Domestic Homicide and Suicide Review Taskforce minutes: March 2025

Attendees and apologies

Attendees

• Anna Donald, Chair, Criminal Justice Division, Scottish Government
• Emma Forbes, Victims and Witnesses Policy Team, COPFS
• Faith Curry, Scottish Fatalities Investigation Unit, COPFS
• Alisdair MacLeod, COPFS
• Sarah Taylor, Police Scotland
• Katie Brown, COSLA
• Ann Hayne, NHS Lanarkshire
• Lorraine Hall, NHS Shetland
• Duncan Alcock, NHS State Hospital
• Fiona Wardell, Healthcare Improvement Scotland
• Jennifer Layden, Healthcare Improvement Scotland
• Laura Mahon, Alcohol Focus Scotland
• Iris Quar, Abused Men in Scotland (AMIS)
• Fergus McQueen, Abused Men in Scotland, (AMIS)
• Fiona McMullen, ASSIST
• Jessica Denniff, SafeLives
• Carrie Sykes, Victim Support Scotland
• Jodie McVicar, Scottish Women’s Aid
• John Devaney, University of Edinburgh
• James Rowlands, Durham University
• Karyn McCluskey, Community Justice Scotland
• Graham Robertson, Public Protection, Scottish Government
• Tamsyn Wilson, Justice Analytical Services, Scottish Government
• Rod Finan, Social Work Advisor, Scottish Government
• Nel Whiting, Equality Unit, Scottish Government
• Vicky Carmichael, Criminal Justice Division, Scottish Government
• Laura-Isabella Muresanu, Criminal Justice Division, Scottish Government
• Jude Thomson, Criminal Justice Division, Scottish Government
• Erin Murphy, Criminal Justice Division, Scottish Government

Guests

• Frank Mullane, AAFDA
• Nicki Norman, AAFDA
• Rachel McPherson, University of Glasgow
• Maureen Taylor, Glasgow Caledonian University
• Lesley McMillan, Glasgow Caledonian University

Apologies

• Deborah Demick, National Homicide Unit, COPFS
• Sarah Holmes, COPFS
• Graham Grant, Police Scotland
• Emma Fletcher, NHS Tayside
• Edward Doyle, Scottish Government/NHS Lothian
• Giri Polubothu, Shakti Women’s Aid
• Kate Wallace, Victim Support Scotland
• Ann Fehilly, ASSIST
• Fiona Drouet, EmilyTest
• Vivien Thomson, Social Work Scotland
• Sarah Dangar, City University of London
• Claire Houghton, University of Edinburgh
• Khatidja Chantler, Manchester Metropolitan University
• Graham McGlashan, Scottish Law Commission
• Lynne Taylor, Directorate for Mental Health, Scottish Government
• Marsha Scott, Scottish Women’s Aid
• Jeff Gibbons, Criminal Justice Division, Scottish Government

Items and actions

Welcome, Introductions and Apologies

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

AD reminded 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. 

Criminal Justice Modernisation and Abusive Domestic Behaviour Reviews (Scotland) Bill

AD provided an update on the progress of the Criminal Justice Modernisation and Abusive Domestic Behaviour Reviews (Scotland) Bill. AD noted that the Criminal Justice Committee recently published its Stage 1 report, and the Scottish Government’s response will be published on the 27th of March, ahead of the Stage 1 debate. The following recommendations will be addressed as part of the response:

Definition of domestic abuse

AD mentioned that the definition of ‘domestic abuse’ included in the Bill has been informed by the consultation and targeted engagement undertaken in 2023. While recognising that it does not mirror the definition within Domestic Abuse (Scotland) Act (DASA) 2018, it is acknowledged that the Committee report recommendation is to not undermine the 2018 Act, and that is in part been why the Bill title refers to ‘abusive domestic behaviour’. However, the 2018 Act and Part 2 of the Bill have two different purposes. It is also useful to note that the Committee report welcomes the inclusion of honour based abuse and familial homicide. This inclusion would see a further departure from the 2018 definition, so all efforts will be undertaken to ensure that the differences are made clear.

Definition of a ‘child’ and ‘young person’

The definition of ‘child’ and ‘young person’ featured in the Stage 1 report, and the rationale for not including an age limit in relation to children in terms of what was called in the consultation ‘domestic abuse related family homicide’ was discussed through the Taskforce, Subgroup and other Task and Finish Group meetings. Where ‘connected deaths’ are referred to, the definition of a child of someone up to their 18th birthday, or 26th birthday if they had been previously looked after, is used.

Retrospective cases

AD noted that the Cabinet Secretary for Justice and Home Affairs committed to look at retrospective cases, and this will be discussed with relevant partners to understand the impact of including retrospective cases even if for a short period of time. If there were to be a delay between the Bill receiving Royal Assent and implementation of the model, then a backlog of cases would likely create challenges for those participating in the learning review.

Review bodies and membership

AD mentioned that through the call for views and the evidence sessions, there were a number of gaps highlighted in terms of public bodies that should be included within the Bill, such as the Parole Board and the Risk Management Authority. The gaps will be addressed through future amendments.

Lord Advocate’s power to pause or end a review

AD noted that the Criminal Justice Committee asked those invited to give evidence whether they were supportive of the provision in the Bill for the Lord Advocate to pause or stop a review. AD mentioned that there was one point of clarification sought on when the Lord Advocate would stop a review. AD observed that this will be set out in the protocol with the Crown Office and Procurator Fiscal Service, but it is anticipated that a review would stop where a Fatal Accident inquiry (FAI) is to take place.

Resourcing

AD noted that the Scottish Government is committed to resourcing the costs of operating the domestic homicide and suicide reviews, which are fairly significant. The intention is to not duplicate work, and to take forward joint reviews where appropriate, to help minimise the burden on professionals and families.

Complex review landscape

AD mentioned that the complex review landscape was another point made within the Stage 1 report. AD observed that much of the detail about the interaction between joint reviews will be covered within the statutory guidance. That process will involve engagement with relevant parties, who will have the opportunity to raise any concerns and ensure the guidance is sufficiently robust and flexible to adapt to emerging issues. AD reflected that discussions across the Taskforce structure have always progressed with the fundamental determination that a new model was required and not one built into an existing or existing review processes where there is already an awareness of existing limitations.

Review reports

AD highlighted that the publication of review reports and how these would be shared with families was addressed as part of the Stage 1 report, and this is likely to constitute the next focus of the Information Governance Delivery Group. The intention will be to prepare a paper informed by the discussions of the Group and bring this to the Taskforce for consideration on what may be the approach to be adopted, whilst still leaving flexibility for where a different approach may be requested or required.

AD highlighted that the government response to the Stage 1 report will soon be published, noting that the issues raised had already been identified through the written submissions and the evidence sessions held by the Criminal Justice Committee. AD acknowledged that Taskforce members would have a diversity of views on the points raised, and invited those in attendance to share their thoughts on any particular areas that they would want to emphasise.

Ann Hayne (AH) raised the issue of consent in relation to the publication of reports, and asked whether consent for publication would also be sought from the perpetrator. Vicky Carmichael (VC) answered that consent will be discussed with the Information Commissioner’s Office in an upcoming meeting, and the Information Governance Delivery Group will work on determining the most suitable lawful basis for the publication of reports.

AH also mentioned the concerns around the definition of ‘domestic abuse’ as it currently exists in DASA, and observed that from the wording in the Stage 1 report, it is unlikely for a death to result from a single incident of domestic abuse, and this may be helpful in satisfying people to understand why the remit of domestic homicide and suicide reviews would be slightly broader than the definition in the 2018 Act.

Alisdair MacLeod (AMcL) noted that the reference to the definition of ‘domestic abuse’ in DASA is a reference to the definition itself, and not the offence of DASA, as domestic abuse can occur outwith the DASA offence, and there can be a single incident of domestic abuse that is prosecuted and classified as domestic abuse. However, DASA provides the statutory definition for ‘domestic abuse’ in Scotland.

Understanding Domestic Homicide in Scotland Study – Overview of Key Findings

AD welcomed Dr Lesley McMillan (LMcM) and Dr Maureen Taylor (MT) from Glasgow Caledonian University, and Dr Rachel McPherson (RMcP) from the University of Glasgow, who will be presenting on the findings from the ‘Understanding Domestic Homicide in Scotland’ study.

LMcM noted that the study looked at a small number of Police Scotland case files over a 10 year period (no pre-Police Scotland cases). The team worked with third sector partners to more fully understand domestic homicide of women, the patterns of behaviour that precede it, the challenges it presents in terms of prevention, and the opportunities that may exist for safeguarding. LMcM highlighted that some of the key findings were made in relation to social connection and isolation, relationship trajectories, social issues, and institutional responses.

RMcP mentioned that the research team met with Police Scotland in April 2022 to discuss the research proposal regarding femicide in Scotland. As a result, ten cases were identified that had not been subject to substantial media coverage, given the risk of identifying the individuals in those cases, particularly when considering smaller jurisdictions. In all cases, the male partner or ex-partner had killed the female partner or ex-partner, and the cases resulted in a conviction for murder or culpable homicide. The project sought to examine what can be done with the police files, rather than being an investigation of patterns of femicide, of which much is known internationally. A key part of the methodology consisted of working with a number of partners (Police Scotland, ASSIST, Scottish Women’s Aid, Emiliy Test, NHS Lanarkshire, Victim Support Scotland and HMICS) to develop a data collection tool and find out what was known by professionals working in the field, and equally, what would be useful for them in terms of the work that they were doing. The research team organised four workshops using the World Café method to informally share ideas, allowing participants to work in groups and reflect on other people’s views. These discussions were visually summarised by illustrator Catriona Swanton, ensuring that all the themes were captured while also ensuring the anonymity of participants.

RMcP noted that there was rich data present in all cases, however, the data was not consistent across all cases. For example, in some cases, there were post-mortem and psychiatric reports, but not in others. This lack of consistency limited the scope of what could be used for research purposes to approximately 25 pages of data per case. The research team created timelines of events in the relationship, and analysed the social networks of both the victims and the perpetrators. RMcP observed that in nine of the cases there was an ongoing relationship, and in only one case the relationship had ended. This is slightly at odds with broader literature, however, the dataset used is very small. The duration of relationships ranged from short-term to several decades, and in terms of living arrangements, two of the couples lived separately, while the others would live in what legally constitutes a cohabitation. Five of the couples did not have children, whereas the other five had a mix of either adult children or children under the age of 18 years old. Six couples had a police footprint, of which there were three convictions ranging from relatively minor public disorder offences to violent offences, and one male partner who had been charged but not convicted.

RMcP noted that the majority of victims and perpetrators were unemployed, and there was alcohol and drugs usage identified as a significant part of the life of eight perpetrators and three victims. Equally, there were eight perpetrators and three victims with recognised mental health problems. In terms of the mental health of the perpetrators, this appears to have had an impact on their diminished criminal responsibility. International research also indicates that most men who are accused of homicide will try to use diminished responsibility as a defence, although not always successful. RMcP noted that the killings took place in the home, which is the case for most domestic homicides, and there were no visible elements of premeditation or attempt to conceal the facts. However, the perpetrators attempted to conceal or deny their criminal responsibility in a number of cases. RMcP observed that international research indicates that this stands in contrast with cases of violent resistance homicide, where the women who kill following domestic abuse contact the police immediately and admit responsibility for the fatality.

MT presented several charts that illustrated some of the key findings in relation to the social networks and level of isolation for both the victim and the perpetrator. The charts were produced by extracting the names and relationships given in the case files, with each individual relationship plotted on a chart and colour coded. The charts denote not only the existence of a relationship at the time of the homicide, but also its qualitative or subjective nature (strong, fractured, weak, or a relationship within which domestic abuse is perpetrated). MT highlighted that one of the key findings was that few women, if any, presented objectively as very isolated. Furthermore, there was no evidence that the perpetrators were isolating the victims. The findings indicate that there was a pattern of well-connected women who had a number of objective social connections, described subjectively as ‘good’, although there were various levels of disclosure within these relationships, and often women kept the gravity or longevity of domestic abuse hidden from families, friends, or colleagues.

MT observed that in some cases, it was evident that women’s networks were ‘safety zones’, as a number of these women held multiple jobs and maintained a wide range of friendships, which may have been protective strategies to avoid being at home. Those women who held multiple jobs may have shown signs of isolation occurring as a result of financial abuse and being held financially responsible for the household. The study found that between the networks of the victims and the perpetrators, the perpetrator would have very few connections, whereas the victim was well-connected. A number of the men in the sample did not have jobs, friends, or hobbies, attended very few family events and maintained very few family relationships, did not claim benefits – even though some of them would have been entitled to do so – and did not engage with statutory services, spending most of their time at home. MT reflected that this lack of social connection would be more likely to reinforce the perpetrator’s paranoid thoughts, offering few opportunities for others to challenge, monitor, or survey their behaviour, thus leading to an increased risk for the victim. MT added that there are different patterns for the perpetrator’s self-isolation, including circumstances where the perpetrator does not stay at home, is well-known and engages with others, however, those relationships are very superficial. Equally, there are different mechanisms through which the victim could become isolated, even though the perpetrator may not necessarily seek to achieve that. MT described circumstances where there would be a withdrawal of family and friends from the victim’s social network during the relationship, once the abuse started. There are different reasons for this withdrawal of support, ranging from avoiding an association with the perpetrator’s troubling behaviour and putting oneself or loved ones in danger, to intently withdrawing support in the hope that the victim would end the relationship with the perpetrator. However, the effect of this withdrawal was a further isolation of the victim and loss of a support network.

LMcM noted that for a large proportion of these cases, it appeared that no incidents were disclosed previously, either to agencies or families and friends. In contrast, some relationships showed significant repeated violence from early in the relationship, which was associated with contemporaneous agency involvement and disclosure. In many of the cases studied, there was an impression that the homicide could have happened at any time, and there were neither clear trigger events nor indications of an escalation within the relationship. LMcM reflected that some of the cases presented a series of missed opportunities for intervention, and it was notable in the sample that no cases appear to have involved MARAC or MATAC, despite previous offending and previous domestic abuse conduct. LMcM further added that where the perpetrator was bailed during the relationship, it was not immediately clear whether the perpetrator’s previous conduct was taken into account. LMcM concluded that from the dataset available, the patterns of isolation and social connection for both the victim and the perpetrator appear to be much more complex than what the literature suggests, and the perpetrator’s isolation could constitute a risk marker in cases of domestic abuse.

Jessica Denniff (JDen) asked whether any thought had been given to how to build on this process by adding information from other domestic homicides to create a core dataset, and using the findings to inform the work of the Taskforce. AD answered that this is something to be considered, and noted that some members of the Taskforce already have a connection to this work.

John Devaney (JD) welcomed the research and the findings, as well as the collaboration between Police Scotland and colleagues at the two universities in Glasgow. JD highlighted the importance of ensuring that domestic homicide and suicide reviews achieve the balance between looking at what happened to the victim and trying to understand what was occurring in the case of the perpetrator as well. JD recognised the usefulness of building a core dataset to start identifying a number of patterns. JD also emphasised the point that working with mental health services, and substance use services is really important, and the Think Family Approach, in relation to raising awareness about the impact of mental health on family members – including children – could be a useful model to consider and adapt

Frank Mullane (FM) reflected that the presentation demonstrated how hard it is sometimes to understand the full story. FM noted the finding that perpetrators were not claiming benefits even though entitled to do so as very curious, and wondered what the reasons might be. RMcP answered that there was not necessarily any evidence about why they were not claiming benefits, but the evidence showed that they were not engaging with services across the board, therefore it would be indicative of a wider pattern of lack of engagement. LMcM drew attention to a form of economic abuse, where men in the household refuse to contribute and deliberately make the family finances lower, and this would be part of one of the theories of the changing nature of coercive control.

Fiona Wardell (FW) wondered whether the victims had been in touch with any other healthcare services, such as maternity or screening services. FW noted that Healthcare Improvement Scotland develop screening and maternity standards at the moment, and they remain thoughtful of victims’ engagement with healthcare 

Iris Quar (IQ) observed that many of the points raised in the presentation were familiar to AMIS in their work to support male victims of domestic abuse, but others would require further thought and consideration to how they could be used as part of their work.

AD thanked LMcM, MT, and RMcP once again for such an interesting presentation, and highlighted the importance of staying connected given the crossover between the work of the Taskforce and the research being undertaken.

Testing Scotland’s Domestic Homicide and Suicide Review Model: Phase One

AD invited Nicki Norman (NN) and FM from Advocacy After Fatal Domestic Abuse (AAFDA), who facilitated the Phase 1 testing of the model, to present on the findings from the day.

NN provided a brief introduction to the work of AAFDA, and summarised the main findings and points for consideration resulting from the ‘Testing Scotland’s Proposed Domestic Homicide and Suicide Review Model’ workshop facilitated by AAFDA on 27 November 2024 at St Andrew’s House in Edinburgh. The workshop included 26 participants with diverse expertise acquired in Scotland, United Kingdom, and internationally. NN noted that the agreed objectives of the day were to:

• Achieve a facilitated walkthrough of the proposed Domestic Homicide and Suicide Review (DHSR) process;
• Identify unique factors about the Scottish political and cultural context which may impede or enhance DHSRs;
• Identify the strengths and weaknesses of the model;
• Support the identification of gaps within the proposed legislation and statutory guidance; and
• Identify next steps.

NN observed that the approach taken by the facilitators was to utilise small group discussions throughout the day with a focus on three different stages of the DHSR process:

Identifying when a DHSR is required and instigating a DHSR

• Scope/criteria for undertaking a review
• The decision-making process   
• Establishing the review’s chair and panel

Conducting a DHSR

• Effective information gathering to inform the review 
• Equality, diversity and inclusion
• Involvement of family, friends, community

Facilitating learning from a DHSR

• Reporting on the DHSR 
• Sharing and acting on learning 
• Accountability and governance arrangements

NN added that where available, information that is known to be proposed regarding the approach to be taken was presented to the groups. The powers and responsibilities were also set out in a separate handout for all to have to hand. As part of this, group members considered:

• The strengths and any limitations of the proposals
• Whether the proposed legislation is sufficiently robust
• What needs to be included in the related statutory guidance to support best practice
• Whether any additional tools were required to support best/safe practice.

AD thanked NN and FM for presenting on the findings from the day and thanked them for facilitating the workshop. AD acknowledged that some of the points raised during the day were also raised by the Criminal Justice Committee and reflected in the Stage 1 report.

VC mentioned that in terms of next steps for the Phase 1 report, the plan is to publish the report in due course, alongside the Scottish Government response to the report. VC noted that the report will be circulated to members once this is published. VC added that AAFDA will be undertaking the second and third phase of the testing of the model, and those sessions will soon be arranged.

JD recognised that the workshop was very helpful in allowing in-depth discussions on some of the more complicated issues, and it was beneficial to have the participation of colleagues from other jurisdictions who were able to lend their experience in this process.

Action 1: Scottish Government officials to circulate to Taskforce members the Phase One report from the ‘Testing Scotland’s Proposed Domestic Homicide and Suicide Review Model’ workshop.

Model Development Updates

Domestic Abuse Related Suicide Task and Finish Group

AD invited VC to present the paper mentioned at the December Taskforce on the proposed points that might help the Review Oversight Committee in its considerations on whether a domestic abuse related suicide proceeds to review.

VC mentioned that the paper has been considered by the smaller working group of the Domestic Abuse Related Suicide Group, which was operational for approximately six months, and it was discussed by the Model Development Subgroup. VC noted that a four point test was detailed in the paper, which requires that consideration is given to the recency and impact of domestic abuse, the connection between the domestic abuse and the circumstances of the death, the potential for identifying learning from the death, and the suitability for other review process to be undertaken instead. VC highlighted that the intention is for the four point test to be included within the statutory guidance, however, it is important to ensure that these points are not seen as a criteria to be ticked or met before a review could proceed. VC emphasised that each case is to be considered on its own merits, and these points are only intended to support the considerations of the Review Oversight Committee. VC added that if Taskforce members are content with the proposals, then the next steps of including the four point test within the statutory guidance could commence.

AH noted a surprise in relation to the fact that it would not be only the suicide of the partner or ex-partner that would be reviewed, and the suicides being reviewed would mirror the other deaths included within the scope of the model, such as children. AH highlighted that this could potentially be a very significant undertaking. VC clarified that in terms of domestic abuse related suicide, the deaths being reviewed would only be partners and ex-partners. AD added that this should be further clarified in the paper.

JDen queried about the potential to identify relevant learning, and noted that it would be useful to hear from other processes that may employ similar language around learning, and clarify what exactly that means and what it refers to in terms of learning. JD answered that the current statistics on suicide indicate that there could potentially be a large number of such reviews commissioned, which may result in very superficial reviews being undertaken that do not really delve into any systemic issues. JD noted that in this case, it would be important to identify those cases where there would be sufficient learning, and that a justification should exist for both cases that are being reviewed and those that are not. JD welcomed any suggestions on how these considerations could be improved and communicated clearly.

AD thanked Taskforce members for their input and noted that the Taskforce agrees with the proposals as set out in the paper.

Children and Young People Task and Finish Group

AD invited VC to present the paper on the work undertaken by the Children and Young People Task and Finish Group.

VC observed that the theme discussed in the paper emerged during the Phase One testing workshop that took place in November 2024, as well as during discussions within the child protection sector. VC noted that in terms of the number of reviews involving children and young people, the domestic homicide and suicide review would become an additional review process, however, concerns were raised that by virtue of being a statutory process, it will mean that a hierarchy of reviews is introduced. This theme also emerged during the Criminal Justice Committee evidence sessions, and is reflected in the Stage 1 report. VC mentioned that to try and alleviate these concerns, the Children and Young People Task and Finish group developed a set of principles to guide the undertaking of these reviews. The principles, if approved by the Taskforce, would be used to respond to the recommendation in the Stage 1 report and would be included within the statutory guidance.

AD acknowledged that at a high level, the principles appear to be sensible, but it would remain to be determined how these would work in practice. AD invited Taskforce members to share any views on the proposed principles.

Rod Finan (RF) noted that he was involved in these discussions as part of the Children and Young People Task and Finish Group, endorsing the principles in the paper, and agreed with AD that the most significant part of this work lies in the details. RF added that from a social work perspective, clear communication and continuous review of the process would be essential in avoiding the perception that some of the local processes are being replaced. RF noted that in its essence, the paper refers to a process similar to an inter-agency referral at operational level, when deciding how best to proceed with a review.

AH mentioned cases where there are drugs and alcohol related deaths alongside the perpetration of domestic abuse, and queried, where there is involvement of children and young people, whether there would be a hierarchy of what is expected in terms of review processes. VC answered that where children and young people are involved in drugs and alcohol related deaths, there would be a general point to be made around the undertaking of joint reviews, discussing how this would look like, and establishing suitable terms of reference. AH and JDen highlighted that as part of MARACs, there has been an increase in the number of victims under the age of 18 years old being considered as victims of domestic abuse.

JDen mentioned that under the information about MAPPA in the paper, in relation to the criteria for when a significant case review would be undertaken, the way in which the information is currently written would indicate that a significant case review could only be undertaken only when someone is MAPPA managed, whereas there are several other reasons and circumstances in which a significant case review would happen, and clarification to this effect would be beneficial.

AD thanked Taskforce members for their input and noted that the Taskforce agrees with the proposals as set out in the paper.

Action 2: The Domestic Abuse Related Suicide Task and Finish Group to consider how other learning reviews filter or test cases to identify those with the maximum learning to be gained.

Any Other Business (AOB)

VC mentioned that Historic Environment Scotland how now received the permission to install a permanent board at the Cairn for Margaret Hall in Holyrood Park, and this would be installed over the course of the next few weeks. VC noted that she is in discussions with Historic Environment Scotland in relation to any promotional events surrounding that, and will keep Taskforce members updated.

Date of Next Meeting (DONM)

The next meeting will take place on Thursday, 19 June 2025, 14:00 to 16:00.