Domestic Homicide and Suicide Reviews in Scotland: Statutory Guidance

Reporting, Publication and Dissemination

Section 11 – Learning, Recommendations, Actions and Reporting

This section provides guidance on how learning should be identified, interpreted and translated into clear findings, recommendations and actions arising from domestic homicide and domestic abuse related suicide reviews and then preparation of the review report. The aim is to ensure that learning leads to meaningful change across agencies, strengthens safeguarding practice, and reflects the needs and experiences of victims, children and families.

11.1. Identifying Learning, Recommendations and Actions

Reviews should focus on identifying what can be learned from the circumstances that led to the death and in some cases, post death, patterns in agency 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, measurable, achievable, relevant and time bound – SMART
• go deeper into addressing ‘why’ certain decisions were made or actions were taken/ not taken – they should be meaningful not superficial and be orientated towards system change and improvement and not individuals
• based on evidence received from all sources of the review process including information from families, friends, colleagues and community members, practitioners, Individual Management Review reports, research and additional expertise provided to the review
• split into local recommendations, local recommendations with national applicability and national recommendations – they should encompass local and national actions and system level change
• highlight where similar recommendations have been made previously within domestic homicide and domestic abuse related suicide review and other relevant learning reviews
• assigned to a named organisation with a lead role identified within the organisation. Where recommendations sit across more than one organisation e.g. multi-agency or partnership recommendations, recommendations are to clearly identify which organisation(s) are accountable for what aspects of a recommendation. This flows through to the action plan for how each aspect will be actioned through each organisation and collectively
• include an aspirational recommendation of the Case Review Panel and another of the family – recognising that these may not be SMART but collectively the aspirational recommendations form part of the wider, thematic learning from domestic homicide and domestic abuse related suicide reviews.

Recommendations are to be evidence based and the rationale for how a recommendation was reached will be discussed with relevant agencies and where relevant, local public protection forums such as Chief Officers’ Groups. Agencies will not be able to veto a recommendation but a discussion will be had with them on how these are framed. Recommendations can and should be stretching but they are also to be reasonable and feasible, for instance, a recommendation that would cost a small victims organisation over £1 million to implement is not reasonable or feasible and this is not the kind of recommendations that the Case Review Panel should be making, particularly to agencies with limited staffing and financial resources. Should there be disagreement on the practical feasibility of implementing a recommendation, the Case Review Panel Chair will discuss this with the relevant agency or agencies and it would be anticipated that agreement would be able to be reached on how a recommendation is to be articulated in the report. Should agreement not be reached the Case Review Panel Chair may wish to discuss the matter with the Review Oversight Committee but if the recommendation is based on evidence and is considered reasonable and feasible, the recommendation will remain in the report. What is important is that recommendations do not come as a surprise and that discussion is had on their feasibility and framing.

Recommendations relating to decision making in respect of a criminal or civil case or inquiry, or relating to prosecution policy or other independent prosecutorial functions, are not within the scope of a domestic homicide or domestic abuse related suicide review. Recommendations may, however, be made in relation to systemic or service‑level matters concerning the operation of justice agencies, for example, how a court functions and the service it provides.

Where learning is identified in relation to independent decision making or other matters that are outwith the scope for recommendations, that learning may be identified and shared, but must not be framed as a recommendation. In such cases, there should be discussion between the Case Review Panel Chair and the relevant justice agency to ensure that boundaries are maintained and independence respected.

Action plans are to be prepared by the Case Review Panel and discussed with the relevant agencies. Discussions are to include timescales for implementation and agreed points or milestones where progress is to be followed up with agencies. Where recommendations and actions involve more than one agency, this will be clearly specified to ensure clarity around ownership of each component, as well as collective responsibility. This will ensure there are clear lines of accountability for delivery.

11.2. Preparing Review Reports

Domestic homicide and domestic abuse related suicide reviews, and the subsequent reports, should be recognised as the first step towards implementing organisational and system change.

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

• a pen picture/ tribute to the victim
• an introduction setting out the purpose of the review, the legislation underpinning the review, a summary of the events that led up to the death and post death where a review has been expanded, the scope and review Terms of Reference
• a summary of significant relationships within the lives of the victim and perpetrator, where they were partners/ ex-partners, and any changes to those relationships prior to the death
• the methodology used – the approach taken (trauma-informed, rights-based and the agreed principles for how the Case Review Panel were going to work together), agencies involved, family participation and how their questions and views shaped the report, key lines of inquiry and relevant information e.g. there is guidance but it has not been updated in over 10 years, summary of information sources e.g. scoping, Individual Management Review reports, additional expertise, facilitated learning event, interviews with family members, friends and neighbours, information on recommendations identified by agencies that have been implemented, information relevant to agencies/ panel members e.g. an agency has domestic abuse training but it is not mandatory
• family, friends, colleagues and community members involvement and their reflections – this is to include reflections on who the victim was and their relationship with their perpetrator, any known or suspected domestic abuse, any friends or support services the victim or perpetrator was engaged with. This section should also include what contact was made with the family and others in relation to review e.g. notification of a review being established, a meeting with the Case Review Panel Chair, attending a Case Review Panel meeting etc.
• summary of key events – this is a summary of the full chronology e.g. the key events, contacts with agencies within the temporal scope and key points taken from the Individual Management Review reports, facilitated learning events and engagement with family and others. This can be set out using a table or using a visual to demonstrate the level of agency interaction which may be more impactful than by text.
• agency involvement – a brief summary of the role of each agency where an Individual Management Review report was received and a summary of key contacts, decisions, referrals made and areas of good/ safe practice e.g. 30 police reported incidents within 18 months prior to the death of XX. Referred to XX on XX.
• analysis – approach to the analysis e.g. socio-ecological, causal analysis, appreciative inquiry, systemic issues and patterns identified. This section considers the thematic, multi-agency and system analysis, patterns and key aspects identified including opportunities missed and taken. It should also reflect any disagreement between Case Review Panel members on aspects of the case. The key lines of inquiry as outlined in the Terms of Reference provide a framework for the analysis.
• learning identified – summary of thematic and specific learning identified including agency level, multi-agency level, victim learning, perpetrator learning, child and young person specific learning where relevant, domestic abuse specific learning, domestic homicide/ homicide learning and domestic abuse related suicide/ suicide specific learning. This is in addition to other learning themes specific to the circumstances of the death. This section should clearly outline the supporting evidence for each learning point.
• recommendations – SMART recommendations that set out local learning, local learning with national applicability and any national recommendations. Where recommendations have already been implemented following a death these should be noted as well as relevant context e.g. a new ICT system was recently added which all staff have now been trained on. Where recommendations relate to agencies not represented on a Case Review Panel, a draft report or part of a draft report will be shared. The names of the victim, perpetrator and relevant others including children, will be pseudonymised before any report is shared as well as other attributable or identifiable information. Where there is any disagreement on the feasibility of recommendations by panel members, practitioners or families, friends etc, this will be discussed. Where these disagreements remain they should be recorded within the report. The action plan is also to be prepared at this point.
• conclusion – summary of key learning, reflections of the Case Review Panel, the experiences of families including children where relevant, and future prevention.
• annexes – a number of annexes are to be included such as the full chronology, a table of Individual Management Review Reports received, Terms of Reference, Case Review Panel Chair, membership and statement of independence of the Chair, etc.

11.3. Language, Framing and Victim Blaming

The language used in the report should be accurate, respectful and free from bias. Domestic homicide and domestic abuse related suicide reviews should adopt framing that:

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

It is important that domestic homicide and domestic abuse related suicide review reports are written in a way that supports publication, scrutiny and accessibility. Reports should be clear and meet the needs of a range of audiences including families, practitioners, policy makers and the public, so that reports can be understood and free from technical language that obscures meaning.

Where a review includes the death of a young person or a domestic abuse related suicide, the report should ensure that specialist considerations, such as developmental needs, cumulative adversity or suicidality, are explained in an accessible way.

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. In reviews involving children it should be noted that behaviour may reflect trauma, developmental stage or the impact of living with domestic abuse.

11.4. Anonymity of persons

The Review Oversight Committee Chair must take all reasonable steps to ensure that individuals are not identifiable, including through jigsaw identification, in the publication of review reports. While data protection legislation applies only to the personal data of living individuals, the 2025 Act attaches the anonymity requirement to those who require it. This includes the person or persons who have died, the perpetrator and living family members, but does not extend to the authors of the review report. In addition, where young people are concerned, due regard must be given to Article 16 of the United Nations Convention on the Rights of the Child, which affirms every child’s right to privacy, including protection from unlawful or arbitrary interference with their private and family life. This reinforces the need for heightened care when reporting on cases involving young people, whether deceased or surviving. To support this, consideration should be given to the pseudonyms used, the removal of identifying details and careful consideration of contextual information that could indirectly identify individuals.

The real names of victims, perpetrators and any children or young people will therefore not be used within the report to help prevent identification. Pseudonyms will be used instead. The pseudonym used will be discussed with the family, friends of the victim and their advocate if preferred. The Case Review Panel Chair can provide options based on what they have learned about the victim through the review and their engagement with the victim’s family, friends and others. Family and friends of the victim can suggest an alternative but consideration must be given to ensuring that the suggested pseudonym does not identify an individual.

11.5. Sharing Draft Review Reports

Where a domestic homicide or domestic abuse related suicide review report is in draft i.e. it has not been submitted for approval to the Review Oversight Committee, it is anticipated that there will be a need for some review reports or part of a review report to be shared with agencies that are not represented on the Case Review Panel. The sharing of the draft reports/ part of a report is for the purpose of factual accuracy checking and to ensure the operating context is reflected correctly within the report. A discussion will also be had where necessary on the framing of recommendations within the report. This will be particularly important in relation to joint reviews but it is also important to ensure that local public protection forums including the local Chief Officers’ Group, Violence Against Women Partnership etc., are aware of the findings and recommendations where relevant, and that they have the opportunity to help frame any recommendations that relate to them. Given the sensitive nature of the content of the review 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 Chair, in accordance with the protocol and in line with data protection processes and protocols. Where a draft report is shared for the purpose of checking accuracy, a copy is to be provided to the Scottish Ministers.

Where a report or part of a report is able to be shared, it will only be permitted to be shared by the Review Oversight Committee Chair or the Case Review Panel Chair, with those specific individuals they consider appropriate. This means that the report cannot be shared with wider members within an agency unless approved by the Review Oversight Committee Chair. Case Review Panel Chair. Should additional members of an agency require sight of the draft review report, the Single Point of Contact should discuss this with the Secretariat who can liaise with the relevant Chair to seek the requested approval.

11.6. Involvement of Family and those Supporting Families

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

Following finalisation of the draft domestic homicide or domestic abuse related suicide review report, and where the timing is appropriate e.g. where criminal proceedings are not ongoing, the Case Review Panel Chair will invite the family of the victim or their friend(s) where relevant to meet with them to discuss the report. If family or friends have chosen not to engage within the review process, the Chair will still reach out as per the initial discussion following the determination that a review was to be undertaken. This engagement will be handled sensitively and the Case Review Panel Chair may discuss with the advocate or other relevant support agencies on who the communication should come from.

Where the offer to meet with the Case Review Panel Chair is taken up, the Chair will:

• Discuss with families when it may be more appropriate to meet e.g. consideration of the status of any criminal proceedings.
• Explain their role as Case Review Panel Chair and the independence of the role.
• Outline the purpose of a domestic homicide and domestic abuse related suicide review and the purpose of the meeting, which is to explain the process of their loved one’s review, findings, recommendations and actions, and to listen to the reflections of family/ friends. Outline that the review is about learning not blame and set out clearly what the meeting is not and what it will not cover e.g. criminal justice proceedings.
• Remind families/ friends that the review is victim-centred and their views and reflections are valued.
• Check whether they wish to proceed and if so, outline the approximate time to go through the report and suggest where may be helpful to pause/ take breaks. Remind families/ friends that they can stop at any time and that support is available.
• Remind families/ friends of the questions they asked at the beginning of the review process (where relevant), the Terms of Reference and their aspirational change they outlined initially plus the aspiration of the panel.
• Outline the key lines of inquiry, key findings, learning, recommendations and actions.
• Invite family/ friends to share their questions, views, concerns and their experience of the review process. It is important that the Case Review Panel Chair clarifies any points of uncertainty and if there are any details that are unable to be shared, to explain the reason for this.
• Next steps should be clearly set out in terms of the process in relation to the review report and whether any changes are to be made following the meeting, the process for making and agreeing those, the role of the Review Oversight Committee in relation to quality assurance and Lord Advocate approval prior to publication. A discussion about dates to avoid for publication of the report and whether families/ friends want to be kept updated in relation to progress on implementation of recommendations. The Case Review Panel Chair will also make families/ friends aware of the biennial report and the timescales for this in relation to their loved one’s review.
• The Case Review Panel Chair will thank families/ friends for meeting with them and will make the family/ friends aware that they will contact them following the meeting to check in and remind them of the support available to them.

Families have a right to reply to the draft report. This is to enable families to highlight any inaccuracies or omissions, provide additional context or insights about the victims’ experiences or circumstances, and raise any questions or concerns regarding the findings or recommendations. The points raised by families or by their dedicated advocate will be recorded. Case Review Panel should carefully consider all family input and where any changes to the report may be needed. Families should be made aware of the changes made to the report. By offering families the right to reply, the intention is to demonstrate to families that their voices are being listened to and are respected.

Following submission of the report to the Review Oversight Committee and where it is to be published, families will be kept updated on progress on implementation should they choose to be. This can be done directly or through their advocate or victim support organisation.

11.7. Finalising Draft Review Reports

Following any final changes to the draft domestic homicide or domestic abuse related suicide review report, the Case Review Panel Chair will finalise the report. Where there are points of disagreement, these are to be captured within the report. The 2025 Act does not allow a report or part of a report to be published except with the consent of the Lord Advocate. In addition, publication of a full report event with pseudonyms will often be incompatible with avoiding ‘jigsaw identification’. Instead, a ‘public summary’ will be prepared that clearly communicates:

• the key learning
• at least the main recommendations
• any local, regional or national or structural matters identified
• opportunities missed or taken
• sufficient context to ensure a meaningful summary yet one which protects identities
• any wider themes and key aspects relevant to policy, practice and system change.

The public summary is to be prepared in such a way that it is suitable for publication whilst also safeguarding anonymity. Where the case involves a domestic abuse related suicide, the report and summary should take into account where there may be cultural sensitivities around suicide. Review reports should also avoid simplistic narratives about cause, responsibility or intent. When the Case Review Panel Chair is preparing for the reports and action plan to be submitted to the Review Oversight Committee they should also outline any associated risks in relation to publication that the Review Oversight Committee should consider.

11.8. Submitting a Report to the Review Oversight Committee for Quality Assurance and Approval

Once the Case Review Panel Chair has prepared the report and public summary, the accompanying action plan and associated risk assessment, the Case Review Panel Chair must submit these to the Review Oversight Committee for quality assurance and approval. The quality assurance and subsequent approval process will include the Review Oversight Committee considering whether:

• the quality and depth of analysis is to a high standard
• engagement with families where appropriate, was done to a high standard
• there is coherence between evidence, learning and action
• there was adherence to confidentiality, ethics and trauma-informed principles
• the report and public summary are clear and accessible
• the report meets the statutory requirements outlined within the 2025 Act
• the report meets the requirements within the Terms of Reference
• learning has been fully captured
• recommendations and action plans are specific, measurable, achievable, relevant and time-bound
• assurance that discussions have been had with relevant agencies and local forums and partnerships such as Chief Officers’ Groups, in relation to the review, learning identified, recommendations and actions. Whilst it is recognised there may not always be agreement there should be no surprises for agencies
• the report is suitable for publication.

Where additional expertise was required at the sift stage, the Review Oversight Committee should consider involving such expertise to support the quality assurance process of the review.

Where changes or clarifications are required to review reports, the Review Oversight Committee will ensure these are clearly outlined to the Case Review Panel Chair.

11.9. Sharing of Approved Reports that cannot be Published

Following approval by the Review Oversight Committee, domestic homicide and domestic abuse related suicide review reports must be approved for publication by the Lord Advocate before a report can be published.

Where publication of neither the report nor a public summary in the form outlined at 11.7 is possible or possible at that point in time, it is important to ensure that learning is not lost. Review reports or summaries can be redacted but an alternative form of summary e.g. a briefing or poster summarising the key learning in shorter form could be published. If limited to information about the recommendations this does not need the Lord Advocate’s consent. This would be done with the overarching aim of supporting learning aimed at safeguarding those affected by abusive domestic behaviour or promoting victims' wellbeing. This must be done in accordance with the protocol.

Where an alternative to a report or summary as outlined at 11.7 is to be published, families/ friends must be informed and the reasons for this approach explained. If publication of a report or summary is to wait until the outcome of criminal proceedings, families/ friends will be kept updated on the timescales for publication.

Following sign off by the Review Oversight Committee, but where Lord Advocate approval to publication has not been granted, the Secretariat will consider with COPFS what can and cannot be published in order to ensure the publication duties within the 2025 Act can be met.

Regardless of whether or not a report can be published, all domestic homicide and domestic abuse related suicide review reports 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.

There may be occasions where Scottish Ministers or the Chair of the Review Oversight Committee would look to share (in full, in part or extracts of) a domestic homicide or domestic abuse related suicide 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 promote the learning of lessons with a view to safeguarding those affected by abusive domestic behaviour or promoting the wellbeing of victims of such behaviour. Any sharing of approved but not published reports must be done in accordance with the protocol. Sharing may only be with specific individual(s) within an organisation selected by Ministers or the Review Oversight Committee Chair. The recipients may not share more widely within their organisations. If they think dissemination to other named individuals is needed, they should ask Ministers via the Secretariat or the Review Oversight Committee Chair to share with those persons.