Domestic Homicide and Suicide Reviews in Scotland: Statutory Guidance

Section 10 – Review Analysis

This section focuses on the analysis of a domestic homicide or domestic abuse related suicide review. Case Review Panels will use a structured analytical framework to identify learning and understand system dynamics.

10.1. Review Analysis – Structure

All report analysis within a domestic homicide or domestic abuse related suicide review, will be conducted through the lens of the victim, prioritising their experiences, perspectives, and the impact of events on their life. The Case Review Panel will seek to ‘walk in their shoes’, considering what the victim may have seen, felt, and experienced at each stage, ensuring that learning is centred on improving outcomes for those at risk. The approach will 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
• Appreciative enquiry – recognising examples of effective practice and innovation that may inform wider improvement.

For domestic abuse related suicide reviews, contribution analysis must consider cumulative stressors, any mental health history, patterns of coercive control and whether agencies recognised the intersections between domestic abuse and suicide risk. It should be noted again that a causal link between the domestic abuse and the suicide does not need to be established as part of the review.

Where a child or young person has been bereaved, analysis is to consider the child’s developmental needs, lived experience, exposure to harm and how agencies responded.

10.2. Analysis

Phases of review analysis typically include:

• Summarise family, friend and community insights and any questions they are seeking answers to that are within the scope of a domestic homicide or domestic abuse related suicide review.
• Presenting the key lines of inquiry based on information collated and processed including information from family, friends, colleagues and the community, to gain valuable insights.
• Collating Individual Management Review reports and chronologies and analysing these for accuracy, consistency, and completeness. Additional expertise, advice, briefings, reports or information may be sought if gaps in knowledge or expertise are identified.
• Presenting the initial findings and chronology to the Case Review Panel for discussion, clarification, and thematic analysis.
• Meeting/ speaking with family and keeping them updated on progress should they choose to be.
• Analyse the findings from the facilitated learning events to incorporate local expertise and the practitioner’s voice.
• Triangulation of information from professional panel members representing involved organisations, local practitioners, and families (including children, friends, neighbours, and colleagues) to build a rounded understanding of the case. This ensures that the domestic homicide or domestic abuse related suicide review captures multiple perspectives, identifies gaps or inconsistencies as well as opportunities taken, and supports the generation of meaningful, actionable learning for future practice.
• Requesting any further information, expertise, or clarifications from agencies or contributors before forming findings, recommendations and conclusions.

Training will be provided to Case Review Panels on undertaking domestic homicide and domestic abuse related suicide reviews including review analysis and development of recommendations.