Contents Part executive Summary 8

International examples of death review processes

1. United States of America

The United States of America was the first country to establish a domestic violence death review mechanism, in the city of San Francisco.

The establishment of the review followed a high-profile murder-suicide which took place in the context of domestic and family violence.¹⁵⁹ In this case, the victim had reached out to numerous agencies in the months before her murder, having obtained restraining orders and custody orders and made official complaints to police.¹⁶⁰

Following the murder-suicide a coalition of service providers assisting victims of domestic and family violence requested the Commission on the Status of Women conduct an investigation into the murder. The Commission agreed, and established a subcommittee to examine the systemic, policy and procedural issues that related to the case.¹⁶¹

The report made several recommendations to various government agencies in order to prevent or reduce the likelihood of similar deaths occurring in future. The final recommendation of this report was for:

The creation of a review team to examine homicide cases related to domestic violence [which] will evaluate the system’s response to individual cases, submit reports and make further recommendations…on improving the system.¹⁶²

Since 1991, at least 82 death review mechanisms have been established across the United States.¹⁶³

There are several examples of Teams in the USA which currently analyse and report on suicides and near fatalities that occur within a domestic violence context. The jurisdictions that review near fatalities generally have lower numbers of domestic and family violence homicides. Reviewing a wider range of cases can provide more opportunities to identify themes and common characteristics.¹⁶⁴

2. Canada

The first death review mechanism in Canada was established in Ontario in 2002. This followed the release of findings for two inquests into domestic violence homicides. The recommendations from these inquests identified several areas in which policies, procedures and other systemic responses could be improved. One of these recommendations was for the establishment of a Domestic Violence Death Review Committee.¹⁶⁵

Since 2002, death review mechanisms have also been established in several Canadian provinces, including Alberta, Manitoba, New Brunswick and British Colombia.¹⁶⁶

3. New Zealand

New Zealand established the Family Violence Death Review Committee in 2008. The establishment of the Committee followed years of advocacy for the establishment of a domestic violence death review mechanism.¹⁶⁷ The Committee is a ministerial committee working under the Public Health and Disability Act (2000)(NZ).

The Committee first met in 2008 and released its first report in 2009. Four other annual reports have since followed.¹⁶⁸

4. United Kingdom

In 2011, the United Kingdom passed an amendment to the Domestic Violence, Crime and Victims Act (2004) (UK) to require domestic homicide reviews to be carried out after every death that takes place in the context of domestic violence in England and Wales.¹⁶⁹

Local government areas that are responsible for individual reviews submit reports to the Home Office. Since 2011, dozens of domestic homicide review reports have been submitted.¹⁷⁰

11. Positive outcomes of domestic violence death review

We are convinced that this work saves members of our community from early and tragic death.¹⁷¹

Domestic and Family Violence Death Review Teams have assisted law enforcement agencies, judicial and social service agencies and other public agencies to improve practices in Australia and internationally. One of the most tangible benefits of death review is its ability to identify a systems approach to protecting victims of domestic violence. It can make connections between organisations and see the larger picture.

In Victoria, findings and recommendations of the Death Review Team have helped to encourage collaboration and transparency among government and non-government organisations working in the area of domestic violence.

The Coroners Act requires agencies to respond to recommendations within three months of receiving them from the court, and responses are then published on the family violence investigations page of the court’s website. To date, the findings of 17 cases have been posted and responses for seven cases have been published. This process is an opportunity to monitor themes and patterns in family violence deaths, point out systemic gaps and consider the Coroner’s recommended solutions.¹⁷²

The international literature on the benefits of death review is extensive.

In the United States, for example, Hennepin County have made over twenty-five improvements to their justice system based on recommendations by the Domestic Violence Fatality Review Team. These improvements include increased consequences for perpetrators and greater support for victims.¹⁷³

Similarly, in 2006 the Macomb County Death Review Team in Michigan made a number of recommendations after looking at the operation of family and local criminal courts with respect to restraining orders. The Team was able to identify procedural problems and issues with jurisdictional overlap.¹⁷⁴ A number of their recommendations were subsequently adopted, which has led to a more streamlined, inclusive and cohesive approach to the way courts monitor restraining orders in the region.

The San Diego Death Review Team, identified access to firearms as one of the greatest risk factors for death. Of the thirty-seven domestic violence homicides in that period, twenty-two were committed with a firearm.¹⁷⁵ The Team made a number of recommendations that were supported by Senator Christine Kehoe, who introduced a Bill requiring perpetrators of domestic violence to surrender their firearms to police. By 2006, only eight of the twenty-five domestic violence homicides were committed using a firearm; a reduction of approximately 50 percent.¹⁷⁶

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