Domestic homicide reviews: identifying best practice in learning lessons and implementing change

4. Further areas to consider

4.1 Publication of reports

There was a lack of consensus in the Scottish Government’s targeted engagement consultation on what the process for the publication of reports should be, with mixed views on whether a full anonymised report should be publicly available, whether only an anonymised report summary should be publicly available, or whether the report should only be available on request for legitimate purposes (Kurdi, 2023). There is an argument that the publication of reports is essential for effective dissemination of learning, both in terms of clearly communicating the complete analysis and rationale of the review and its recommendations, and of creating public awareness and capacity for accountability. However, there are ethical considerations to be taken into account. While anonymisation and the use of pseudonyms is common in reports, in practice this can be ineffective due to case details being reported in the media, often making it easy to cross-reference and identify those involved (Jones et al., 2022; Cook et al., 2023; Rowlands, 2023). Considering this, there are concerns around the publication of personal and intimate details about individuals’ lives and the circumstances surrounding their death. Additionally, there may be safety risks to living subjects of the review such as family members, particularly in cases where the perpetrator was not charged (such as in death by suicide cases) (Cooks et al., 2023).

These ethical risks and considerations of confidentiality for all involved must be balanced with the goal of sharing and disseminating key learning and promoting public awareness. It has been recommended for Ireland, for example, that due to the difficulty in anonymisation (particularly for a small population), individual reports should not be published, but rather only the necessary changes identified and the actions being taken should be publicised (Department of Justice (Ireland), 2023).

4.2 Alignment of recommendations and learning with other review processes

Something to consider as the detail of the model develops is how it will align with other review processes that may also apply to the case being investigated. The domestic homicide and suicide review process will be introduced into an existing landscape of learning reviews, and the aim should be to complement these existing processes and provide an opportunity for comprehensive learning. This will need to be managed such that it does not place additional burdens on those participating in and/or managing reviews, and that it does not duplicate or obfuscate learning. The Single Unified Safeguarding Review model introduced in Wales aims to unify all learning review processes to avoid burdening families with having to participate in multiple reviews, and has a centralised co-ordination hub to oversee reviews and collate learning (Welsh Government, 2023).

4.3 Taking a gendered and intersectional approach

It should be further considered how developing the model with a gendered and intersectional approach could contribute to greater learning, and increase the capacity of the review to take an effective systems-based approach to understanding what fundamental changes are needed in the way that domestic abuse is tackled. A feminist grounding would seek to recognise domestic homicide as part of a continuum of male violence, and therefore assess cases through this lens, advancing an understanding of the complex and structural gendered dynamics that have contributed to the death (Sheehy, 2017). Additionally, a gendered lens would seek to prioritise women’s voices and experiences in seeking responses from services when evaluating whether improvements have been made (Sheehy, 2017). It is important to draw upon these feminist understandings of domestic abuse and utilise them to improve responses to the issue, without relying on this lens exclusively (recognising that there may be cases of male victims also), and looking across a wider body of theories that may be additionally helpful to gain further important perspectives on this area and ensure the model is informed by the most recent and robust evidence available.

In particular, there has been emphasis placed on the importance of reviews taking an intersectional lens, in order to establish a comprehensive understanding of how intersecting factors (such as race, immigration status, and socioeconomic status) may contribute to domestic homicide and suicide cases. Any learning gained from a review which does not consider the influence of these factors will inevitably be limited, as it will not include a consideration of how these structural dynamics may have affected the circumstances of the case and/or the responses from services. It is therefore important to consider, in the development of the model, how this intersectional lens may be integrated into the process, such as ensuring that review panels include expert voices that are able to speak to particular experiences and backgrounds (Dawson, 2021; Centre for Women’s Justice and Imkaan, 2023).

When cultural experts are integrated into the review panel, they can interpret and provide insights on important dynamics of a case that may otherwise be missed, therefore improving the learning gained and identifying key opportunities for service change (Centre for Women’s Justice and Imkaan, 2023). Experts can facilitate and contribute to open discussions about specific issues such as honour-based killings, and can assist the chair and other panel members in discussions with community members and cultural or religious institutions (Centre for Women’s Justice and Imkaan, 2023). It is important that appropriate organisations and representatives are identified to carry out these roles on the review team, and that they have the necessary specialist knowledge of domestic abuse as well as of the intersectional dynamics they are contributing their expertise on (Centre for Women’s Justice and Imkaan, 2023).

4.4 Involvement of family and friends in learning and evaluation

The extent to which family and friends will be able to give their input to reports and recommendations should be considered further. Guidance for domestic homicide reviews in England and Wales advocates for family involvement in the process, including the ability to review reports prior to publication and record any areas of disagreement (Home Office, 2016). It is unclear, however, whether and how families are given the opportunity to follow up on recommendations, and to be involved in the process of evaluating the effectiveness of changes (Rowlands and Cook, 2022). Where there is to be regular reflection opportunities on the impacts of reviews and the learning gained over time, the inclusion of families’ voices alongside professional views should be considered. The Advocacy After Fatal Domestic Abuse conference is an example of facilitating connections between bereaved families, practitioners, and government representatives, to share progress made and create opportunities for further reflection and development (Advocacy After Fatal Domestic Abuse, 2022).

The inclusion of families would broaden the opportunity for evaluation and learning, and provide additional valuable perspectives when considering the effectiveness and impacts of review approaches and recommendations. This would need to be carried out in a trauma informed way which recognised the importance of giving families space to move on from the death, and appreciating that if they have already participated in the review itself, that being asked for further input on evaluation may be over-burdening. It would be important, therefore, to prioritise their agency in choosing or declining to offer further input, and offering appropriate support to guide their understanding and facilitate any contributions they may wish to make.