Domestic Violence Fatality Reviews: What They Do, and How to Improve Them

Each year, approximately 1,500 women are killed by their current or former intimate partners. That number is staggering – but it is only the lower limit of the number of fatalities domestic violence creates every year. Some victims kill themselves rather than having to endure ongoing abuse, while others kill their abusers. Abusers commit murder-suicides at an alarming rate. And still more victims die as a product of homelessness or other consequences of the violence. It is truly sobering to realize the immense toll that domestic violence takes each year in sheer human lives, on top of the pain and suffering it causes to its victims.

There’s no way to put a positive spin on these tragedies, but there are ways to make sure that domestic violence-related deaths do not occur in a vacuum. Ultimately, every domestic violence-related fatality is preventable at some step; sometimes police should have arrested the murderer on a previous DV call, sometimes advocates should have tried harder to get the victim to stay in counseling, sometimes one part of the court system was unaware of a piece of information that had come out in another courtroom. Consequently, each fatality provides a learning opportunity for organizations in the field – by recognizing what went wrong and what didn’t work, experts can try to stop future deaths from occurring. This is where the “domestic violence fatality review” comes in.

The Big Picture

The basic concept behind a DV fatality review is extraordinarily simple. Domestic violence is a complex problem, and preventing it requires the efforts of many different actors: law enforcement officials; the court system; victim advocates; health care service providers. Too often, these actors and agencies do not work in concert with one another – instead, they consciously or unconsciously undermine the efforts of other organizations or let victims ‘slip through the cracks’ between agencies. While each organization should want to conduct internal scrutiny of its own practices when a fatality occurs, internal reviews alone will never account for inter-agency gaps or failures in communication.

In addition to investigating agencies’ interactions, fatality reviews create valuable opportunities for participating organizations to benefit from one another’s expertise. Domestic violence advocates will typically have more nuanced interpretations of the reasons an abuser was still able to access his victim after she left, for example, while police officers will have firsthand experience attempting to assess the immediate danger an abuser poses. The specific knowledge experts can bring to the table helps everyone develop more effective policies, and having a fresh set of eyes evaluating agency responses and policies can help identify points of improvement as well.

Some may be confused by the single focus on DV fatalities, as opposed to preventing domestic violence as a whole. Many jurisdictions do have domestic violence prevention committees, where representatives from relevant agencies meet to discuss general strategies toward combating the issue. But fatality review has the benefit – loosely speaking, of course – of focusing on some of the worst cases of domestic violence, and cases in which the system spectacularly failed those it was meant to help. By probing these cases in-depth, it is possible to identify factors which, if changed, would also help victims of less severe violence.

What Fatality Reviews Do

There are currently about 175 domestic violence fatality review teams in operation, many of which are mandated by state statutes or executive orders, and several which receive funding from government sources like the Office for Violence against Women. Some reviews happen at the statewide level; others occur at a more local level before feeding into a statewide fatality review meeting. The National Domestic Violence Fatality Review Initiative (NDVFRI) serves as a clearinghouse for fatality review reports and recommendations, and provides technical assistance and sample data collection tools to individual review teams.

To be clear, individual teams greatly differ in how they approach the actual task of fatality review. Some cover only ‘closed’ cases – that is, cases which involve a murder-suicide or for some other reason don’t have a pending court trial. Others deal with ‘open’ cases, but make sure to adopt stringent confidentiality standards to protect the privacy of families and suspects. Some teams conduct interviews with the family members of the victims and their killers; others limit themselves to information gained from official records. Some are more open about who they include in the discussions, accepting input from religious leaders or school administrators as well as DV specialists; others have smaller meetings with less ‘outside’ input. For a particularly good example of a fatality review team doing things the right way, I recommend watching this brief video about the Montana Fatality Review Commission.

Output also varies between review committees. The FAQ section of the NDVFRI website lists several ‘formal’ and ‘informal’ products of fatality review. The informal products include better-educated and better-trained team members; greater awareness about other members’ jobs; and greater collaboration on other issues in the future. It certainly seems useful to unite representatives from various agencies (especially ones which often seem to be somewhat at-odds with one another) and give them a common goal and forum for discussion; I have no doubt that on teams like the Montana one, such discussion is frequent and very informative, but I will shortly discuss settings in which these informal products are less apparent.

The formal products, likewise, can include a variety of tangible resources: from case-specific reports that delve into the history of a particular abusive relationship to state-wide data collection that can greatly assist systemic changes in the future. The 2012 Georgia Report, which we’ve been touting as a model for future fatality review reports and data collection, offers a good mix of statewide statistics and focus on individual cases. It even has interviews with survivors of near-fatal experiences, providing an additional perspective that many review teams don’t seek out. The quality of reports and data collection, especially statewide data collection, vary immensely – but people from all over the country can look to the Georgia report and others for enlightening data and sound recommendations.

The NDVFRI website also publishes newsletters on a somewhat regular basis which detail ‘best practice’ approaches that have developed as a result of individual fatality review initiatives. In 2011, for example, Arizona started a six-month pilot program to increase strangulation convictions by improving forensic exams of strangulation victims – after fatality review reports from Minnesota, Wisconsin, Maryland, and Maine focused on the extreme lethality risk of strangulation. In general, nationwide data about the factors surrounding domestic violence fatalities can give advocates and policymakers increased ammunition to push for stronger victim services and protections.

As a whole, there seem to be several good reasons to adopt (in those states that don’t already mandate it) fatality reviews, as well as good reasons for existing teams to communicate with others and swap ideas across state lines. Unfortunately, it seems that any good idea in the world of domestic violence must overcome substantial roadblocks before it is effectively implemented across the board.

Improving the System

The most immediately apparent obstacle to conducting fruitful fatality review meetings is the lack of involvement many victims have with the system. Estimates hold that only a small percentage of domestic violence fatality victims had some form of contact with victim services before their deaths; the Georgia report, for example, puts the statewide number at 16%. The police were not previously involved in a significant number of cases, as well.  The Georgia team found that only 77% of victims had any contact with law enforcement before their deaths – and the Florida team concluded that only 35% of the decedents had previously reported domestic violence to the police. This might be expected, since the most severe cases are often those where the victim has the least opportunity to make contact with outside resources. But just because a victim didn’t have contact with the system before her death, this does not preclude a critical discussion of how future victims might be proactively involved in victim services or criminal justice. To put it another way, in the realm of fatality review, any data is useful data.

That being said, there are certain serious administrative issues that do hinder effective fatality review. As I mentioned earlier, the confidentiality of victims and abusers is of serious importance in a legal and ethical sense. Teams must be careful to either focus on closed cases, or to sign and honor confidentiality agreements suppressing any information that might identify an individual person rather than an aggregate. Some states have legislation specifically allowing fatality review teams to discuss otherwise confidential information. Confidentiality is not a critical roadblock to any fatality review team, but it is occasionally a sticking point nonetheless. Similarly, team members are frequently concerned about the confidentiality of their own statements within the fatality review proceedings, for fear that an admission that their organization made a mistake would then be used against them in a lawsuit. Certain states also have legislation exempting team members from legal liability for their statements while in fatality review.

One other administrative issue involves the simple problem of data collection. While individual reports and qualitative descriptions can prove very important and influential, there is still a clear value to broad-based data describing general trends: how DV homicides are committed, what services victims utilized the most, whether children were involved, and so on. A lack of standardized data collection procedures within a state can seriously impair the accumulation of useful data that can truly advance policymaking.

On top of all of this, unfortunately, the biggest impairment to conducting a successful fatality review is usually inter-agency tensions and a desire to defer blame. Even when all of the member organizations want to avoid future fatalities, and even when they recognize that some gap somewhere was usually responsible for the fatalities they review, tempers can flare when a representative from one organization points out that a different agency could have done something differently. For this reason, the NDVFRI emphasizes the need for a “no blame and shame” ethos – the notion that everyone should go into the room accepting that they or their organization may face questions and concerns about current practices, but that these concerns are motivated not by a desire to blame others for the fatalities at hand, but rather by a desire to prevent future deaths – but the site also emphasizes the need for organizational accountability. Not only must organizations be held accountable for their current policies, but they must also be accountable for future changes that will prevent similar tragedies from occurring. Unfortunately, interagency concerns about disrespect or public embarrassment also impede this future accountability.

As fatality review becomes more of an ingrained institution, these tensions may diffuse. As it is, though, meetings and Q&A reports are occasionally fraught with defensive retorts and attempts to deflect criticism, as opposed to a single-minded focus on the actual task of fixing a system that lets people die before they get sufficient help. This is unfortunate, since input from other agencies may provide the fresh pair of eyes needed to fix the flaws with an imperfect system. (As a side note, the “no blame and shame” ethos does not necessarily apply to the victims – sometimes, in an attempt to deflect scrutiny from their organizations, team members will turn to the victim’s proximity to her abuser at the time of the murder or other actions as an explanation for why the death occurred. This undermines the entire point of the session, which is to create a space where experts can talk about how they help victims leave potentially life-threatening relationships, and diminishes accountability in a particularly pernicious way. The presence of victim advocates who are willing to speak out against this sort of victim-blaming is instrumental in preventing the deflection of responsibility.)

What’s Next?

At the end of the day, the case for fatality reviews seems simple, and despite the problems, it certainly is the case that fatality review teams have prompted real and positive changes in domestic violence policies across the country. It’s also true that unlike many of the things we write about on this blog, the fatality review is an institution many lawmakers already see as important and have legally mandated. While the NDVFRI is the first to admit that it’s not possible “to prove in any scientific manner that fatality reviews reduce domestic violence or the number of domestic violence related homicides,” the benefits of these reviews in terms of improved legislation, improved policies, and improved interagency communication are clear.

I can’t help wondering, though, whether the fatality review is only a prelude to increased cooperation in other aspects. Last week, I wrote about the Jefferson County Domestic Violence Intake Center, which unites advocates and the court system to give victims the best possible legal advice. There are certainly other avenues for cooperation out there. A once-a-month meeting among people who care about domestic violence is great, but it’s by no means a substitute for more sustained partnerships. Hopefully more and more jurisdictions are wising up to this. As always, I’m interested in hearing your thoughts – are you aware of any advancements that have come about in your jurisdiction as a product of fatality review?

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About The Mary Byron Project

The Mary Byron Project was established in 2000 in memory of the young woman whose tragic murder led to the creation of automated crime victim notification technologies. As a nationally recognized thought leader on domestic violence, the Mary Byron Project cultivates and supports efforts that extend beyond crisis management to attack the root causes of this epidemic and help build safer, healthier communities. Solutions are within our grasp. The Mary Byron Project was established with that quest in mind.
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