Frequently Asked Questions

Domestic violence fatality review refers to the “deliberative process for identification of deaths, both homicide and suicide, caused by domestic violence, for examination of the systemic interventions into known incidents of domestic violence occurring in the family of the deceased prior to the death, for consideration of altered systemic response to avert future domestic violence deaths, or for development of recommendations for coordinated community prevention and intervention initiatives to eradicate domestic violence.” This deliberative process can be formal or informal, relatively superficial, offering basic demographic details of victims and perpetrators, or very detailed (Barbara Hart).

Some skeptics have suggested it is better to channel scarce resources into direct services for victims of domestic violence than to scrutinize the relatively small proportion of cases where victims die. We have a lot of sympathy with this perspective. It is indeed the case that fatality review is not a process that every community will want to embark on. Some communities will want to use their funds for direct service for battered women. Others will conduct safety and accountability audits. Neither is it possible to prove in any scientific manner that fatality reviews reduce the amount of domestic violence or the number of domestic violence related homicides. In defense of fatality reviews, it does appear that domestic homicide attracts widespread attention and can serve as a vehicle for improving service delivery. It is also a highly focused mechanism for bringing diverse agencies to the table to discuss major social problems.

The media is a powerful tool and teams have been both helped and hindered by media coverage of team reviews.

The media can help in significant ways such as:

• Sharing investigative information and thoughts with the team. Reporters usually are among the first to gather facts, talk to witnesses and synthesize information following a death. If they are willing to share their thoughts and research, this can be helpful to a team. Even without personal appearances or interactions with a team, news reports often provide a great deal of foundational information for teams.
• Publicizing the work products of the team. Very often, teams recommend greater awareness and deeper public understanding domestic violence, as well as system reforms and additional resources for domestic violence agencies. The media is key to getting the word out and thus promoting needed social change.

However, the media can be problematic in other ways, such as:

• Revealing private or hurtful information about a victim’s life or family.
• Reporting on fatalities in ways that perpetuate myths and stereotypes about domestic violence such as calling a homicide the result of “unrequited love” and engaging in victim-blaming.
• Intimidating team members in ways that undermine the “no blame no shame” philosophy. Teams do not invite the media into reviews for a number of reasons, including the well-founded fear that the media unfairly will target individuals or agencies. Members may find that the presence of a member of the media inhibits them. Media representatives are occasionally invited after teams conduct initial reviews and when they formulate or announce policy recommendations.

It is important to reassure the media that confidential fatality reviews will, in the long run, improve our understanding of domestic violence homicides, and system accountability.

There are formal and informal products of fatality review.

Among the informal products are:

• Better educated and trained team members as the team review is an intensive and in-depth learning process. Very often, team members incorporate what they have learned into improving their daily jobs as well as improving training programs.
• Team member awareness about others’ jobs expands; team members begin to appreciate the duties and responsibilities of other system and agency players and this can help improve communication between them outside of the review.
• Greater collaboration on other projects like grant applications, policy initiatives or advocacy for resources.

Among the formal products are:

• Annual reports. An annual or regularly produced report gives coherence to the work of a fatality review team. Team reports often make formal findings and offer recommendations for action such as public awareness and prevention campaigns, and can focus attention on needed system reforms or on particular topics such as suicide, teens, marginalized women, or firearms. (See Washington State)
• Data and other aggregate information. The team can also produce aggregate data based on information gathered from a number of reviews or teams. Such information can be valuable for supporting policy changes, raising awareness and helping policy makers to allocate resources more responsibly. (See Florida.)
• Legislation and other reform. Team reviews can highlight the need for legislative reforms in a particular area.
• Press events and public awareness campaigns. The release of an annual report that contains aggregate information or policy recommendations can rivet public attention and motivate reforms.

While it is obviously too early to determine with any certainty what the effects these death review teams are having, early anecdotal information suggests that the process has revitalized coordinated community responses and provided a new focus for interagency liaison work and communication. This appears to be of vital community importance.

Some examples illustrate the kinds of changing taking place as a result of fatality review work:

• The West Palm Beach Domestic Violence Fatality Review Team feels that the fatality review process has already had an impact on their community and how it responds to domestic violence. Team members are now working internally with their agencies to change policies and procedures.
• In Orange County (Orlando), the process of reviewing domestic homicides brought new people to the table and really helped open lines of communication between people and agencies.
• The Pinellas County Domestic Violence Fatality Review Team feels that the process of fatality review has already had an impact in their community. New collaborations have been formed, especially with people and agencies not traditionally involved or at the table. For example, before the formation of the fatality review team, the Felony Division of the State Attorney’s Office was not very active on the issue of domestic violence. Since becoming members of the fatality review team, new collaborations have been formed and new lines of communication have been opened. In addition, Pinellas County’s coordinated community response has improved. The process of fatality review has been an educational process for members who are not typically exposed to the issue of domestic violence.
• In Washington State, reviewers noted the dangers posed by suicidal abusers and recommended “officers should routinely ask victims about the abuser’s history of making homicidal or suicidal threats.” If such threats have been made officers should “urge the victim to call a domestic violence program for help with safety planning.” The report also recommends expanding the sections of the Washington Association of Sheriffs and Police Chiefs Model Operating Procedures on “screening for suicide and responding to suicidal abusers.”

A number of statewide reviews recognize the urgent need for translation services in cases of domestic violence involving victims and perpetrators whose first language is not English. The Washington State report recommends that “Institutions such as law enforcement, hospitals, domestic violence programs, and Temporary Aid to Needy Families (TANF) offices should create collaborative relationships with grassroots organizations based in limited English-speaking communities.” The report continues, “consistent with our state law, law enforcement agencies should conduct investigations of domestic violence crimes with qualified interpreters.” In one domestic homicide case in Washington State, “a law enforcement officer asked a six-year-old child to translate for the family member on the scene who had discovered the bodies of the two victims.” In another case, “a hostage situation went for at least an hour, and because no translator was present, the young hostage had to provide translation while the murderer held a gun to her head.” In addition to the potentially traumatizing effects on on-scene unprofessional translators, the use of imprecise translators may also impede the subsequent case investigation in both domestic homicides and non-lethal domestics.

Yes. Cookie cutter approaches to reviewing domestic violence homicides may be convenient, quick, and produce aggregate data that can be relevant to effecting social change. However, many fatality review teams have tried to craft reviews that are local, democratic, operate at the level of grassroots community activity, and that access the subjective experiences of the parties involved. Such reviews involve much more than merely completing a survey or questionnaire. Meticulous, highly nuanced case reviews comprise exercises in local democracy and as such can be invaluable. Members should consider an array of options used by other jurisdictions when piecing together the elements of their team processes.

The federal government, some individual states, and many individual jurisdictions have begun to explore the reasons for domestic violence-related deaths in a systematic manner. Approximately 45 states have at least some form of domestic violence fatality review. In some regions these reviews dovetail with or naturally build upon existing coordinated community responses to domestic violence. The highly detailed examination of the relationships between service delivery systems in a fatality review also has much in common with the approach used by safety and accountability audits, otherwise known as safety assessments or institutional analyses. Put differently, fatality reviews increasingly form part of an expanding array of multi-agency, interdisciplinary strategies for confronting domestic violence. Moreover, fatality reviews and safety audits can be combined, with the latter intervention offering a powerful tool for implementing the recommendations created by the former.

Underpinning each of these strategies is a concern with the experiences of women and other family members, a desire to improve the accountability of individual agencies and enhance interagency and system coordination. In fatality reviews, such processes, if conducted thoughtfully, are likely to yield much deeper and more detailed understandings of domestic homicide.

Working with family members or friends who have lost loved ones to domestic homicide requires considerable sensitivity. It is important for teams to determine at the outset, what their position will be regarding interviewing victim or perpetrator contacts. In the course of our work we have met family members and friends who did not want to discuss the homicide. We have also met people who are traumatized by the insensitivity of service professionals who initially notified them of the death of their loved one, or who subsequently became involved in the prosecution of the perpetrator.

Most fatality review legislation does not permit fatality review teams to share information with family members or anyone else concerning the homicide, unless that information is part of the public record. If family members or friends approach review teams and state a willingness to provide information to the team, it is important for the team to spell out the limitations regarding what they can share about the case. It is important for survivors to feel they have access to the review team; at the same time it is important for the review team to adhere to its statutory duties regarding the disclosure of information.

It might also be wise for a trained counselor who works on the team or a team member who had previously established a relationship with the family to assume the responsibility of being the “point person” to work with the family and others who were close to the deceased. This counselor might wish to inform them that digging more deeply into the death of their loved one, even by using available public record data, might uncover information or accusations about the decedent that the family members were not aware of prior to the death.

Finally, remember that there are persons close to the perpetrator who may also wish to participate and from whom the team may wish to request information. Once more, it is imperative that teams consider all options regarding interviewing persons close to either the victim or perpetrator before beginning the review process. The NDVFRI can provide helpful resources to assist teams in making this determination and establishing protocols for communicating with persons who were close to a decedent.

Reviewing the life and deaths of other human beings can be a disturbing and emotionally taxing process. People react differently to the details that surface during death reviews and it is important for teams to anticipate this. Teams should establish a process of “taking care” of each other and discuss the impact fatality reviews are likely to have on them emotionally. For instance, some reviewers are openly disturbed by evidence such as crime scene photographs. As such, members should be allowed to opt out of this portion of a review or teams should decide whether the emotional impact of viewing photographs outweighs factual value.

To date, most teams are resourced by volunteer efforts and many have done exemplary work without funding. Team members incorporate death review work into their regular and very busy work schedules. Some teams have sought and received funding. For example, one team in Florida receives funding from the county for a line item in the municipal budget to fund two persons to engage in death review work and at least one team has received funding from the state’s STOP grant program. Similarly, the Washington State death review team also received state STOP Grant funding.

There are also a variety of funding opportunities through the various federal agencies that offer assistance to multi-agency teams working to prevent to domestic violence. These agencies include the Violence Against Women Office (including the STOP Grant Program and the Grants to Encourage Arrest Grant Program). The State Justice Institute has also funded state fatality review development in New Hampshire.

When teams are formed as subcommittees to existing state or local domestic violence task forces, funding and resource support (such as administrative staff to set meetings, take minutes, prepare reports and monitor recommendations) can come from those umbrella efforts to support fatality reviews. It is also wise for teams to solicit the presence of local business people on their teams. Not only is domestic violence and domestic homicide an important workplace issue; these individuals may be able to offer support or sponsorship to assist with supplies, telephone costs, and other administrative expenses.

Although a number of states have confidentiality legislation that protects the deliberations of domestic violence fatality review teams, it is a good idea to sign confidentiality documents at the start of each review. In this way, each participant understands his/her responsibilities. Each team should develop its own set of protocols about how to conduct reviews. New teams need not reinvent the wheel here; we can provide lists of working teams, many of whom will be happy to share their existing protocols. Otherwise new teams can visit the NDVFRI website to see sample protocols. Note that while it is helpful to see and draw upon the work of established teams it is important to go through the process of formulating protocols as part of team building.

Alana Bowman has identified a number of possible steps involved in creating review teams (Bowman, Alana. 1997. “Establishing Domestic Violence Review Teams.” Domestic Violence Report, August/September 1997, pp. 83, 93-94.)

We paraphrase the following:

• Decide upon an agency to house the project, send out notices, gather information, and generate reports.
• Identify key agencies and their possible representatives and alternates.
• Require everyone involved to sign confidentiality agreements, both individually and on behalf of their agencies.
• Define goals, purposes, and philosophies of the team.
• Develop procedures and protocols for what the team will review, including the scope of review and types of cases that will be reviewed. For instance, only closed cases, murder-suicides, or all cases within one year.
• Select cases to review.
• Have team members conduct reviews of their own agency involvement in a case and contribute this information when team review convenes. The team can then synthesize respective contributions into an overall review.
• Create a timeline of events leading up to the tragedy, identify possible red flags, determine agency involvement and the degree of coordination and collaboration, create rational recommendations to implement in the near future.
• Summarize review.
• Decide upon dissemination of review findings.
• Develop aggregate data from many reviews and decide upon public dissemination and formatting.

As a primary order of business, teams first need to develop protocols regarding the above points before conducting the first review. Teams also can do practice reviews using hypothetical situations. (Contact the NDVFRI for training tools and hypotheticals.)

Existing teams examine intimate partner homicides, for the most part, although many more deaths are linked with and traceable to domestic violence. Teams have paid less attention to sexual competitor killings, women’s suicides, family homicides, or mercy killings, but these types of case reviews are also important. Teams that form in areas with few or no intimate partner homicides might consider exploring cases such as women’s suicides. Here they might begin by exploring whether the person who killed herself had injuries consistent with prior domestic violence, or whether police had ever visited her home on a domestic disturbance call, or whether she ever was the recipient of a domestic violence injunction or restraining order. They might also examine perpetrator suicides.

Intimate partner homicide usually involves a man killing his female partner, often after a long and escalating pattern of woman battering. When women kill male partners, they typically do so in self-defense, although such defense may not qualify as such in a court of law. However, deaths attributable to domestic violence far transcend intimate partner killings. Non intimate partner family members also kill each other in so called “family homicides.” Fathers kill children, mothers kill children, children kill their parents, brothers kill sisters, and so on. Men sometimes kill other men over a woman they sexually compete for. These “sexual competitor killings” are much smaller in number than either intimate partner or family homicides.

Many more Americans die from suicide than homicide. Most of these suicides involve male victims, some of whom kill their female intimate partners before taking their own lives. Research suggests that a significant number of the 6,000 or so women who commit suicide each year do so because of their violent victimization at the hands of an intimate male partner. Stark and Flitcraft note specifically, “in most cases we believe battered women are provoked to attempt suicide by the extent of control exercised over their lives.” According to these authors the proximity between woman battering and women’s suicide attempts in general, strongly suggests that battering may be one of the principal causes of the suicide attempts. Stark and Flitcraft point out that a number of studies identify abuse as a factor in as many as 44 percent of female suicide attempts. For these researchers it is very telling that over a third of the battered women in their sample, “visited the hospital with an abuse-related injury or complaint on the same day as their suicide attempt.”

As the proportion of the elderly in the U.S. in the population increases, researchers have become increasingly aware of domestic violence among their ranks. Old stereotypes die hard, and social service providers and law enforcement agencies sometimes assume that because people are elderly they are not capable of committing or being victimized by domestic violence. This attitude sometimes translates into an assumption that homicide-suicides among the elderly usually take the form of “mercy killings.” Police officers or others who investigate the homicide-suicide and find a note telling authorities that the couple could not live on with ailing health might hastily label the death a “mercy killing.” Upon further investigation we find it is nearly always men who commit these killings and that in a significant number of cases their female victims had expressed to other family members a desire to live not die. Indeed, Donna Cohen found that homicide-suicides involving elderly women in West Central Florida accounted for 20 percent of the total homicides of people aged over fifty-five. Cohen also notes that while 50 percent of the women’s health had deteriorated, two-thirds had expressed “no desire to die.” Evidence that women killed in so-called mercy killings or suicide pacts had previously expressed “no desire to die” may suggest they were being battered before their demise.

Deaths traceable to domestic violence and therefore subject to fatality review, increase considerably if we include women who die as prostitutes, HIV victims, or from causes related to homelessness. For example, one might argue that because battered women appear more vulnerable to HIV infections than non-battered women, some deaths of women attributed to HIV or some complication thereof, might be traceable to the women’s compromised status as battered. The same could be said of homeless women dying on the streets since roughly half of homeless women report “fleeing abuse” as the reason for their homelessness. Likewise, prostitutes have experienced enormous amounts of interpersonal abuse at the hands of male intimates, family members, and their clients.

* Stark, Evan and Anne Flitcraft. 1995. Killing the Beast Within: Woman Battering and Female Suicidality. International Journal of Health Services, 25, 1: 43-64.

• Police department homicide logs.
  Examine for overall estimate of domestic violence homicides in a jurisdiction.
  Check classification/coding of cases.
  This is a good important starting point.
• Newspaper reports.
• Crime scene investigations.
• Detective’s follow-up investigative reports.
• Details of any prior protective orders, temporary, and permanent.
• Notice of service of protective orders.
• Affidavits requesting issuance of protection orders.
• Civil court data regarding divorce, termination of parental rights, child custody battles, or child visitation.
• Any criminal histories of the perpetrators and victim.
• Child protective agency summary data and prior abuse histories.
• Summaries of psychological evaluations/reports appearing in public record documents such as police files.
• Medical examiners report.
• Autopsy report.
• Workplace information, perhaps regarding harassment, abuse, alerts among Medical data, hospital emergency room data.
• Shelter/outreach data from advocates for battered women, if appropriate and legally permissible.
• School data regarding children reporting abuse in the home.
• Statements from neighbors, friends, witnesses, and so on. May be contained in police files as transcribed material, or in court documents/transcripts from trials.
• Pre-sentence investigation report (probation).
• Parole information including notification of victims.
• State statutes on domestic violence.
• Information regarding weapons confiscation, purchase, background checks.
• Drug and alcohol treatment data.

The simple answer to this question is, resources permitting, as many cases as the team feels it is able to review in order to better understand, intervene in, and prevent domestic violence and domestic homicide.

Cases for review can include:

• Closed cases (perpetrator has been convicted, most or all appeals have expired)
• Open cases (case is pending)
• Child deaths
• Familicide (where entire family is murdered)
• Near deaths
• Murder-suicide (a type of closed case, where the perpetrator is dead)
• Suicide
• All deaths of women between certain ages
• High-profile or cases deemed significant by community

The Philadelphia Death Review Team reviews hundreds of women’s deaths per year, taking perhaps 30 minutes per review. The idea in Philadelphia is to identify as many cases as possible where women died as a direct or indirect result of domestic violence. Conversely, reviews like the Charan Investigation (a homicide-suicide case in San Francisco in 1990) seek to identify system failures through an extremely detailed analysis of one case. Some jurisdictions review a large number of cases in summary fashion, others delve into individual cases in great depth. Both approaches have the potential to improve the delivery of multiple services to victims of domestic violence.

Confidentiality and Fatality Review
Robin H. Thompson, Esq.
Consultant, NDVFRI

How effective can a fatality review be if some of the information is confidential and the team cannot have complete access to it? When does the team cross the line into discovering or discussing information that is private and should be kept out of the public eye? What impact will the disclosure of information to a fatality review team have on a domestic violence victim’s desire to access a shelter, to call law enforcement or to hire a lawyer?

Laws regarding an individual’s right to privacy and the public’s right to know attempt to balance these interests. Often positioned between these two interests is the work of the domestic violence fatality review team. When teams meet, they process all levels of information, some public, some private and some in between. It is essential that the fatality review teams respect both the privacy of the persons whose lives, and deaths, it studies…

Teams operate in a variety of ways, depending on available resources, participation, legal or legislative direction and local preferences. For example, some Florida teams (e.g. Miami) have a two-tiered organization structure. The actual review team contains those agency players who bring information to the table in order to discuss domestic violence related deaths. Usually one or two of the members of these review bodies assume responsibility for leading the team, coordinating meetings, and a variety of other duties. These chairs / co-chairs are usually actively involved in domestic violence cases and are well placed to orchestrate the activities of a wide range of professionals. Rotating leadership is desirable in order to avoid burnout, inject new ideas into team deliberations, and insure that as many reviewers as possible learn about chairing team activities. Other teams (New Hampshire’s statewide team) has a single tier for review, and a small group that carries out administrative and organizational tasks. Washington State’s review teams are both regional and statewide. The regional teams meet and provide information to the statewide team, which reviews regional findings and produces a statewide report.

Teams are also located in a variety of ways, all of which impact their mode of operation. Some are domestic violence coalition or advocate based (Washington state, Denver, CO, Berks County, PA). Some are located as a subcommittee of an existing domestic violence coordinating effort (Palm Beach County, FL, Santa Clara County, CA, New Hampshire). Still others are system-based and are an adjunct to a governmental office (Philadelphia, PA).

Many domestic violence fatality review teams have tried to adhere to a “no-blame and shame” ethos. Given it is often the batterer or his violent behavior that causes the death in question, philosophies that point the finger at agencies, or seek to blame and shame individual agency personnel are counterproductive. Such a blaming approach, often referred to as “tombstone technology” in fields such as aviation and nuclear power, might encourage the covering up of information in cases of death. It is also the case that men who batter women blame their victims for much that is negative in their lives. Using reviews to blame others merely perpetuates that negative and destructive style of thinking and contributes little to healing.

Although the perpetrator of domestic homicide bears the ultimate responsibility for the killing, many agencies that work with victims of domestic violence might have become more involved, perhaps saving a life. The failure to prevent deaths through inaction, negligence, malfeasance, corruption, the inability to better coordinate service delivery, and so on, is common in many walks of life where the safety and security of the public are at stake. It is essential that review teams gather information to make informed decisions about how to introduce changes to prevent domestic violence. In other words, the review team works with a philosophy of kindness and concern, a philosophy that respects the rights of surviving family members, but with a philosophy that recognizes that better agency coordination can save lives. The “no blame and shame” philosophy does not remove the need for agency accountability.

Usually adult fatality review teams are inclusive rather than exclusive, often being open to incorporating new members and agencies.

Anyone remotely involved with or affected by a domestic violence fatality might serve on a team. Two observations are helpful: teams ought be inclusive rather than exclusive, creatively constituted with an eye on learning more about how the deaths might have been prevented. Also, teams might consider having a core group or executive committee work on administrative and process issues, as well as a larger group.

Finally, membership can be local or statewide, depending on the jurisdiction where the team is being established. Here are some membership suggestions:

• Attorney general
• Prosecution
• Law enforcement
• Public Health
• Medical examiner/coroner
• Emergency medical department representative
• Nurse
• Mental health service provider (psychiatrist, psychologist, counselor)
• Social worker
• Victim advocate
• Judiciary/court personnel
• Animal control
• Public defender/defense
• Legal aid
• A surviving family member
• Representative from employers/business community
• Education/Schools/Universities
• Child protective services
• Probation and parole
• Batterer intervention program
• Public at large
• Housing authorities
• Substance abuse treatment specialist
• Faith community representative
• Researcher/evaluator

Some states legislate membership.

For example, according to the Florida fatality review legislation (Section 741.316, Florida Statutes), “local domestic violence fatality review team” should include representatives the following offices, agencies and organizations:

• Local law enforcement
• State attorney
• Medical examiner
• Certified domestic violence center
• Child protection
• Office of court administration
• Clerk’s office
• Victim services programs
• Citizens at large
• Other representatives as determined by the local community

Domestic violence fatality review provides a systematic way of reviewing domestic homicides through a lens of prevention and accountability.

While it is important that each review team determine their specific purpose for conducting reviews, most review teams share the following underlying objectives:

• Prevent future domestic violence and domestic homicide.
• Provide safer provisions for battered women and their children.
• Hold accountable both the perpetrators of domestic violence and the multiple agencies and organizations that come into contact with the parties.

Fatality review can also enhance a community’s coordinated response. Fatality Review provides an opportunity for a diverse, multi-disciplinary group of professionals and community members to meet on a regular basis and discuss issues of system response and social change. Many teams have reported that the relationships developed as a result of fatality review have been invaluable and have enhanced coordination among individuals, agencies, and the community as a whole.