Domestic Homicide and Suicide Review Taskforce minutes: March 2024

Minutes from the meeting of the group held on 7 March 2024.

Attendees and apologies

  • Anna Donald, Chair, Criminal Justice Division, Scottish Government

  • Deborah Demick, National Homicide Unit, Crown Office and Procurator Fiscal Service (COPFS)

  • Sam Faulds, Police Scotland
  • Ann Hayne, NHS Lanarkshire
  • Laura Mahon, Alcohol Focus Scotland
  • Karyn McCluskey, Community Justice Scotland
  • Marsha Scott, Scottish Women’s Aid
  • Kate Wallace, Victim Support Scotland
  • Ann Fehilly, ASSIST
  • Iris Quar, Abused Men in Scotland (AMIS)
  • Jess Denniff, SafeLives
  • Lorraine Gillies, Scottish Community Safety Network
  • Fiona Wardell, Healthcare Improvement Scotland)
  • Khatidja Chantler, Manchester Metropolitan University)
  • John Devaney, University of Edinburgh
  • Kate Holliday, University of Edinburgh
  • James Rowlands, University of Westminster
  • Sarah Dangar, City University of London
  • Edward Doyle, Senior Medical Advisor Paediatrics, Scottish Government/NHS Lothian
  • Tamsyn Wilson, Justice Analytical Services, Scottish Government
  • Lynne Taylor, Directorate for Mental Health, Scottish Government
  • Nel Whiting, Equality Unit, Scottish Government
  • Jeff Gibbons, Criminal Justice Division, Scottish Government
  • Vicky Carmichael, Criminal Justice Division, Scottish Government
  • Laura-Isabella Muresanu, Criminal Justice Division, Scottish Government
  • Jude Thomson, Criminal Justice Division, Scottish Government


  • Emma Fletcher, NHS Tayside
  • Faith Curry, Scottish Fatalities Investigation Unit, COPFS
  • Emma Forbes, Victims and Witnesses Policy Team, COPFS
  • Giri Polubothu, Shakti Women’s Aid
  • Alice Nottage, Victim Support Scotland
  • Claire Houghton, University of Edinburgh
  • Fiona Drouet, EmilyTest
  • John Mulholland, Law Society of Scotland
  • Joanna MacDonald, Social Work Advisor, Scottish Government
  • Michael Crook, Drugs Policy, Scottish Government
  • Katie Brown, Convention of Scottish Local Authorities (COSLA)

Items and actions

Welcome, introductions and apologies

Anna Donald (AD) welcomed members to the fifth meeting of the Domestic Homicide and Suicide Review Taskforce.  

AD outlined to members that some of what would be discussed in terms of subject matter might be difficult and sensitive. Emphasising the importance of everyone’s wellbeing, she invited members to take time out and look after themselves as required.  

Members were asked to introduce themselves when first speaking during the course of the meeting and apologies were noted.

Chair's update

AD provided an update on progress since the previous meeting of the Taskforce on 30 November 2023:

  • Sarah Dangar will take on the role of Deputy Chair for the Domestic Abuse Related Suicide Group which Fiona Drouet will Chair.
  • Eddie Doyle will Chair the Children and Young People Group, with Claire Houghton as Deputy Chair.
  • The Cabinet Secretary for Justice and Home Affairs has confirmed that the finalised domestic homicide and suicide review reports will be submitted to the Scottish Government. This should enable learning and recommendations to be tracked as well as monitoring the impact whilst having the ability to work across portfolios to ensure learning is being implemented.
  • Taskforce members John Devaney (JD), Khatidja Chantler (KC), Sarah Dangar (SD), James Rowlands (JR), and Vicky Carmichael (VC) attended the Community of Practice for the Study of Domestic Homicide in Dublin, where VC and University of Edinburgh PhD Candidate, Zain Kurdi, presented on the work of the Taskforce and the findings from the consultation and targeted engagement that took place between September – October 2023.

AD invited Taskforce members to ask any questions in relation to the updates provided.

Kate Wallace (KW) asked whether a decision has been made on the anonymity of reports. VC responded that a decision has not been made and the publication of reports is still under consideration. JD added that the families’ expectations around the review and report have to be understood when deciding, and the accessibility of reports to family members is also to be further determined.

Minutes and actions

The minutes of the fourth Taskforce meeting have been published on the website, as agreed during the November 2023 Taskforce meeting.

Three of the six actions have been completed. Of the remaining three, one action is related to the use of homicide data in the development and operation of the model; one action is related to the Risks and Issues Log, which will be discussed during subsequent Model Development Subgroup and Taskforce meetings; and one action is on hold – a presentation in relation to perpetrators and the review process. James Rowlands would deliver this presentation at a future meeting.

Marsha Scott (MS) asked about the data related to deaths as a result of domestic abuse, and made reference to an European Observatory on Domestic Homicide Reviews European Observatory on Femicide (EOF) (  and the question as to whether Scotland could participate in an upcoming report. MS queried whether this data could become more readily available to enable public statements.

AD emphasised the need to be as open and as detailed as possible on this issue, and reinforced that Scottish Government is willing to support the efforts of contributing to the European Observatory report. VC asked MS to share what data is being sought as part of the report and she would liaise with colleagues in Justice Analytical Services.

JD recalled the recent Community of Practice meeting that took place in Dublin and mentioned that the issue of data on deaths and near misses was a topic of discussion. JD referenced the longitudinal study conducted in Norway, looking at the rate of general homicide as compared to that of domestic homicide, and suggested that this is something that Scotland could consider in the future.

Action: Marsha Scott (MS) to share with Vicky Carmichael (VC) what data is being sought as part of the collation for the European Observatory report.

Model Development Subgroup and model approaches Situation, Background, Analysis, and Recommendation (SBAR)

AD invited JD to provide an update on the activity of the Model Development Subgroup and the model approaches SBAR.

JD mentioned that since November 2023, the Model Development Subgroup met four times and discussed the following:

  • The findings from the consultation and targeted engagement that took place between September – October 2023
  • The implementation of learning from domestic homicide reviews and the paper produced by PhD intern Kate Holliday (KH)
  • The different options in terms of the approach to the model for Scotland before reaching its recommendation to the Taskforce.
  • The proposed Task and Finish Groups necessary to support the work to develop the model, the remits and membership.
  • An updated version of the paper on Scotland’s reviews landscape from the June Taskforce

JD set out that there were two recommendations that the Model Development Subgroup were making to the Taskforce, the first on the review approach option to take forward, and the second on the Task and Finish Groups to be established.

JD noted that in relation to the first recommendation, there were three model approach options considered, which were further detailed in the paper circulated to Taskforce members ahead of the meeting. JD emphasised that there is no perfect model, but members were being asked to consider the approach that would be the most suitable from a Scottish context. The options include:

  1. The Standing Review Committee
  2. The Individual Case Review
  3. The Hybrid Model

From the Model Development Subgroup discussions, the hybrid model was considered to be the most suitable. This was due to members concluding that it takes the best of having a standing group of people to oversee the process and combines it with the flexibility of appointing individual Chairs and committees to review specific deaths. In this case, the standing group would be able to quality assure the reports and check compliance with the terms of reference, while also taking a more strategic approach to the emergent learning and consider systemic or thematic findings alongside patterns that may occurs in very particular types of deaths, e.g., deaths of adolescents in dating relationships. The disadvantage is that this option is more resource-intensive, and consideration should be given to what additional resources may be required. JD also highlighted that Police Scotland and COSLA expressed a preference for a standing committee model, as it reflects internal practices and presents the benefit of building expertise over time. However, they were supportive of the proposed recommendation to the Taskforce to adopt a hybrid approach.

JD invited Taskforce members to share any reflections on the first recommendation.

Khatidja Chantler (KC) observed that the hybrid model has many strengths, as well as some downsides, such as being resource-intensive, as already mentioned, and the additional pitfall of groupthink. KC reinforced the importance of having an overarching structure for these review processes, which is one of the crucial benefits of a standing committee model.

Ann Hayne (AH) queried what a standing committee would look like and what would be the expectation on their involvement. Ann stressed the importance of quantifying the resources required, such as staff hours from the agencies involved.

MS was complimentary of the Model Development Subgroup’s work to date. MS asked whether there is a mechanism of independence that can be built into this process to insulate any potential outcomes from the political landscape.

KW recognised the attraction of the hybrid model, especially in relation to the quality assurance aspect. KW mentioned that the feedback often received from families points towards the variable quality of reviews. KW echoed MS’s query and potential concern in relation to the independence of the group undertaking the review. KW highlighted a preference towards the standing committee option due to the opportunity of building an expertise and providing a more robust quality assurance. KW mentioned that with regards to resources, she thought that agencies could come together to find a solution.

James Rowlands (JR) noted support for the hybrid model, and the fact that to an extent it presents some similarities with approaches currently undertaken in New Zealand or Florida. JR highlighted the secretariat function as a key issue of this model, connecting the overarching body to the delivery arm actually undertaking the review. JR observed that in some of the other models, the real strength lies in the appointment process for the oversight body, which brings together varied expertise.

AD reinvited JD to share any initial thoughts on the comments made by Taskforce members.

JD mentioned that the reflections are very helpful and reinforced that there is no approach that stands out as perfect. In relation to the role of the standing committee, JD echoed JR’s thoughts on the appointment process, which could be carried out through a variety of methods, e.g., open competition or recommendations by key agencies, but would need to be a formal appointment process for the independent chair to enable the confidence of families, agencies, and the general public. The standing committee would look at initial case reviews, therefore it is important to know who would make the decision about whether a referral proceeds to full review, as it’s not only a question of the agencies that were directly involved with the victim, but also the standing committee’s ability to review the process of appointing chairs and to ensure that timescales and performance expectations are met. The standing committee would further review the reports before they are shared with the Cabinet Secretary for Justice and Home Affairs, and they would be responsible for the dissemination of learning, overviewing action plans, and monitoring the implementation of action plans. For example, in some areas, there is a 12-month period after a review where agencies report on the implementation of learning. JD also emphasised the secretariat as a critical resource to keeping the model operational. In relation to resources, JD observed that the role of the Model Development Subgroup is to make a recommendation on the most robust process that can be implemented, even though that may pose some challenges in terms of resources, and some compromises may have to be agreed by the Taskforce.

MS returned to the question on independence and whether there could be some part of the process that is not entirely statutory. JD answered that in Northern Ireland, the reports are shared with the Justice Committee once per year, which ensures accountability within government.

MS also made a similar point in relation to the secretariat being critical and mentioned that the secretariat is vital to ensuring the independence on the process and should be cautiously considered. The secretariat could perhaps be funded centrally but not operated centrally.

AD thanked Taskforce members for their participation in the discussion and asked whether all agree with the Subgroup’s recommendation for the hybrid model to be further explored as a review approach option. Taskforce members agreed.

In relation to the second recommendation, JD outlined the four groups that the Model Development Subgroup proposed are established in order to support the development of the detail of the model. The four proposed groups included:

  1. Domestic Abuse Related Suicide Task and Finish Group
  2. Children and Young People Task and Finish Group
  3. Workforce and Training Task and Finish Group
  4. Information Governance Delivery Group

JD noted that the recommendation on the Task and Finish Groups will be discussed in more detail by VC in a subsequent agenda item.

AD thanked JD for the updates provided and Taskforce members for their consideration of this work.

Implementing the learning from domestic homicide and suicide reviews

AD invited KH to present the findings set out in her paper on learning from domestic homicide reviews, which she developed during her internship within Justice Analytical Services. The aim of the paper is to act as a useful resource to help the Model Development Subgroup develop the model and ensure that it can successfully implement learning following domestic homicide and suicide reviews. KH developed the paper from reviewing academic literature, responses to the consultation and targeted engagement, and discussions with academics within the UK and internationally and practitioners working within adult and children learning review models in Scotland.

KH summarised the findings into three themes: reviews and reports; recommendations from domestic homicide and suicide reviews; and monitoring and evaluation. KH highlighted that as the development of Scotland’s model is still at the early stages, the findings are intended to be used flexibly as the model develops further. The paper will be shared with members following publication on the 26 March 2024.

AD thanked KH for her presentation and contribution to this work and invited questions and comments from members.

MS asked about the recommendations that reflect systemic change and at what level of detail those operate. For example, do they refer to broader considerations, such as the way domestic abuse is approached in courts, or more detailed ones, such as risk assessment criteria for MARACs. KH answered that the system-level approach to change is something that New Zealand have started doing recently, where recommendations are no longer given to agencies specifically, but are mostly concerned with broader transformational change. The paper details the multiple lenses that may need to be applied to a review at a foundational level, for example, a gender or intersectional lens, and this is a point of reflection when considering systemic changes.

Deborah Demick (DD) emphasised that deconstructing a criminal justice process is very different than undertaking the same for a domestic homicide review, and COPFS would need to be closely involved in any recommendations that concern changes to the criminal justice system. DD queried whether there are any sanctions in place where the same recommendations are made repeatedly and agencies fail to implement them, either as a result of a barrier or other reasons. KH mentioned that from the discussions that took place, it emerged as very difficult to implement a system where recommendations were forced onto agencies under the threat of sanctions for failure to comply, and a system of positive reinforcement was preferrable. Understanding the value of undertaking a review and making clear recommendations is more effective than a sanctions-based model.

Edward Doyle (ED) asked about the existing Scottish reviews and processes for circumstances where a death has occurred, and echoed DD’s comment on the need of seeing through the implementation of recommendations, which may prove to be difficult even if there is overall agreement on the importance of it.

JD addressed DD and ED’s comments and discussed the child death reviews process that was set up in Northern Ireland, where once a recommendation was made, a senior person within the agency would confirm receipt and commitment to implementing the recommendation.

MS observed that there may be a need to invent a new mechanism to challenge how the system operates, and reflected on recommendations made in other jurisdictions, where for a variety of reasons, these were not successfully implemented and were repeated in subsequent reviews.

AD reflected that this is a new process with every opportunity to shape into a meaningful one that addresses the above-raised concerns.

KH thanked Taskforce members for their comments and invited them to read the full paper once this is published. AD advised members that the report would be published on 26 March 2024 and once published would be circulated to members.

AD thanked KH for her presentation and the very thorough work that had been undertaken. She emphasised the usefulness of learning gained from other models, particularly around how recommendations are made, actioned, and the existing accountability measures.

Action: Scottish Government officials to circulate the paper once published on the 26th of March 2024.

Supporting the Model Development Subgroup

AD invited VC to present the proposed revision to the Taskforce structure to reflect the findings of the consultation and decision by the Cabinet Secretary for Justice and Home Affairs.

VC presented the current governance structure of the DHSR Taskforce and provided further detail on what else is needed to support the model development e.g., the necessary Task and Finish Groups, remits, chairs and membership. The Model Development Subgroup recommends the establishment of the following Task and Finish Groups:

  1. Domestic Abuse Related Suicide Task and Finish Group
  2. Children and Young People Task and Finish Group
  3. Workforce and Training Task and Finish Group
  4. Information Governance Delivery Group

VC invited questions and comments from Taskforce members.

MS emphasised the importance of co-production and moving away from solely ensuring that the voices of those with lived experience are represented. Scottish Women’s Aid offered to support this work. MS further expressed interest in Scottish Women’s Aid being represented on the Children and Young People Task and Finish Group and the Workforce and Training Task and Finish Group.

AH offered to request input form NHS Lanarkshire Information Governance Officer for the Information Governance Delivery Group. AH also expressed an interest in joining the Workforce and Training Task and Finish Group as a health board representative.

Ann Fehilly (AF) queried whether ASSIST could be represented on the Workforce and Training Task and Finish Group.

AH proposed that with regards to Public Health Scotland, both the Gender Based Violence and Suicide leads could be considered for the Workforce and Training Task and Finish Group, as well as the Domestic Abuse Related Suicide Task and Finish Group. AH further proposed that Healthcare Improvement Scotland could contribute to co-production modelling, and equally, the bereaved families service run by Victim Support Scotland could be key to considering the co-production roundtable.

AD asked Taskforce members whether all agree with the Subgroup’s recommendation on the Task and Finish Groups to be established. Taskforce members agreed. AD further invited members to consider any other discussions that would need to take place in support of this work, which many not necessarily need to happen within the formally established structure of a Task and Finish Group but could also happen as a roundtable or an ad-hoc group.

Action: Scottish Government officials to finalise and issue the Task and Finish Groups invitation letters.

National standards

AD invited VC to discuss the benefits that the development of national standards could have for this work.

VC set out the benefits of developing national standards for the model, which could be progressed in parallel to the development of the model. The standards set out the expectations that people can have when using a service, as well as how organisations are supposed to deliver on these expectations. They are often strengthened by indicators, which could be useful for measuring progress. VC offered as an example the national standards developed by Healthcare Improvement Scotland for forensic examination services for victims of rape and sexual assault. VC asked Taskforce members whether they consider that the development of national standards could enhance the domestic homicide and suicide review model for Scotland and whether this is something that should be explored further.

MS observed that this is something that could be explored later in the process when it will be clearer what the associated needs will be.

AH mentioned that within a health board, national standards can be very effective in driving action, and the performance indicators can further augment this.

ED noted that it was worth exploring further. There is a challenge in ensuring that key performance indicators are person-centred, but anything that can give more impetus and weight to the process is worth developing.

AD highlighted that developing standards for a domestic homicide and suicide review process is different than doing the same for the Sexual Assault Response Coordination Service (SARCS), the latter being a more focused on service delivery, however, there is an opportunity to understand how this could add value.

AD thanked members for their contributions to the discussions.

Action: Scottish Government officials to discuss the development of national standards with Healthcare Improvement Scotland.

Any Other Business (AOB)


Date of Next Meeting (DONM)

The next meeting will take place on Thursday, 6 June 2024, 14:00 – 16:00.


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