Undertaking domestic homicide and suicide reviews: draft statutory guidance - consultation

Section 1 – Context and Policy Background

1.1. Policy Context

Domestic Homicide and Suicide Reviews aim to identify lessons following a domestic abuse related death or a connected death of a young person, with the overarching goal of helping to further tackle domestic abuse, ensure systemic learning, and preventing future abuse and deaths. Unlike criminal investigations, domestic homicide and suicide reviews focus on learning, not blame, and are framed by the idea that they "illuminate the past to make the future safer".^[1]

1.2. Background

In Scotland there are on average eight homicides a year where a homicide victim has been killed by a partner or ex-partner. In relation to domestic abuse related suicide, data is not currently available, but work undertaken in England and Wales estimates that the number of domestic abuse related suicides could be as much as double the number of domestic homicides. Similarly, in relation to children, there is a gap in data relating to the number of children killed in a domestic abuse context or bereaved by it.

The Homicide in Scotland statistics^[2] demonstrate that women are most likely to be killed by a partner or ex-partner and men are most likely to be killed by an acquaintance. The statistics reinforce that domestic homicide is a gendered crime that is overwhelmingly committed by men against women. However, there are also a consistent number of male victims of domestic homicide in Scotland, across the wider UK and other jurisdictions. The gendered nature of domestic homicide is not unique to Scotland – it is a worldwide issue.

1.3. Scotland’s Approach

The work to develop the national domestic homicide and suicide review model has been undertaken through a Scottish Government led multi-agency taskforce, two comprehensive consultations, development of a set of core principles, establishment of a robust evidence base, significant engagement with stakeholders, and experts which includes those with lived experience of domestic abuse and engagement with bereaved families. This engagement has been with those within Scotland, the wider UK and internationally.

The core principles developed from the outset of the work are outlined below. These have been central to the model development work through to implementation and beyond.

Person Centred: respecting an individual's needs and values, treating them fairly, communicating with them clearly and recognising that they are the experts in their own lives.

Trauma Informed: recognising the impact that trauma can have, making sure to minimise the risk of re-traumatisation and understanding that access to support promotes recovery.

Transparent: operating in an open, honest, clear and comprehensive way.

Inclusive: ensuring we are open to all, equal, fair and respectful. Whilst fully recognising that the overwhelming majority of domestic homicides are carried out by men against women, there are a consistent number of male victims of domestic homicide each year in Scotland. As such the approach taken in Scotland is an inclusive one which will include victims of all genders.

Domestic Abuse Component: understanding that abuse can take many forms, recognising the gendered nature of domestic abuse, understanding the impact on victims and children, the complexity of victims’ needs, and understanding how to respond appropriately.

The cumulative views, expertise and evidence have shaped the model development and the legislation which provides a statutory underpinning for domestic homicide and suicide reviews in Scotland^[3].

1.4. Creating the conditions for learning

The domestic homicide and suicide review model in Scotland is designed to create the conditions for meaningful learning by ensuring independence, transparency, and a structured approach to capturing and implementing learning. At the heart of this framework is the establishment of a Review Oversight Committee (ROC), responsible for overseeing the review process and ensuring that findings lead to tangible improvements.

To maintain independence and public trust, the chair and deputy chair of the Review Oversight Committee and Case Review Panel chairs are Ministerial appointments, ensuring they have the necessary expertise and objectivity. A stable membership within the Review Oversight Committee will build collective knowledge over time, allowing for a consistent and informed approach to identifying patterns and gaps in system responses.

A critical aspect of the model is the need to capture learning as quickly as possible. Reviews should therefore commence soon following a death. Where there are criminal proceedings, this should not prevent a review from progressing if done so in line with the protocol. In addition to the protocol to mitigate risk of prejudicing legal proceedings, the Lord Advocate has the power to pause or halt reviews if necessary.

Commencing reviews as soon as possible will help to ensure that those involved still have fresh recollections and that records remain readily available. Delays in starting reviews, as seen in some jurisdictions, have often resulted in missed or outdated learning, preventing timely improvements and frustration for families seeking change.

To promote transparency and accountability, biennial thematic reports will be laid in Parliament, detailing common themes, key learning points, actions taken, and the impact of implemented recommendations. This ensures that learning is not only captured, shared and acted upon at both a local and national level but ensures accountability for learning to be implemented. The report will also highlight areas of good practice to ensure wider learning across the system. The involvement of multiple agencies in the review process will further ensure that learning is evidence-based, rooted in best practices, and reflective of the operating context within Scotland.

Importantly, learning must translate into practical change. Review findings will be shared with organisations responsible for implementing recommendations, and discussions will take place to ensure that the proposed recommendations are clear and feasible. However, organisations will not have the ability to veto recommendations, ensuring that meaningful changes are pursued. The Scottish Ministers will also monitor progress to track how effectively learning is being implemented and whether it is leading to tangible improvements.

Legislative provisions play a key role in reinforcing this model, providing a legal basis for mandatory participation and information-sharing while instilling confidence in the process. By taking into account lessons from other review processes in Scotland and other jurisdictions, Scotland's approach aims to avoid the pitfalls of weak governance structures, unclear recommendations, and lack of follow-through whilst supporting and lifting up other review models operating in Scotland. The model is designed to be robust, evidence-driven, and adaptable over time as understanding of domestic abuse, domestic homicide and suicide evolves.

Finally, the model places a strong emphasis on the role of families in the learning process. Families will be kept informed throughout the review process if they choose to be, given time to digest findings, and provided with opportunities to discuss the outcomes with the panel. A dedicated advocacy service will be available to support families through the review process. In some cases, there may be circumstances where a report cannot be published due to legal constraints. On such occasions, it is envisaged that a summary of recommendations will always be shared and published to ensure that knowledge gained from each review is used to drive systemic improvements. This commitment to transparency, accountability, and meaningful engagement ensures that the review process not only honours those who have died but also contributes to the prevention of future domestic abuse and deaths.

1.5. Equality, diversity and inclusiveness

The domestic homicide and suicide review model in Scotland is committed to embedding principles of equality, diversity, and inclusion (EDI) at every stage of the review process. Recognising that domestic abuse, domestic homicide and suicide disproportionately affect certain groups, particularly women, disabled individuals, and other marginalised communities.

The model aims to ensure that data collection and analysis reflect the diverse and intersectional experiences of victims. To achieve this, reviews will look to systematically gather demographic data, including ethnicity, gender, disability, and other relevant characteristics. This will facilitate the identification of disparities, understand how professional responses may be mediated by these identities and inform targeted interventions to ensure that EDI is central to the recommendations made. This aligns with Scotland’s broader policy landscape, including the public sector equality duty under the Equality Act 2010, which requires public bodies to proactively address inequalities and advance equal opportunities.

By capturing and analysing this data, the model will not only provide a clearer understanding of risk factors within different communities and service responses to them but also support the development of policies and services that are responsive to the needs of all victims.