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

2. Best Practice Considerations: Summary of Key Messages

2.1 Reviews and reports

1. Reviews should go beyond a simple description of the case and a timeline of events, instead taking an in-depth analytical and reflective account of why certain decisions were made and actions taken (or not), what was done well, and where opportunities may have been missed.

2. Reviews should be established from the outset as an opportunity for collective learning and improvement, with commitment to the process and open and productive discussions being encouraged in pursuit of this aim.

3. Reviews should ensure that chairs and participants are trained and supported on an ongoing basis to fulfil their role effectively and to participate fully in the review process.

4. Reports should follow template guidance to ensure consistency in quality and information gathered, and should then be held in a national repository, to facilitate comparison and disseminate learning.

5. The Review Model should establish a quality assurance mechanism to review reports prior to sign-off and publication, and to provide feedback for future review conduct.

2.2 Recommendations from reviews

6. Recommendations should be produced from engagement with all relevant stakeholders to ensure feasibility and maximise effectiveness.

7. Recommendations should be CLEAR (case for change, learning orientated, evidence based, assign responsibility, review).

8. Reviews should focus on creating a small number of meaningful, key recommendations to be generated into an action plan, and avoid over-burdening agencies with an excess of superficial or unrealistic recommendations.

9. Recommendations should encompass local and national actions as well as system-level changes, placing the case within a wider context and connecting to previous reviews which will create a systems-focused approach to learning and improvement.

10. Reviewers should be mindful of recommendations made in previous reviews, and consider whether making the same recommendation is warranted, or to refer to the previous review recommendation as still being relevant.

2.3 Monitoring and evaluation

11. views should establish an accountability mechanism where agencies are required to provide a detailed progress update on the effective implementation of recommendations.

12. Reviews should establish an overarching body to monitor the implementation of recommendations and the ongoing effectiveness of reviews, which will provide regular progress reports on key themes, actions that have been taken, and impacts that have been made.

13. Reviews should explore creative and effective ways to disseminate the learning produced from reviews to ensure lessons are taken forward and embedded into organisational practice.

14. Reviews should evaluate the success of the model on a variety of measures, as well as recognising the inherent value in simply conducting the process effectively.

15. Reviews should view DHSRs as a continuous process of reviewing, monitoring, and evaluating, with the report itself being only the first step towards organisational and system change.