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

Reporting, Publication and Dissemination

Section 10 – Learning, Recommendations and Action

This section provides guidance on how learning should be identified, interpreted and translated into clear recommendations and actions arising from Domestic Homicide and Suicide Reviews, including combined and joint reviews. The aim is to ensure that learning leads to meaningful improvement across agencies, strengthens safeguarding practice, and reflects the needs and experiences of victims, children and families. Reviews must ensure that learning reflects both individual lived experience and wider system factors, and that insights from child and suicide-related reviews are fully considered.

10.1. Identifying learning, Recommendations and Actions

Reviews must focus on identifying what can be learned from the circumstances that led to the death, including patterns in service involvement, cumulative harm, barriers to disclosure, gaps in risk assessment or intervention, strengths in practice and wider contextual factors. Learning should be evidence-based, linked clearly to the chronology and analysis, and should take account of the intersection between domestic abuse, trauma, mental health and, when relevant, child development and family functioning.

Recommendations should flow directly from the identified learning and be:

• specific, actionable and proportionate;
• assigned to named organisations or partnerships;
• oriented towards system improvement rather than individual fault;
• aligned with national child protection and suicide prevention improvement priorities where relevant; and
• reflective of both short-term changes and longer-term development needs.

Actions should set out how organisations will implement the recommendations. These should include clear steps, responsible leads, milestones, and arrangements for monitoring progress. Where learning highlights structural factors or national gaps - particularly in relation to children’s services, information-sharing or suicide-risk pathways, this should be signalled for national consideration through oversight bodies or Ministers.

10.2. Preparing Review Reports

Review reports must present learning and recommendations clearly and coherently. Reports should be structured to provide:

• an overview of events and a timeline of any key events prior to the death and post death where a review has been expanded;
• a summary of significant relationships person A and B (where they were partners/ ex-partners), had prior to the death and what changes (if any) there were to those relationships;
• clear evidence supporting each learning point;
• information on opportunities missed or taken by services;
• the panel’s recommendations;
• explicit links between learning, recommendations and actions;
• reflection of the experiences of children, where relevant;
• conclusions of the review panel, reasons for these and any areas of disagreement;
• any additional reflections from the review panel; and
• any other relevant points the panel choose to include.

Reports must be written in a manner that supports publication, scrutiny and accessibility under the legislation. They must be clear enough for families, practitioners, policy makers and the public to understand, without technical language that obscures meaning. Where the death involved a child or a suicide, the report should ensure that specialist considerations, such as developmental needs, cumulative adversity or suicide warning signs, are explained in an accessible way.

10.3. Language, framing and victim blaming avoidance

Language used in the report must be accurate, respectful and free from bias. Reviews should adopt framing that:

• avoids implying responsibility on victims for the behaviour of perpetrators/ accused;
• recognises the role of coercive control, trauma and structural barriers;
• reflects lived experience, including the perspectives of children; and
• highlights systemic rather than individual limitations or missed opportunities.

Descriptions of victim behaviour must be contextualised. This is particularly important in domestic abuse related suicide reviews, where symptoms of distress or withdrawal must not be interpreted as personal failings, and in reviews involving children, where behaviour may reflect trauma, developmental stage or the impact of living with domestic abuse.

10.4. Involvement of family and those supporting families

Families play a critical role in helping reviewers understand the person who has died, the relationships around them and how services were experienced or were not approachable. Families will be kept updated as the review progresses should they choose to be and in a way that they determine.

Following the preparation of a report, Case Review Panel Chairs will invite families to meet with them. The Chair will talk through the contents of the review report and discuss the learning and recommendations.

They will also be kept updated on progress on implementation should they choose to be. This can be done directly or with/ through an advocate or victim support organisation.

Where bereaved children are involved in a review, participation must be facilitated through age-appropriate approaches and with the support of specialist services such as Bairns’ Hoose where available and accessible and/ or through victim support workers familiar with the child(ren) and families. Support organisations and advocates may contribute contextual insights and ensure families feel informed and heard throughout the drafting of the report.

10.5. Anonymity of persons

The Review Oversight Committee Chair must take all reasonable steps to prevent identification including jigsaw identification in the publication of review reports. While data protection legislation only applies to the data of living individuals, the 2025 Act attaches the anonymity requirement to those who need it e.g. it will apply to the person(s) who have died and living family members but not to authors of the review report. Important points relating to review reports include the:

• use of consistent pseudonyms;
• removal identifying details; and
• careful consideration of contextual information that could indirectly identify individuals.

In suicide-related cases, particular care should be taken to avoid speculative conclusions or sensitive personal details being shared unnecessarily.

10.6. Sharing draft review reports

Where a review report is still in draft e.g. it has not been submitted for approval to the Review Oversight Committee, it is anticipated that there will be a need for reports to be shared for the purpose of checking factual accuracy. Given the sensitive nature of the content of reports and that there may still be live criminal proceedings, any sharing of draft review reports must be done by the Review Oversight Committee Chair or the Case Review Panel, in accordance with the protocol.

Where a report or part of a report is able to be shared, it will only be able to be shared by the Review Oversight Committee Chair and the Case Review Panel Chair, with the specified individual(s). This means that the report cannot be shared with wider colleagues. Should additional members of an organisation request sight of the draft review report, approval is to be sought by those who are parties to the protocol.

10.7. Finalising Draft Review Reports

After consideration of review report comments the Case Review Panel Chair will finalise the report. Where there are points the Case Review Panel do not agree, these must be captured within the report. A report must be published but this will not be the full detailed report. Instead, an executive summary will be prepared that clearly communicates:

• the key learning;
• the main recommendations;
• any local, regional or national or structural matters identified;
• opportunities missed or taken; and
• any wider themes relevant to policy and practice.

The executive summary is to be prepared in a way that it would be suitable for publication whilst also safeguarding anonymity. Where the case involves a child or suicide, the summary should ensure that explanations are sensitive and avoid simplistic narratives about cause, responsibility or intent.

10.8. Submitting report to Review Oversight Committee for Quality Assurance

All finalised draft reports must be submitted to the Review Oversight Committee for quality assurance. The Committee will consider whether:

• the report meets the statutory requirements
• meets the requirements within the ToR
• learning has been captured fully, including child-specific or suicide-specific factors where applicable;
• recommendations are proportionate, evidence-based and achievable; and
• the report is suitable for publication or restricted publication.

Where improvements or clarifications are required, the Committee may request further amendments before approval or may modify the report itself.

The ROC must maintain rigorous quality assurance standards to ensure that reports are consistent, robust and aligned with the aims of the legislation. Quality assurance should consider:

• the quality and depth of analysis;
• proportionality and clarity of recommendations;
• the coherence between evidence, learning and action;
• adherence to confidentiality, ethics and trauma-informed principles; and
• the accessibility and clarity of the final text, including for families.

Publication of finalised reports must be approved by the Lord Advocate. Where a report cannot be published due to reasons such as safeguarding or due to ongoing criminal proceedings, a report or part of a report may be able to be shared with specific individuals in order to ensure learning is disseminated. This must be done in accordance with the protocol. The same will apply where it is not feasible to remove all potentially identifying information from the report for publication and therefore publication may not be possible. In such instances an alternative summary of lessons learned would be published in order to ensure learning can still be gained and shared from each review.

Following approval by the ROC, the finalised report must be submitted to the Scottish Ministers. Where a review involves a child or an adult at risk, the report must also be submitted to the Care Inspectorate.

10.9. Sharing of approved reports that cannot be published.

Following approval of a review report by the ROC, reports must be approved by the Lord Advocate before being published. There may be occasions where a report is unable to be published due to legal, ethical or safety constraints. Where publication of the review report is not possible or not possible at that point in time, it is important to ensure that learning is not lost. Review reports can be redacted but an alternative form of report e.g. a poster summarising the key learning could be published. This would be done with the overarching aim of supporting learning aimed at safeguarding those affected by abusive domestic behaviour or promoting victims' wellbeing.

There may be occasions where Scottish Ministers would look to share (in full, in part or extracts of) a review report that has not been published e.g. where there is a cross border review. Any sharing will only be able to be done with those considered relevant and appropriate and where the findings, learning, or recommendations are relevant to the recipient organisation. Again, there must be an overarching aim of helping to safeguard those affected by abusive domestic behaviour or promote the wellbeing of victims of such behaviour. Any sharing of approved but not published reports must be done so in accordance with the protocol.

Section 11 - Publication of Reports and Dissemination of Learning

This section provides detail on the publication of domestic homicide and suicide review reports and dissemination of learning.

11.1. Informing Families

Where the Lord Advocate consents to the publication of a review report, families must be informed on:

• what will be published (executive summary);
• how anonymity and confidentiality will be protected;
• when publication is scheduled, and where they may access support.

Families are to be offered a named contact to discuss publication arrangements. This is an essential part of trauma-informed practice.

11.2. Dissemination of Learning

This section sets out how the Review Oversight Committee (ROC), case review panels, and named agencies should ensure that learning from domestic homicide and domestic abuse related suicide reviews is communicated, acted upon and recorded in ways that protect confidentiality, respect families and drive system change.

11.3. Implementation of Recommendations

After a report is approved by the ROC, the committee should issue formal letters to the senior representative(s) of each organisation named in the recommendations and required to respond by a statement in the report under section 29(1) of the Act. Each letter should:

• enclose a copy of the report (summary/ full);
• state the specific recommendations directed to the organisation;
• seek detail on the actions the organisation will take;
• name a senior lead responsible for the recommendations that can be followed up with; and
• set a reasonable deadline for the written response.

It will ordinarily be the ROC that will write to relevant persons but Case Review Panels can also issue letters (where approved by the ROC). A copy of the relevant review report will be provided to the relevant SPOC who will prepare a statement of progress to the ROC and Scottish Ministers.

The statement is to include what has been done to deliver the recommendation(s) or what is proposed to be done to deliver the recommendation if the report has not long been received, responsible leads, milestones and measurable indicators of progress. Statements should distinguish immediate safety actions, medium-term service changes and longer-term cultural or systems improvements. The ROC or Scottish Ministers may publish the agency’s written response (in full or in part) including where there has been a failure to response or to implement.

Implementation planning should include evaluation of impact as per the impact framework. This document will be provided to agencies to support them to self assess and measure what changes have been made, for whom, and what impact the change has made. Where a recommendation has national significance, the Committee should flag this to Scottish Ministers for consideration of system-level action.

11.4. Monitoring of Recommendation Implementation

The Review Oversight Committee will maintain a central tracker of recommendations and responses, capturing: the recommendation text; named responsible organisation(s); deadline for response; copy of the written response; implementation milestones; and evidence of progress. The tracker forms the primary source for the Committee’s assurance work and for information about actions taken and their impacts requested by Ministers for periodic reports.

Section 12 –Biennial Thematic Reports

The 2025 makes provision for the Scottish Ministers to prepare and publish, as soon as reasonably practicable after the end of a two year reporting period, a domestic homicide and suicide review thematic report. This report is to be laid before Parliament.

12.1. Thematic Review Report

The biennial thematic review reports are to include a range of information as set out below. However, Scottish Ministers can include additional points or information beyond:

• any common themes emerging from domestic homicide and suicide reviews;
• information about any lessons identified which Scottish Ministers consider should be highlighted in relation to e.g. disability, male victims or animal abuse;
• information about actions taken following recommendations made and where known, the impact of those actions;
• the reasons for any cases being sifted out e.g. where a death was not reviewed because the connection to Scotland was too peripheral;
• the number of notices given by the Lord Advocate which suspend, discontinue or allow the resumption of a review, along with the reasons given for any suspension or discontinuation, and
• statistical information that will provide an overall picture of the work taking place throughout the reporting period in respect of the review model.

The report will be prepared by the DHSR Team within Scottish Government who will consult with relevant persons including Review Oversight Committee Chair and Deputy Chair, Case Review Panel Chairs and other such appropriate persons.

Section 13 – Statutory Guidance

The statutory guidance is intended to support the Review Oversight Committee and Case Review Panels to undertake domestic homicide and suicide reviews which both the Committee and Panels must have regard for.

Given that domestic homicide and suicide reviews are a new process, it is anticipated that the first version of the guidance will be updated within approximately two years post introduction of domestic homicide and suicide reviews. This will allow for value feedback to be gained and utilised to revise the guidance in order to ensure it supports the effective undertaking of domestic homicide and suicide reviews.