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

Undertaking of a Review

Section 6 – Establishing a Domestic Homicide or Suicide Case Review Panel

The establishment of a Case Review Panel is a foundational step in delivering a credible, independent, and trauma-informed Domestic Homicide or Suicide Review. Panels are responsible for examining the circumstances surrounding the death, identifying lessons for prevention, identifying good practice, and making recommendations for systemic improvement.

This process must be underpinned by clear governance, professional competence, and inclusive representation to ensure that the review is both robust and sensitive to the complexities of domestic abuse and suicide. This section sets out the statutory requirements and best practice guidance for establishing a Case Review Panel, including the development of Terms of Reference, information governance, panel composition, and the integration of specialist expertise.

6.1. Terms of Reference for a review

Each review must be underpinned by a clear and specific Terms of Reference (ToR). A standardised ToR will be amended by the ROC to reflect the circumstances of the death. Where a Case Review Panel is to be established the bereaved family would ordinarily then be contacted unless this is not appropriate. In respect of the ToR, the Case Review Panel Chair may look to further amend the ToR in light of information received from bereaved families, friends, colleagues and community members. Further detail on engagement with families, friends, colleagues and communities is set out at section 7 of the statutory guidance. Any changes to the ToR are to be approved by the Review Oversight Committee (ROC). The ToR should define:

• The purpose, scope and objectives of the review, including the specific types of death and the abuse contexts being reviewed.
• The questions to be addressed by the panel to generate learning and inform future prevention.
• The timescales for initiating and completing the review. Reviews are to commence as soon as possible following a death, including in parallel with ongoing criminal investigations, unless otherwise directed by the Lord Advocate. The protocol (section 24) sets out how the reviews should be conducted to avoid prejudicing live criminal investigations, proceedings or inquiries).
• The anticipated products, such as a pseudonymised summary report with recommendations for local and national learning.
• Where the review remit has been expanded to include events beyond the death (see 5.7), the ToR must reflect that expansion.

Where appropriate, the Case Review Panel Chair will discuss the ToR with bereaved family members where they choose to engage in the review process. Following discussion with bereaved families and other relevant persons, the ToR will be updated and sent to the Review Oversight Committee for approval.

The ToR should also identify how combined and joint and reviews (see paragraph 6.6.) will be undertaken in cases involving children, other victims or where other review processes overlap with a domestic homicide or suicide review.

6.2. Data Sharing and Data Protection

To ensure lawful and effective reviews, statutory duties on participation, co-operation, and information sharing apply under the 2025 Act. Section 25 provides a duty on designated core participants to co-operate in a review. Such designated core participants are outlined at section 25(6). This includes a duty to participate in a domestic homicide or suicide review when requested, provide as soon as reasonably practicable information or assistance requested by the Review Oversight Committee and/ or Case Review Panel. Such designated core participants include:

• a local authority,
• a health board (territorial board)
• a special health board
• the chief constable of the Police Service of Scotland
• the Scottish Police Authority
• the Police Investigations and Review Commissioner
• the Lord Advocate
• the Scottish Courts and Tribunals Service
• Scottish Prison Service
• Community Justice Scotland
• the Risk Management Authority
• Social Care and Social Work Improvement Scotland (Care Inspectorate)
• the Scottish Social Services Council
• Social Work Scotland Ltd.

Section 26 makes provision for the Scottish Ministers, the Chair of the Review Oversight Committee and the Chair of a Case Review Panel by notice to, require a person to provide as soon as reasonably practicable information within its possession or control that is considered necessary for the carrying out of a review. This includes a wide range of persons such as voluntary organisations, general practitioners, dentists, banks, etc.

It should be emphasised that these duties in relation to the provision of information only extend to information which is reasonably considered necessary for the performance of functions relating to DHSR’s. These powers cannot be used to conduct a “fishing expedition” into an individual’s entire background and circumstances. If information is sought by a panel conducting a review for example, then it needs to be relevant to the matters being considered by the review. In the case of a domestic homicide, it may well be reasonably necessary for example to know about convictions of the perpetrator which are known to or may relate to domestic abuse, or where person B (the victim) is known also to have been the victim of the offence. This may be the case even where the conviction is old, as the purpose of a review includes identifying opportunities which may have arisen in the past to intervene in a way which may have changed the course of events. There are circumstances where certain convictions of the victim might also be reasonably necessary to know about, for example where there is a history of coercive control which included inducing the victim to commit offences for the benefit of the perpetrator and those convictions may provide evidence of continuing coercive control during a period. It is not however likely to be “reasonably necessary” for information to be required relating to anything an individual may ever have been convicted of.

Information that may be sought where reasonably necessary includes but is not limited to:

• Personal details such as name, date of birth, address and biographical details
• Family, lifestyle and social circumstances
• Criminal proceedings, outcomes, sentences, alternatives to prosecution
• Civil Proceedings and Tribunals
• Religious or other beliefs of a similar nature
• Physical or mental health or condition
• Financial details
• Goods or services provided
• Sound and visual images
• Licenses or permits held
• Sexual life/ sexual orientation

This can be information that is held in electronic and hard copy formats. Electronic records include information stored on a computer and Close Circuit Television (CCTV), while hard copy records include paper records, i.e. in a file.

Section 25 and section 26 also set out that a person is not required to produce information which that person would be entitled to refuse to provide in proceedings in a court in Scotland. However, it does not relieve a person of the obligation to provide any information in relation to spent convictions or alternatives to prosecution where this is covered by an exemption under the Rehabilitation of Offenders Act 1974. Exemptions may be created by secondary legislation and the intention is to do this in connection with DHSR’s before 1 April 2026. This will enable reviews to have access to evidence of spent convictions and alternatives to prosecution where this is reasonably necessary to the review.

A legal data gateway has therefore been created to support compliance with the UK GDPR and the Data Protection Act 2018, particularly Article 6(1)(c) and/ or (e). All review participants to comply with relevant data protection principles, including:

• Minimisation (sharing only what is necessary),
• Purpose limitation (for the purpose of the review only),
• Confidentiality, and
• Secure handling and storage.

Where necessary, written requests for data may be issued by the Review Oversight Committee Chair or Case Review Panel Chair. Reviews must include explicit safeguards to prevent jigsaw identification, especially in small communities.

6.3. Case Review Panel and Chair

The Chair of each Case Review Panel will be drawn from a pool of Ministerial appointed Chairs. Chairs will be independent in order to ensure transparency in the review process, foster public and family confidence, avoid conflicts of interest, and improve quality and consistency across reviews.

Chairs should demonstrate strong knowledge of domestic abuse, trauma-informed practice, multi-agency safeguarding, and systems learning. Chairs should also be capable of leading a complex, emotionally sensitive, and structured reviews. A small pool of trained Chairs will be maintained nationally, with each allocated to reviews as required. Appropriate training will be provided to Chairs. Where there is a conflict of interest, an alternate Chair will be drawn from this pool.

6.4. Assembling a Case Review Panel

Membership of a case review panel will be established on a case by case basis depending on the circumstances of the death(s). However, each panel will include the following representatives:

• Police Scotland,
• COPFS
• Health representation (GP or health board if more appropriate)
• Victim support organisation

The optimal panel size is typically between 5 to 7 members, to ensure a balance of perspectives while maintaining functionality and efficiency. Review panels will have a mix of members from organisations that will be on all reviews and others that will be ad hoc. Agencies or services that will have a representative present at each review are set out above. Members that will have representation more flexibly or ad hoc include faith leaders or housing professionals to reflect the specifics of the case. In cases involving children, panel membership will include expertise in child protection or early years.

6.5. Additional Expertise

Where specialist expertise was not identified earlier by the Review Oversight Committee, the Case Review Panel Chair is empowered to request additional input. This may include:

• Cultural advisors
• Mental health professionals
• Representatives from marginalised or minoritised communities

Such appointments should be proportionate to the scope and complexity of the case and align with the principles of intersectionality, cultural safety and trauma-informed practice.

6.6. Combined Deaths and Joint Reviews

Where one or more domestic abuse deaths or connected deaths occur e.g. a domestic homicide where person A kills their partner and the child of their partner, the Review Oversight Committee may instruct the Case Review Panel to undertake a combined review if each death independently meets the sift criteria. This avoids two separate reviews being undertaken on two related deaths. If the ROC determine that a combined review is to proceed the ROC Chair will confirm the Case Review Panel Chair for the joint review and notify all participating agencies in writing.

There are a number of learning review processes in Scotland most of which are non statutory reviews. The deaths within scope of the domestic homicide and suicide review model can meet the criteria for another learning review e.g. child protection learning review or suicide review.

The statutory nature of domestic homicide and suicide reviews means that if a death(s) meet the criteria then a domestic homicide or suicide review will be established, although whether the sift criteria are met is a matter of judgement for the ROC as these are not “bright-line” criteria but are capable of being met or not to varying degrees.

The 2025 Act makes provision for joint reviews which could also include a combined review. To use the example above person A kills their partner and their partners child. This may lead to a combined review but where relevant and appropriate, the Review Oversight Committee may instruct the Case Review Panel to carry out a domestic homicide or suicide review in conjunction with another review type e.g. a joint review, such as where it is determined there is also to be a child protection learning review into the death of the child.

In such cases, the review process as set out within the 2025 Act is to be followed. Due to timescales for death notifications, domestic homicide and suicide reviews will look to be established shortly following a death. Close engagement will be had between those who are parties to the protocol but the expectation is that reviews will run in parallel to investigations and proceedings unless directed otherwise by the Lord Advocate.

It is anticipated that where the Review Oversight Committee instruct a joint review, it should be able to be undertaken under the auspices of a domestic homicide or suicide review. It is recognised it may not always be possible for a joint review to be undertaken. Where a joint review is possible, this should help to reduce duplication, burden on the workforce and bereaved families whilst ensuring the domestic abuse lens is not lost or diluted. Through a joint review the aim should be to reach a single set of recommendations which will be tracked and monitored at a national level through the domestic homicide and suicide review model. This will help to ensure that learning is implemented timeously, help to build confidence, whilst ensuring that those who have died and their families remain at the centre.

6.7. Combined and Joint Review Terms of Reference

The Terms of Reference (ToR) for a domestic homicide or suicide review are set by the Review Oversight Committee. This is a standardised ToR that is amended in response to the circumstances of each death. As with a ToR for a domestic homicide or suicide review that is to be neither a combined or joint review, the specifics of the ToR will be amended to reflect the circumstances of the death(s) to be reviewed under a combined and/ or joint review. Aspects of the ToR that may differ from a non-combined/ joint review ToR include:

• Possible expansion to the scope to encompass areas that would be of focus under the other relevant review process(es).
• Any variation to the timescales to be considered under the review. These are ordinarily two years unless there is reason to go back further or to look at specific periods of time or events from previous years.
• Additional persons/ agencies to be included within the review process
• Any additional governance, communication and information and data protection arrangements, processes and protocols.

Where the remit of the review is to be expanded beyond the point of death and where this has been approved by the Lord Advocate, the ToR must include this.

Where appropriate, the Case Review Panel Chair will discuss the ToR with bereaved family members where they choose to engage in the review process. Following discussion with bereaved families and other relevant persons, the ToR will be updated and sent to the Review Oversight Committee for approval.

Where a criminal investigation, proceedings, inquiry is ongoing, the review must operate within the framework of the protocol to avoid prejudice to such proceedings.

The Review Oversight Committee retains responsibility for overseeing the review including whether that be a combined or joint review.

6.8. National Hub for Reviewing and Learning from the Deaths of Children and Young People

Where a domestic homicide and suicide review involves the death of a child or young person who was under the age of 18 years old or 26 years old if previously looked after, the Chair of the domestic homicide or suicide review will complete the Core Data Set and upload to the National Hub unless informed by the health board that it will undertake this process.

Section 7 – Engagement with Family, Friends, Colleagues and Communities

This section outlines expectations for the involvement of family, friends, colleagues, and communities in domestic homicide and suicide reviews, reflecting the policy objective that reviews are trauma-informed, person-centred, and inclusive. It builds on the clear consultation consensus that such involvement is central to meaningful learning and system improvement.

7.1. Engaging with Family, Friends, Colleagues and Communities: Point of Contact

At the point where a Case Review Panel Chair is assigned to a review, the Case Review Panel Chair will look to contact the family to make them aware of the review. Before contacting bereaved family members, the Case Review Panel Chair will liaise with the Senior Investigating Officer and/ or Family Liaison Officer first or other relevant authority e.g. if there has been a death abroad, and outline that a domestic homicide or suicide review has been established. The Chair will outline how engagement with the family is proposed. The Chair will seek contact details from Police Scotland or another relevant agency, if not already provided, on who to discuss this further with.

There are occasions where it may not always be possible or appropriate to contact a family e.g. there may not be any family members to contact. Given the timing of the reviews, the Chair will be guided by police and/ or relevant others on when and how to contact families.

The presumption should be that a named, trusted point of contact is allocated to each family at the outset. This individual should provide relational continuity and serve as a liaison across the entirety of the review. Where families already have a trusted support worker or advocate, they may opt for that individual to fulfil this role.

Engagement must be planned in trauma-informed stages and remain sensitive to the individual needs, pace, and preferences of families, friends, colleagues and community members. This is to minimise the number of persons contacting bereaved family members following a death.

7.2. Family Engagement: Information and Support

All families are to receive accessible information on:

• The purpose, scope, and limitations of the DHSR
• The process stages and expected timelines
• The role they may play, and the voluntary nature of their involvement

Information should be delivered using plain English, available in a variety of formats and languages, and accessible for people with additional communication needs.

Families’ participation must be informed and consensual and accompanied by proactive offers of independent advocacy. Advocacy will be offered as standard practice.

Advocacy provided will be:

• Independent from statutory bodies and the review process
• Centred on empowering the family
• Available throughout the review and in post-review stages
• Flexible to cultural and individual family contexts

Advocates will help families understand the process, express concerns, interpret findings, and engage with final reports. They must never support both the family of the deceased and the accused in the same review.

7.3. Review Participation: Information and Support for Children

Following a domestic homicide or suicide, bereaved children should be referred to an Interagency Referral Discussion (IRD) involving police, health and social work at a minimum as core IRD partners. During the IRD, alongside immediate safety planning, consideration will be given to what support is necessary for the child(ren).

What is key is that consideration is given to what the right support is for each child as there is not one support service that suits all children. Where a child has experienced significant harm, this support could be delivered or coordinated by a Bairns’ Hoose or by an alternative local support service. In providing an integrated, rights-based model of care that will prioritise safety, recovery, and participation, Bairns’ Hoose is well-placed to ensure that bereaved children who have experienced significant harm receive the support they need to recover from the trauma they have experienced and to respond to the child’s needs as they change over time.

Where a child chooses to participate in the DHSR and in accordance with the protocol, engagement must be:

• Voluntary, person-centred and rights-based
• Developmentally appropriate
• Supported by an independent advocate for children
• Framed with clear boundaries around expectations, scope, and support before, during, and after participation

Information for children and their carers should be made available following a domestic homicide or suicide. Information will be available to services for them to provide and discuss with bereaved family members.

7.4. Review Participation Process

The review must be structured around transparency, honesty, and trust. Families must be clearly informed of:

• The difference between DHSRs and criminal investigations
• What the review can and cannot deliver
• The opportunity to shape, review, and respond to findings

Participants should be supported through:

• Early and regular communication
• Tailored updates
• Visual tools such as process flowcharts, panel member biographies, timelines, and glossaries

Participation must be flexible. Families can define the level, format, and frequency of their engagement. Emotional and psychological safety is paramount. Participation must never be tokenistic, and the emotional labour of sharing must be recognised and supported.

Cultural sensitivity must underpin engagement. This includes:

• Recognising differences in what constitutes “family”
• Using translation and interpretation services where needed
• Drawing on local knowledge and culturally grounded support models where relevant

7.5. Review Participants’ Experience

There is no requirement for families to provide feedback on their experience of engaging in a domestic homicide or suicide review. However, where appropriate, feedback should be sought from families on their experience of the review process. This should be gathered through:

• Anonymous and confidential surveys
• One-to-one debriefs
• Group feedback sessions, where appropriate
• Through a support organisation or advocate the family is being supported by
• A means in which families would like to provide it

Learning from participant feedback will be incorporated into review model improvements. The Review Oversight Committee will:

• Monitor participant satisfaction and accessibility
• Report on improvements made as a result
• Ensure visibility of changes enacted following feedback

Families’ engagement in a review must be acknowledged. Families must also be kept updated on implementation of recommendations (if they choose to be kept updated). Their experience of engagement in the review process should also inform broader workforce development, including training in trauma-informed, culturally competent, and inclusive practice.

Section 8 – Conducting a Domestic Homicide or Suicide Review

This section sets out the core expectations for how domestic homicide or suicide reviews should be conducted. It provides guidance for Review Oversight Committee (ROC) members, panel chairs, review panels, and participating agencies on the process of gathering, analysing, and interpreting information. Reviews should be victim-focused, proportionate, and trauma-informed, with an emphasis on learning and system improvement rather than attribution of blame.

8.1. Individual Management Review (IMR)

Individual Management Review reports will be used to gather relevant information on persons subject to review. Each participating organisation must provide comprehensive information on the services they provided to the persons who the domestic homicide or suicide review will concern. This includes any contact they had with the individuals before the death and in some cases for some individuals, post death. This information should be submitted using the template provided to them. The IMR report is to include a summary of:

• the nature and extent of the organisation’s contact with the individual;
• key decisions made, actions taken, and services provided;
• the rationale for professional judgments; and
• initial reflections or lessons identified by the organisation.

IMR reports form a kay part of the review and should be comprehensive, factual, and analytical.

Where the deceased was registered with a General Practitioner, information from the GP is essential. GPs are expected to cooperate with the review process under their professional obligations whilst adhering to General Medical Council (GMC) guidance on confidentiality, information sharing, and posthumous disclosure. Section 26 of the 2025 Act makes provision for such information to be shared by GPs and other relevant persons for review purposes.

The Case Review Panel Chair should ensure that where information is sought that this is precise, proportionate, and made in writing. The relevant legislative provisions should also be outlined as well as the reasons for seeking the information.

It may be necessary for mental health histories, GP notes, psychological therapy records, and any documentation of suicidal ideation or self-harm to be obtained. Such records may contain critical information relating to coercive control, stalking, or escalating domestic abuse. GP and mental health records may contain critical information relevant to domestic abuse-related suicide, including missed disclosures, symptoms of trauma or depression, crisis-related presentations, or previous self-harm, and should be reviewed with appropriate safeguards in place.

Where a child or young person has died, or where a child was bereaved, information should be sought from agencies that had contact with the child and their family. This includes education, early years services, health visitors, paediatrics, CAMHS, child protection, social work, youth justice, voluntary sector organisations and relevant others, which provided support or engaged with the child. Reviews involving children should be undertaken in line with GIRFEC principles, ensuring that information reflects a whole-child, rights-based and holistic view of their needs.

Reviews will consider the child’s lived experience and how services recognised, assessed, and responded to their needs, vulnerabilities and risk of harm. Information should include developmental history, attendance and engagement with education, referrals to support services, early years assessments, and wellbeing indicators. If the child was subject to any child protection processes or multi-agency meetings, those findings are to be included. Reviews should assess whether the child was asked or had the opportunity for their views to be expressed, how cumulative concerns were identified or missed, and how adult and child services communicated.

8.2. Animals

The presence, treatment, and welfare of animals within a household can be a significant indicator of both risk and control dynamics in cases of domestic abuse. Evidence from practice and research shows that perpetrators may harm, threaten, or neglect pets and other animals as a means of coercion, intimidation, or punishment. Victims may delay leaving an abusive situation out of fear for the safety of their animals or because there are limited options for rehoming or temporary care.

Reviews should therefore consider:

• whether animals were present in the household or otherwise connected to the ‘victim’, ‘accused’/ ‘perpetrator’, or children;
• any known incidents of harm, neglect, or threats toward animals;
• the emotional significance of animals to victims and children, including the role of pets as sources of comfort, protection, or attachment; and
• how agencies recognised, assessed, or responded to concerns about animals as potential indicators of abuse or barriers to safety planning.

Information should be sought from relevant organisations such as the Scottish Society for the Prevention of Cruelty to Animals (SSPCA), local animal welfare services, or veterinary practices where there is reason to believe they hold pertinent information. These agencies may have records of injury, neglect, or behavioural signs that provide insight into the household’s dynamics and timeline of events.

Where appropriate, consideration should be given to how inter-agency communication between human and animal welfare services can be strengthened to support early identification of abuse and to ensure that future safety planning includes provision for pets and livestock.

Reviews should also recognise the psychological and emotional impact on children and adults who witnessed or were aware of harm to animals. In such cases, trauma-informed analysis should explore how this affected their sense of safety, attachment, and help-seeking behaviour. Where children were present, reviewers should consider the emotional and developmental significance of pets, as children may experience profound distress from witnessing harm to animals. Analysis should explore whether such harm contributed to their trauma, attachment difficulties or barriers to seeking help.

8.3. Requesting relevant information on person A and services, including children of person A

The panel should also consider whether it is reasonably necessary to obtain information about person A’s contact with statutory and voluntary services. This includes criminal justice social work, police, probation, housing, mental health, and substance use services etc. Where person A had dependent children or regular contact with children, information should be sought from children’s services regardless of whether those children were residing with person A’s partner or ex-partner. Reviews should consider person A’s parenting behaviour towards their children and the extent to which services recognised or mitigated risks posed to children.

Where relevant or reasonably necessary, information relating to person A can be sought on any known history of offending, alternatives to prosecution, previous incidents of domestic abuse, controlling behaviour, crisis presentations and contact with mental health or substance use services. For domestic abuse related suicide cases, reviewers should also consider whether person A presented with distress, suicidal ideation or behaviour that intersected with coercive control or escalating risk.

8.4. Involvement of family, friends and others including support services and bereaved children

Families, friends, and others who knew person A and B provide essential insights into the relationships, behaviours, and services involved. Their participation should be sought sensitively, with clear explanation of the purpose and process of the review and with opportunities to contribute in a manner that feels safe and supported.

Bereaved children are to be offered developmentally appropriate opportunities to contribute their views. This may include direct engagement, facilitated sessions with trusted adults, or contributions through advocates or third sector specialists. Participation should always be voluntary, supported, and paced according to the child’s needs. Reviews should consider the differential impact of the death on each child and the adequacy of support provided to them before the incident and after the death where a review has been expanded.

8.5. Establishing a Timeline/ Chronology

A detailed chronology should be developed to map known contacts, decisions, and significant events involving those who have died, person A, and relevant agencies. This forms the backbone of the analytical phase.

A standardised chronology template is to be used by all agencies. This is provided at Annex 1. The review team will collate submissions into a single composite chronology, identifying overlaps, inconsistencies, and gaps.

For cases involving children, chronologies are to include multi-agency contributions, identification of cumulative concerns, clear separation of fact and professional opinion, and the inclusion of relevant school records, early years assessments and wellbeing information.

For domestic abuse-related suicide reviews, chronologies are to include any mental health crisis presentations, episodes of self-harm, police attendance, domestic abuse disclosures, separation-related risk, digital abuse and any patterns of coercive control.

The final chronology must provide a clear sequence of events and contextual information to support system-level analysis.

8.6. Domestic Homicide Reviews – Additional Factors

Domestic homicide reviews should examine patterns of coercive and controlling behaviour, escalation of risk, and missed opportunities for intervention as well as where there were examples of good or safe practice. Reviews should consider how social, economic and cultural factors shaped the person(s) who have died, access to safety and the effectiveness of multi-agency risk assessment and management.

Where children were involved, reviews should analyse how the child experienced domestic abuse, exposure to coercive control, behavioural changes, and their relationships within the family system. Reviews should examine communication between adult and child services, and how these dynamics contributed to the wider circumstances of the death.

Where multiple victims or complex family structures are involved, the review should ensure that each relationship and risk dynamic is analysed in context.

8.7. Domestic Abuse Related Suicide Reviews – Additional Factors

Where domestic abuse was or may have been a contributing factor to person B’s death, reviews must consider cumulative trauma, coercive control, fear, isolation, and patterns of abuse before death. Reviews should examine recent separation, stalking, threats, ongoing harassment, financial abuse, or immigration-related vulnerabilities. Relevant criteria for determining domestic abuse-related suicide should be applied consistently. Reviews should also consider significant events within person B’s life and any changes or notification of change that may have had an impact on them e.g. their abusive ex-partner being released from prison.

Reviews must explore whether services recognised domestic abuse as a risk factor for suicide and whether responses to any mental health, crisis presentations, self-harm or distress were adequate and informed by an understanding of domestic abuse dynamics.

Information sharing in domestic abuse related suicide cases can be complex due to mental health confidentiality. Information sought must be justified, reasonable and proportionate. Mental health and GP records may contain key insights into risk that were not shared across agencies. Family members, friends and former partners may hold relevant contextual information that agencies did not record.

Section 9 – Review Analysis

Case Review Panels are to utilise a structured analytical framework to identify learning and understand system dynamics. The approach is to combine:

• Socio-ecological analysis – examining how individual, relationship, community, and societal factors interacted to create or reduce risk;
• Contribution analysis – identifying underlying factors, missed opportunities, and systemic weaknesses or limitations that may have contributed to the death; and
• Appreciative enquiry – recognising examples of effective practice and innovation that may inform wider improvement.

For domestic abuse related suicide cases, contribution analysis must consider cumulative stressors, any mental health history, patterns of coercive control and whether services recognised the intersections between domestic abuse and suicide risk. A direct causal link is not required to be determined as part of the review.

For cases involving a bereaved child, analysis is to consider the child’s developmental needs, lived experience, exposure to harm and the adequacy of the response across agencies.

9.1. Analysis and Review Preparation

Phases of review analysis and report preparation typically include:

• Collating individual management review reports and chronologies and analysing these for accuracy, consistency, and completeness. Additional reports may be sought if gaps are identified.
• Presenting the initial findings and chronology to the review panel for discussion, clarification, and thematic analysis.
• Requesting any further information or expertise, preparation of report, amendments, or clarifications from agencies or contributors before finalising conclusions and recommendations.

Training will be provided to Case Review Panels on undertaking reviews including review analysis and development of recommendations. Training will also be provided to Case Review Panel Chairs on preparing a draft review report.