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

Annex 2: Case study examples

New Zealand

• The panel chair and lead coordinator read the review materials themselves rather than inviting agencies to submit reports, which facilitates independent analysis.
• Extensive engagement with stakeholders during the review process ensures that recommendations are practical and that agency buy-in is established.
• Each review provides both local and national recommendations.
• The emphasis within the reviews is to understand the wider system responses and facilitate improved understanding of family violence, in order to prompt transformational change.
• The New Zealand Family Violence Death Review Committee requests detailed updates on progress from the agencies responsible for implementing the recommendations, and reports on the responses.

Ontario

• Organisations and agencies are asked to respond to the Executive Lead of the Domestic Violence Death Review Committee on the status of implementation of recommendations within six months.
• However, these responses are ‘self-evaluated’ by the agencies and responses received are not questioned or challenged, though they are publicly accessible upon request.
• Recommendations given are not legally binding and there is no obligation for agencies to implement them.

Adult support and protection/child protection – Scotland

• Learning reviews provide CLEAR recommendations, and an action plan is drawn up to implement these strategies, identifying who will do what and within what timescale.
• Learning is disseminated at a local level through a variety of methods such as multi-agency reflective sessions, seminars, learning summaries and briefings.
• Learning is disseminated at a national level through the publication of annual overview reports by the Care Inspectorate, through regular meetings of the Learning Review Liaison Group, and through the online Learning Review Knowledge Hub, which allows members to share best practice and information.
• Reviews seek to conduct in-depth analysis and create a continuous ‘thread of learning’ throughout the process, where each meeting is an opportunity for reflection, hypothesis testing, and issue identification.

Single Unified Safeguarding Review (SUSR) – Wales

• SUSR is a single review process incorporating all learning reviews in Wales, to ensure a swift, standardised, and rigorous review process which eliminates the need for families to participate in multiple reviews.
• Relevant practitioners take part in a Learning Event, with a resulting report making recommendations and producing an action plan.
• The SUSR Co-ordination Hub is responsible for disseminating recommendations across Wales and ensuring recommendations and action plans are undertaken.