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

5. Conclusion

It is crucial to consider the lessons that can be learned from existing systems elsewhere in the development of the domestic homicide and suicide review model for Scotland so that the value and effectiveness of reviews are maximised from the beginning. Perhaps the most valuable lesson is the importance of considering the process as a long-term, continuous one, in which the review itself is only the first step towards change. This focus on what happens after the review is not only about ensuring monitoring and oversight mechanisms are in place to track and enable the implementation of recommendations, but also about embedding the goal of creating change and improvements into the very purpose and process of conducting the learning review.

The entire model must be designed and constructed in a way that orientates it towards facilitating learning and prompting system improvement. While it may be inevitable for issues and barriers to arise in such a complex process of multi-agency dialogue and effort, the model should be developed in such a way that recognises these risks and provides mitigations and opportunities. The design of the model must conceptualise the review as a holistic process, where its every element should come together to work towards its key purpose of service improvement and system change.