Contents Part executive Summary 8

Positive change as a result of death review

In its operation, death review has led to changes and improvements in practice.

For example, in South Australia there have been 35 recommendations specific to improving systemic responses to domestic and family violence. These have resulted in significant systemic reform including the state-wide expansion of regional multi-agency collaborations; the implementation of systems for intelligence sharing amongst Specialist Domestic Violence Services to enhance risk and safety assessments; improved policing responses and legal supports; and broader legislative changes.²²

Likewise, in Western Australia, the Ombudsman has reported that in relation to all 54 recommendations made in its report Investigation into issues associated with violence restraining orders and their relationship with family and domestic violence fatalities²³

…the relevant state government departments and authorities have either taken steps, or propose to take steps (or, in some cases, both) to give effect to the recommendations. In no instance has the office found that no steps have been taken, or are proposed to be taken, to give effect to the recommendations.²⁴

Death Review Teams have been shown to assist in interagency relations and cooperation, leading to a more cohesive approach to domestic violence. In Victoria, for example, findings and recommendations of the Death Review Team have identified opportunities for collaboration and increased transparency amongst government and non-government organisations.²⁵

Death review has been able to identify duplication of services and contradictory or conflicting service responses. It has also helped to promote mutual understanding and respect of organisations’ roles, constraints and limits.²⁶

9. Report Findings

	Findings
Part 1: The national picture	Domestic violence death review has proved valuable in informing governments and decision makers about patterns and trends of domestic and family violence deaths. Australia does not have Australia-wide data on domestic and family violence deaths because not all jurisdictions have Death Review Teams. Tasmania, the Australian Capital Territory and the Northern Territory do not yet have this function. Members of the Australian Domestic and Family Violence Death Review Network have agreed to provide training to new Teams collecting data for the National Minimum Dataset. The Network will need to be resourced to do this work as it will take them away from their jurisdictional responsibilities.
Part 2: Australia’s Human Rights Obligations	Australia has obligations under three human rights treaties to collect empirical data about domestic violence deaths and develop interventions based on this evidence. The International Covenant on Civil and Political Rights (ICCPR) describes the right to life as an inherent right that must be protected by law. ‘No one shall be arbitrarily deprived of life and there is a positive duty to prevent death’. Domestic violence deaths are not isolated events. One study has noted that violence is a leading cause of ill-health and death among women aged between 15 and 44 years in Victoria. Aboriginal and Torres Strait Islander women are five times more likely to be homicide victims. Australian children are also victims in domestic violence related homicides.
Part 3: Models of death review in Australian states and territories	There is no one-size-fits-all model for domestic and family violence death review. Death Review Teams vary in their structure, mandate, resources and history. Some of these differences reflect the history of the development of the Team or the size of the population and different caseload requirements.
Part 4: Guiding Principles for Domestic and Family Violence Death Review	The Australian Domestic Violence Death Review Network has developed a set of principles that underpin the effective functioning of the death review process. In order to create a consistent national approach, newly established Death Review Teams or functions should be guided by the same principles.
Part 5: National data Collection, monitoring and reporting	The Australian Domestic and Family Violence Death Review Network has developed a Homicide Consensus Statement which defines the inclusion criteria adopted by the Network for domestic and family violence homicide. The Network has also developed a preliminary data collection protocol for use by Network members. The goal of this data collection is to develop a staged standardised National dataset concerning domestic violence homicides.
Part 5: National data Collection, monitoring and reporting	Australia does not have a funded entity to collate and prepare reports about national trends in domestic and family violence deaths or report on recommendations made to Federal agencies and implementation action. Many Australian states have limited options for following up on Coronial recommendations to federal agencies. Most Coroners agree that there can be improvements to this system. There is no mechanism under statute at the federal level to require federal agencies to respond to coronial recommendations.