australian states and territories. Members of the Network have specialist expertise in domestic and family violence-related issues and are able to access information from coroner's courts, ombudsman's offices and government agencies.

The Network had an MoU with ANROWS (Australia's National Research Organisation for Women's Safety) to research national trends (from 2020-2022).
The data used for this research is sourced through death review teams in each Australian jurisdiction, and is extracted into a national minimum dataset.

Meetings are held at least four times per year.

The second iteration of the Network's report was an 18 month research project

The Senior Research Officer (Domestic Violence) is based within the South Australian Coroner's Office and works as part of the Coronial investigation team and will:
- Identify deaths with a domestic violence context
- Review files, provide interim reports and have specific input into Coronial Inquests which relate to domestic violence.
- Conduct specific retrospective research projects relevant to building the domestic violence death review evidence base.
- Develop data collection systems: including the Coronial Domestic Violence Information System (CDVIS), incorporating over 120 different perpetrator and victim-specific variables and providing the capacity to record data and track trends.

No information found

The WA Police Force informs the Ombudsman of all family and domestic violence fatalities.
A review will be undertaken if the relationship between victim and suspected perpetrator meets the case selection criteria. The extend of the review depends on the circumstances of the death and the level of involvement of relevant agencies.

The review team includes an assistant Ombudsman, a Director, a Principal Aboriginal Liaison Officer and a number of investigating research officers. After the Ombudsman has been informed the team will start the review process:
- Demographic information, circumstances and issues are identified, analysed and reported
- Patterns and trends are identified, analysed and reported

To review this, the team liaises with public authorities and agencies that interact with or deliver services to those at risk of domestic violence.

There is an Advisory Panel (including government representatives and domestic abuse specialists) that provides independent advice to the Ombudsman on issues and trends.

The annual report of the Ombudsman notes that a timely review for family and domestic violence fatalities is important. It reports that 41% of all reviews were completed within six months and 68% of reviews were completed within 12 months

In 2020-2021 the Advisory Panel met two times

The DVDRT is a multi-agency committee and includes a secretariat, constituting of a Manager and a Research Analyst. The team is convened by the State Coroner and brings together representatives from key government agencies and non-government service provides and sector experts.

The DVDRT reviews individual closed cases and identifies systemic issues. It understands domestic and family violence as a complex, intergenerational and 'wicked' problem that requires complex responses that reach across government, non-government and community.

It takes a two-tiered approach to analysis the cases:
- Tier 1: 'real time' domestic violence homicide dataset (for quantitative data analysis)

- Tier 2: Examination of in-depth case reviews (qualitative data analysis), following a comprehensive examination and analysis of all available case material. The secretariat prepares a case review report, which is examined by the team in a series of workshops. Recommendations are developed in consultation with agencies.

It includes a document review, although the 2017-2019 report states opportunities to engage with surviving friends and family is being explored.

Unclear how long the DHRs take, but the aim of the DHR specifies that the team looks at closed cases, meaning they are reviewed after the court process has finished.

Ad hoc panels that include government and non-government representatives.

In 2010 the panel convened on March 9, 10 and 11, at the Office of the Chief Coroner in Burnaby to examine the circumstances surrounding 11 incidents of domestic violence. The 11 incidents that are the subject of this report were selected from a review of over 100 coroner case files dating back to 1995. After examining the circumstances related to the fatal incidents, the panel made several findings and recommended strategies for preventing similar deaths in the future. The panel's findings and conclusions were reported to the chief coroner by the chair.

The 2016 Review was held on June 8-9, and included deaths resulting from intimate partner violence. The circumstances of 100 deaths as a result of IPV incidents were reviewed in aggregate. The panel reviewed the coroners investigative findings, academic literature, information provided by panel members, public policies and strategies and discussed environmental, social and medial factors associated with the deaths, possible trends or themes and existing challenges.

The first review was held during the course of 3 days, the second review was held during the course of 2 days.

It is unclear how much preparation time preceded these sessions, or how much time was needed for writing the report.

The Ministry of Justice compiled a list of domestic violence deaths in Saskatchewan between 2005 and 2014 by examining closed files from the Office of the Chief Coroner. Of all these death some general characteristics were gathered (gender, age, relationship between victim and perpetrator, where the death occurred etc.).
Of the 48 deaths identified, 6 were chosen to review in-depth.

The in-depth review was conducted by a multi-disciplinary panel. The Panel tested a standardized assessment process that used risk and victim consideration matrices to examine cases. The review led to a recommendations presented in a report for the Government of Saskatchewan

The pilot started in 2015, with its final report published in 2018

The multi-disciplinary Review Panel met for seven days over a number of months

The Domestic Violence Death Review Committee (DVDRC) consists of multi-agency representatives. In some cases, external expertise on specific issues is sought if necessary.

When a domestic violence homicide or homicide-suicide takes place in Ontario, the Executive Lead of the DVDRC is notified and basic case information is recorded in a database. Reviews are conducted by the DVDRC only after all other investigations and proceedings – including appeals – have been completed – the executive lead will verify the status periodically.
Once it has been determined that a case is ready for review, the case file is assigned to a reviewer (or reviewers). Each reviewer conducts an examination and analysis of facts within individual cases and presents their findings to the DVDRC as a whole. Information considered within this examination includes the history, circumstances and conduct of the perpetrators, the victims and their families, and community and systemic responses. They are examined to determine primary risk factors, to identify possible points of intervention and develop recommendations.

Family members and other stakeholders can provide input to the DVDRC through the Regional Supervising Coroner responsible for the area where the homicide or homicide-suicide took place. Information is provided through the course of the initial coroner's investigation.

As the committee only investigates a case after all investigations and proceedings have been completed the timescale before a DHR starts can vary.

Unclear how long the process takes once a review commences

Reviews are initiated by Community Safety Partnerships (CSPs). CSPs are local partnerships between the police, local authorities, probation service and voluntary agencies, that develop and implement strategies to protect local communities from crime.

The police informs the relevant Community Safety Partnership in writing on a domestic homicide. The chair of the CSP is responsible for establishing whether a case is to be subject of a domestic homicide review (as set out by the guidelines). When it is decided a review should take place CSP will request a panel to be set up. The review panel can either have a fixed, standing membership or can be tailored for the purpose of a particular homicide review. The panel should include individuals from both statutory agencies (listed under section 9 of the 2004 Act) and voluntary/community sector organisations. The panel must also include specialist/local domestic abuse service representation. Family, friends and colleagues do not sit on the panel, although guidance advices to invite them to participate/contribute to the review.

The review panel appoints an Independent Chair to co-ordinate the review process and producing the final report. The panel will consider the scope of the review and draw up a terms of reference. A case review follows.

The Home Office produces multiagency statutory guidance to lay out the review process in detail. A quality assurance panel is installed to oversee the DHR system as a whole, and approves reports submitted by CSPs to be published.

Where the victim is between 16 and 18 years old, both a Serious Case Review and a DHR are required. These may be run in parallel, and some aspects can be commissioned jointly

The decision to hold a review should be taken within 1 month of a case coming to the attention of the CSP.
The overview report should be completed within a further 6 months of the date the decision to proceed is taken. (could be delayed in case of restrictions due to criminal case)

In practice the average time between a homicide occurring and a DHR report being considered by the quality assurance panel is longer. Rowlands (2020) reported an average of 2.4 years.

The FVDRC is an interagency and multi-disciplinary committee. It has a maximum of eight members, appointed by the HQSC for three years, covering diverse knowledge and expertise on family violence

The FVDRC has a twin-track data collection system:
1. collecting a standard set of data on each family violence death event over time, which the Committee aggregate and report on regularly. Data comes from police and coronial information
2. conducting in-depth reviews of death events to identify the unique details of each event, gain insights into the functioning of the multi-agency family violence system and ways to prevent future deaths. Four regional review panels conduct the death reviews.

Three to four in-depth reviews are held per year. The regional panels include representatives from the key agencies involved in the family violence response along with family violence and cultural experts. The review includes: (i) a traumagram to map experiences of trauma for the families and whānau involved (often over four generations), (ii) collation of narrative life stories of the people involved and (iii) a multi-chronology timeline of key events, agency practice and collaborative work. Analysis is aligned with understanding family violence response as a complex adaptive system.

The committee has started to speak with friends and family, but the families do not engage with the agency representatives present for each review. The committee acknowledges that this creates a non-reciprocal approach, and would like to fully embed the family in a "healing" review process.

Originally the FVDRC was expected to review each family violence death within six months of the death event. However, the judicial process can take over two years to complete, and the information collected through this process is considered of value, therefore the in-depth reviews are now only conducted after this process has been completed.

The Police Service of Northern Ireland (PSNI) sends a notification to the Senior Oversight Forum (SOF) when there is a (suspected) domestic homicide of a person aged 16 or older. If a death can reasonably be judged to fit the case selection criteria, the SOF commissions a DHR. The SOF is chaired by the Department of Justice and comprising representatives from the Police Service of Northern Ireland (PSNI), the Probation Board for Northern Ireland (PBNI) and the Health and Social Care Board (HSCB).

The Department of Justice appoints three Independent Chairs for a period of three years. Each review will be allocated to one of the Independent Chairs from the pool of three (on a rota basis).

The Independent Chair will request initial information from relevant agencies.
A panel will be formed by SOF and the Independent Chair. The members of the panel include statutory, as well as voluntary and community sectors organisations. They should be independent of line management of staff involved in the case.

During a DHR process relevant information is requested from a variety of sources, including commissioning of Internal Learning Review from statutory bodies, community and voluntary sector organisations. There will also be engagement with family and friends.
The information will be analysed by the panel and a DHR report will be written.

A DHR Secretariat provides administrative support to the DHR process.

When a victim is between 16 and 18 years old, the Independent Chair should engage with the Child Case Management Review (CMR) process to agree whether one process could be adopted (and one report published), to avoid duplication.

A decision on whether or not to commission a DHR will be taken as soon as practicable and within six weeks of a death.

The length of time completion of a DHR will take, depends on the specifics of the case and criminal proceedings. Expected time frames are: establishing a panel and undertaking internal learning reviews - 8 to 12 weeks; Analysing information and drafting report - 10-12 weeks; Finishing/submitting report - 4-6 weeks.

Completion of review (including publication or report) is expected within 26 to 39 weeks

Centralized review team, housed at the General Secretariat of the Ministry of Internal Affairs. The team is made up of a coordinator and a case analysis unit (Unidade de Análise e Estudos de Casos). The team coordinator is a magistrate of the Public Prosecutor's Office, appointed for three years. The analysis unit consists of permanent and non-permanent members. The permanent members include government representatives.

The team determines the methodology that is adopted to do a DHR, identify cases that are in their remit, obtain information on these cases, prepare a case dossier, and prepare a final report for each case that includes recommendations.
Information that is analysed includes court documents and health records. The team can request information from agencies that potentially had contact with victim or perpetrator, as well as statements from family and friends.

Per year a maximum of 10 cases will be reviewed (as more than 10 homicide can fit the case selection criteria, priority is given to cases where the victim is a minor and/or where a previous identical situations is known). When a case is selected for analysis, a member of the team will be made the case manager. The case manager is responsible for proposing the appointment of non-permanent and occasional members, arranging technical support, scheduling the team meeting to analyse the case, and prepare the final report

Decision to review a case taken within 10 days

Unclear if there is a timeline for the analysis phase, but the 2020 activity report presents findings of three cases all from 2018. The four case dossiers that were opened in 2020 were still pending analysis. This might be due to the fact that the review is done after criminal proceedings have finished.

The centralized review team meets at least once a month, and designs an action plan for each year.

Local review teams conduct in-depth reviews. In 2018 there were three active local review teams in Colorado.

Case information is compiled with the cooperation of respective law enforcement agencies and/or prosecutors' offices, as well as any other entities authorized to release information related to the case. The compiled cases are presented and discussed by members of the respective review team. The Denver team has 25 members, from a broad range of professional expertise and is coordinated by the Rose Andom Center, which researches and analyses the data and together with the review team develops recommendations.

The CDVFRB collects basic information on all domestic violence fatalities as well as more detailed data from the local reviews. The CDVFRB reports on this collated information and gives policy recommendations.

The board together with the Denver team establishes uniform methods for collecting, analysing and storing data

No information found on specific time-lines

In 2018 there were 37 incidents in Colorado, 11 were reviewed in-depth. The Denver Metro Domestic Violence Fatality Review Team annually reviews 6-10 DA fatality or near fatality incidents in-depth.

Delaware has one state-wide team (the Domestic Violence Coordinating Council's Fatal Incident Review Team (FIRT)). The team consists of core members (of government agencies and victim services), who can invite other people to the panel for each review.
The core team includes three members of the Domestic Violence Coordinating Council (who are co-chairs).

Each core member has a specific role, set out in a Policy and Procedures document.

The Attorney general gives approval to review a case. When a case is approved to be reviewed, each team member will receive a Cover Sheet, to fill in information about the case. Local agencies that had contact with the victim/perpetrator/family are identified and join the panel. Information will also be requested from them.
Once all information has been received a review meeting will be scheduled, led by one of the co-chairs.

Findings and recommendations are formulated by the panel and are only adopted upon a sixty percent (60%) vote of participating members of the review panel. The review team will issue an annual report to the Domestic Violence Coordinating Council summarizing aggregated findings and recommendations made over the year by each review panel. Case specific information is confidential.
In case of a near-death incident, the victim will be asked to participate in a victim interview.

When the victim is a minor, the case is reviewed jointly by the regional panel of the Child Death, Near Death and Stillborn Commission and the FIRT.

The review team will meet on a monthly basis, provided there are cases eligible for review.

Unclear how long it takes to gather all information. The policies and procedure document states that two week before the review meeting takes place all information should be sent to the coordinator.
If during the review meeting it becomes clear there is a lack of information, the panel members should gather the needed information and reschedule the review.
The interview with the victim in near death cases is held before the review meeting

Maryland has 18 county-based domestic violence fatality review teams. The members of a local team will come from a variety of organisations, backgrounds and areas of expertise. The Maryland Network Against Domestic Violence coordinates the teams and provide training and technical assistance.

Each local team creates their own protocols to govern their operations, using a model protocol as a guide (based on the legislation, best practices and experiences from teams around the state).

The teams must meet at least once a year to review county data on domestic homicides and near deaths and give recommendations to improve coordination and reduce deaths.

Some teams have a case screening selection committee, others receive cases from prosecutor or law enforcement or a team consensus selection process by the team itself. When a case will be reviewed, information is gathered from all agencies involved, and interviews can be conducted with family members, friends and/or the perpetrator. This information is reviewed and recommendations are made.

No information found

The teams consist of 16-18 members and are led by a facilitator. They include government and non-government representatives

Each team reviews two cases a year in-depth (an "inch side, mile deep" approach). Quantitative data is captured on all cases of domestic homicides to allow identification of trends.

In each case the teams review all available information, including law enforcement reports, criminal histories, medical and autopsy records, presentence investigations, newspaper stories and criminal justice records. They will also interview family, co-workers, school personnel, friends, shelter staff and all other relevant individuals to learn more about the victim and the perpetrator.

The team then travels to the community where the death occurred, reviewing the case with local partners and compiling a timeline of events leading up to the deaths. The timeline indicates involvement with agencies and services, as well as missed opportunities, things that worked well and gaps in services.

Unclear how much time is spent on information gathering.

Once in the local community, the team takes two days per case

Vermont has one commission comprised of 17 members, including Commissioners of several state departments, Attorney, Defender General, members of DA agencies, representative of law enforcement, victim-survivor of DA, physician and a judge.

(Quantitative) Data is gathered on all cases, but a selection will be reviewed in-depth.

The commission reviews data provided by the Medical Examiner and law enforcement records for all homicides to determine if they are domestic violence related. Of these, the Commission selects one or two cases to review in depth. The cases selected will be fatalities that are not under investigation or are post adjudication.

When a case will be reviewed, the commission will request information from relevant agencies. The commission will meets bi-monthly to discuss all DA related homicide, the in-depth review of one or two cases, trends and recommendations. Recommendations are reported annually and made based on common threads in the case reviews, although occasionally recommendations are based on a single case review

The commission meets 6 times a year.

The legislation states: upon written request of the Commission, a person who possesses information or records that are necessary and relevant to a domestic violence fatality review shall, as soon as practicable, provide the Commission with the information and records.

DHRs are implemented by regional multi-agency panels, convened in fifteen counties. Panels can also invite people on ad hoc basis, for a particular in-depth review. The local panels allow for people who are closely involved in the community response to DA to be actively involved.

The panels review a selection of all cases (between 1998-2010 84 cases were reviewed).

Data is collected on all domestic violence related homicide and suicide deaths in the state, using a standard from, and is combined with other state-wide data sources such as death certificates, court records, census data.

Research and data analysis include: the connection between domestic violence history and suicide; disproportionate rates of domestic violence homicide by race; domestic violence homicide victims' use of child support enforcement; and pregnancy rates among victims killed by intimate partners.

No information found

In Wales DHRs are, similar to England, implemented on a local level, either through a Community Safety Partnership or a Public Service Board (PSB).
The other two homicide reviews in Wales are commissioned either by regional Safeguarding Boards (the CPRs/APRs) or the Health Inspectorate Wales (the MHHRs). In some cases multiple reviews (e.g. both MHHR and DHR) will be carried out for the same case, which can lead to duplication of evidence gathering.

At the moment the process of initiating a review, reporting to the Home Office, setting up the panel and producing the report is similar to England. However, after reviewing the process, the Welsh Government is implementing changes. It has decided to join all types of reviews together under a Single Unified Safeguarding Review (SUSR).

Regional Safeguarding Boards will coordinate Regional Case Review Groups, which will consider all referrals for CPRs, APRs and DHRs. It will recommend whether a SUSR is necessary or an alternative service review can be carried out. New guidance to deliver reviews under a single system whilst delivering against devolved and non-devolved legislation is being prepared. A SUSR Coordination Hub will provide a secretariat, hold a list of approved chairs, and liaise with regional partnership boards on progress against recommendations and actions. Training will be offered to practitioners.

There is central repository (Wales Safeguarding Repository), established in 2021 at Cardiff University (including all past reviews as well).

See England

Under review (changing to Single Unified Safeguarding Review. SUSR have the aim to complete each review within 12 months, with as many meetings of the panel as necessary)

The Australian Review Network shares and collates findings of the different states/territories
It published their first Death Review Network Data Report in 2018 which provided national data with respect to all intimate partner homicides that occurred in a domestic violence context between 2010 and 2014.

The budget of the ANROWS and network's research project (2020-2022) was AUD $129,664 (about £76,000)

Coronial inquests will give recommendations relating to domestic violence systems improvement, which are published.
Since 2015 there is a Coronial Domestic Violence Information System (CDVIS) that incorporates over 120 different perpetrator and victim-specific variables. It is built to support evidence-based decision making in policies and programs to reduce violence against women and their children.

The nine Coronial inquests led to 43 recommendations.

Unclear how the recommendations are followed up

No information found

The annual report (to the government) of the Ombudsman includes a section on Family and Domestic Violence Fatality Reviews, providing statistics of the victims and perpetrators and circumstances of the homicides of that year. The report also provide a discussion of patterns and trend collating data from previous years. Recommendations following the reviews of that year are included.

The reviews led to the Ombudsman's major own motion investigation: "Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities". This was published in 2015, and tabled in Parliament.

The Ombudsman monitors recommendations. In their annual report, implementation of previous recommendations are highlighted (including those mentioned in the major own motion investigation)

The implementation of the recommendations discussed in their major own motion investigation (of 2015) were reported upon (to Parliament) in a second report published in 2016

No information found

The DVDRT reports to the NSW Parliament biennially, and includes recommendations derived from individual (tier 2 - or qualitative analysis) and groups (tier 1 - or quantitative analyses) of cases. The recommendations cover legislation, policies, practices and services.

Every biennial report is followed by a report from the NSW government responding to the recommendations
Both reports are made available on the website of the NSW Coroners Court.

Recommendations are expected to be implemented by government and non-government agencies.

The DVDRT undertakes public monitoring of its recommendations and the responses to these. Information of implementation is recorded in its reports and on its website.

No information found

Ad hoc reporting

In the 2010 report recommendations were made to specific ministers and government agencies.

In the 2016 report the panel put forward 3 (more general) recommendations that would be taken up/led by the Provincial Office of Domestic Violence.

The two current reports are published on the website of the BC Coroners Service.

Unclear whether there is a monitoring process/follow-up on the recommendations listed in the reports.

The 2010 report states: "The panel submits the following recommendations for review, consideration and distribution, as deemed appropriate by the chief coroner"

The Coroners Service organises Death Review Panels regularly, which are not just specific to domestic abuse (there was for example also one on illicit drug deaths and on heath mortality). On average the cost per Panel is CAD $2-3,000 to cover travel, meeting and printing costs (£1300-2000)

An interim report was published in 2017, and a final report published in 2018.
The report includes quantitative data on domestic homicides, a description of the review process and recommendations. No specific information on the in-depth reviewed cases were included.

In 2019 the ministry released a response which outlined the ongoing government-wide initiatives that address the 19 recommendations of the report .

One of the recommendations included in the report was that all domestic violence deaths should be reviewed using the methodology the pilot panel set up. The Panel also recommended that the review should be mandated through legislation or amendments to existing legislation. The government response did not address these recommendations.

No information found

Annual reporting, covering trends, risk factors, patterns identified through the reviews, and recommendations to prevent deaths in similar circumstances. Trends are mainly reported in a statistical overview. Short summaries of each case are included in the appendix of the report.

Recommendations are distributed to relevant organizations and agencies through the Chair of the DVDRC. If a case identifies issues/recommendations that have already been addressed by previous reviews, they might be recorded for information purposes only, or the report might list 'no new recommendations'.

All reports and recommendations are distributed electronically

The recommendations developed by the DVDRC are not legally binding and there is no obligation for agencies and organizations to implement or respond to them. However, organisations and agencies are asked to respond back to the Executive Lead of the DVDRC on the status of implementation of recommendations within six months of distribution.
Organizations are encouraged to "self-evaluate" the status of their response to the recommendations. The Office of the Chief Coroner does not challenge or question responses received.
Responses to recommendations are available to the public upon request

Within coroner's budget. Annual cost CAN $14-26K (£9-17K)

All relevant agencies produce a comprehensive individual management review (IMR) of their full involvement with the victim and alleged perpetrator. The lessons to be learned and proposals for addressing these are drawn out from the IMRs and are presented in an overview report, published for each case. The report also includes any risk factors for domestic violence and abuse that were identified during the review and recommendations for future action (presented in a SMART action plan).

The Home Office Quality Assurance Panel gives permission for the overview report (and executive summary of each review) to be published. When the quality assurance panel approves publication, the CSP publishes an anonymised overview report and executive summary on the CSPs website.

In terms of collecting the overall learning of all DHRs, there is an absence of a common data set, making comparison difficult. There is no routine analysis across DHRs, although the Home Office has published (ad-hoc) reports presenting key findings form analysis of DHRs across England and Wales.

The statutory guidance refers to the need to follow-up on the established action plans: "To derive value from the DHR process and prevent further abuse and homicide, CSPs should satisfy themselves that there are appropriate governance mechanisms in place for monitoring delivery against DHR action plans"

Research has pointed out, however, that there is very little known about implementation of the recommendations. In a review of the English system Rowlands (2020) point out that a particular challenge is that some local authority teams may no longer have a specialist DVA or VAWG lead officer, which might mean that CSPs do not have the right skills, expertise or time to follow-up on the recommendations.

Limited information found

Research by Boughton (2021) showed that CSPs can struggle with the financial investment of doing a DHR. Participants involved in DHRs reported that DHRs are an expensive resource and a single DHR can ran into thousands of pounds.

The committee reports regularly, with each report reflecting on the previous ones. Each report might therefore have a slightly different focus, with early reports focusing on how individual agencies or components of the system responded to cases and more recent reports reflecting on wider systemic processes or structures that work to reinforce violence experiences.

Each report provides recommendations to improve agencies responses and to improve the overall system. They are not directed to individual agencies but are seen as applying to all agencies.

The FVDRC reports on the implementation of past recommendations. This is done by requesting a detailed update on progress from the agency responsible for implementing the recommendation.

Reports reflect on key recommendations of previous reports and how work towards implementing the recommendations has progressed (or not).

In the latest report by the FVDRC, the committee acknowledged that little has changed for those experiencing violence in New Zealand.

No information found

For each DHR a report will be drafted by the Independent Chair. The Chair will also ensure the findings and suggested actions are translated into measurable change (in an Action Plan, attached to the report).
The draft report and action plan will be shared with the panel, who have 10 working days to consider it, after which a meeting takes place to formally sign off the report.
Reports completed by the independent chairs will be considered by the SOF (for quality assurance). When a report is signed off by SOF it will be made publicly available on the DHR website.

The SOF will also drive dissemination of the lessons identified. It commissions the pool of Independent Chairs to work together to produce a thematic report, at least once every two years, to collate information of all the DHRs within that period and reflect on what has been learned from the cases collectively. The thematic repot will be published on the DHR website.

The SOF is responsible of the implementation of actions and lessons learned. The Secretariat collates a regular action plan update, for SOF's consideration. SOF will hold a quarterly meeting to monitor progress against the various action plans for all completed DHRs. Each review will remain as a standing item on the agenda until all of the actions in its action plan have been implemented.

No information found

For each case that is reviewed a report is written. The report consists of the following parts: a) Composition of the Team; b) Summary of the case under analysis; c) Review of the information gathered; d) Description of the facts found; e) Analysis/discussion of the case; f) Conclusions; and g) Recommendations

The reports are published (anonymised) on the website of the review team. The report will also be send to any agencies involved in the case, or that are linked to any of the recommendations.

Each year the team will produce an annual (activity) report, noting all the recommendations that were included in the reports published that year.

The team interacts with relevant agencies to follow up on recommendations (unclear to what extent), and has also provided training.

The methodology used for the DHR is regularly evaluation (biennially), and the manual updated.

No information found

An annual report is written, and submitted to the Health and Human Services and Judiciary Committees of the Colorado Senate and the Public Health Care and Human Services and Judiciary Committees of Colorado House of Representatives.

The board will examine data collected by review teams and identify measures to help prevent domestic violence fatalities and near-death incidents.

Unclear whether there is a monitoring process for the recommendations listed in the reports.

A 2022 Bill introduced to the Colorado General Assembly reviews the DVFRB tasks and will require the board to pursue and implement any recommendations, with a focus on improving communication and information-sharing between agencies, as well as provide coordination and technical assistance and training.

No information found

Annual report, including aggregated findings and statistics, and recommendations.

The annual report includes responses to the recommendations of that year as well as follow up of recommendations from previous years

No information found

Each team prepares an annual report that compiles the recommendations. These reports are public and anonymised (findings are not ascribed to particular cases).

The state-wide team (MDADV) provides an annual report, the DV Homicide Prevention Report, which includes state-wide domestic homicide statistics, information on the review process and their activities (including providing technical support) to support review teams.

All team members will take back any recommendation to their individual organisation with a request for consideration and action. At a subsequent meeting team member may provide feedback from their agency and report on any actions taken. Follow-ups can also be included in the teams' annual reports
If the recommendation applies to laws, community practices, or entities other than those represented by the members, the team will create an action plan to effectuate the recommendations, often with the assistance and guidance of the MNADV.

No information found

Biannual reporting to the Law and Justice Interim Committee, the Attorney General, Governor, Chief Justice of the Montana Supreme Court and the people of Montana.
The Commission meetings and records are confidential, but state law requires it to publish a report detailing (general) findings and recommendations.

The teams monitor the progress of the recommendations that are identified.

The Montana teams are recognized as a model for fatality review in the USA. Representatives from other stated an tribal jurisdictions come to observe the review process.

Paid for by the Violence Against Women Act budget

Commission members volunteer their time

Commission proceedings and meetings are confidential by statute. The Commission reports its findings and recommendations annually to the Governor, the General Assembly, the Chief Justice of the Supreme Court and the Vermont Council on Domestic Violence.

Reports of the commission are publicly available on the Attorney General's website's Reports page

The 2018 report states that the Chair of the Commission and the Coordinator of the Vermont Council of Domestic Violence met monthly to work on implementing the past recommendations.
The annual reports also includes updates on recommendations and successes

No specifics found.

A grant was received in 2014 from the Office on Violence Against Women (federal government)

A biennial state-wide report is published by the WSCADV, as well as issue briefs and summaries of review recommendations.

There are statistics available of fatalities by county, aimed to be updated every 6 months.

The initial legislation called for a recommendation to be made in 2010 as to whether the process should continue. A recommendation was provided to continue the review, and to expand the work to include supporting communities to implement the recommendations made.

The WSCADV have a page on their website "how to use fatality reviews", which includes examples of how recommendations are used by agencies.

Unclear whether there is a systematic follow-up on recommendations

No information found

See England

A national safeguarding repository was established in 2021, and will hold the SUSRs and all previous DHRs, CPRs, APRs, MHHRs

The Minister for Violence against Women and Girls and Sexual Violence commissioned a review of the DHR process, to assess the effectiveness of CSP and other public services to respond to DHR recommendations. It resulted in a change to work with regional safeguarding boards on single unified safeguarding reviews.

A coordination hub will be established to liaise with partners on the progress against recommendations

Chairs are paid on average 10-15K