Domestic Homicide and Suicide Reviews in Scotland: Statutory Guidance

Section 9 – Undertaking a Domestic Homicide or Domestic Abuse Related Suicide Review – Process

This section sets out the process for how domestic homicide and domestic abuse related suicide reviews should be conducted. It provides guidance for Case Review Panels and Chairs on the process of gathering, analysing, and interpreting information. Domestic homicide and domestic abuse related suicide reviews should be victim-focused, proportionate, and trauma-informed, with an emphasis on learning and system improvement.

9.1. Case Review Panel Preparation and Meetings – Overview

Before the first meeting of the Case Review Panel there are a range of important preparatory discussions and tasks that are to take place. These are essential for establishing expectations, setting the scope, and fostering a learning-focused culture from the outset. Key activities for the Case Review Panel Chair include:

• Documentation Review – The Case Review Panel Chair should review the death notification or referral, any scoping returns requested by the Review Oversight Committee and where relevant, previous reviews undertaken, and the Draft Terms of Reference prepared by the Review Oversight Committee.
• Engagement with the Senior Investigating Officer – The Case Review Panel Chair will contact the Senior Investigating Officer or relevant police officer involved in the case to understand the investigative context and gain an understanding of key aspects including family relationships and dynamics. A photo of the victim can also be requested until such time as a photo is provided by family or friends. The photo is to form a part of the Case Review Panel meetings to help ensure the meetings are victim focused.
• Consideration of Information – Following an initial review of the documentation and discussion with the Senior Investigating Officer, the Case Review Panel Chair should consider which agencies had contact with the victim(s) and perpetrator, the timing of those contacts, and any gaps in information. This analysis informs:
  • The scope of the review
  • Panel membership
  • Individual Management Reviews and chronologies required
  • Revisions to the draft Terms of Reference in collaboration with the Review Oversight Committee and relevant partners where there is to be a joint review.
• Case Review Panel Preparation – In preparation for the first Case Review Panel meeting there is additional preparatory work that should be undertaken. This includes but is not limited to:
  • Working with the Secretariat to ensure initial correspondence is sent to the bereaved family or others where relevant, to make them aware of the review. The correspondence should include the relevant leaflets on the process and make them aware of the dedicated advocacy service available to them.
  • Liaising with the Secretariat in relation to local learning reviews which may be relevant and additional points for consideration such as whether a review is to be expanded beyond the point of death, ahead of the first meeting of the Case Review Panel
  • Setting up notifications (e.g., Google alerts or social media monitoring) for the victim and perpetrator).

The below provides an outline of the structure/ content of each Case Review Panel meeting. This is intended to provide an indication of what each meeting will focus on. The points included are not an exhaustive list or a rigid script to be followed. It is a guide to support Case Review Panel Chairs to frame the meetings as the work on a review progresses.

Case Review Panel Meeting One – The initial meeting of the Case Review Panel is introductory. The purpose is to set the tone and learning culture for the review. It does this by emphasising from the outset that domestic homicide and domestic abuse related suicide reviews are a collective endeavour that focus on understanding systems and identifying learning, not on attributing blame. The first meeting sets expectations, introduces the Case Review Panel to the methodology, and begins embedding a reflective, victim-focused culture. The first meeting should comprise of the following:

• A discussion on principles for how the Case Review Panel will work together
• The Senior Investigating Officer (or relevant officer) is invited to provide an overview of the investigation relating to the case.
• The Case Review Panel Chair will provide a report on known engagement with services collated through the notification/ referral and any scoping undertaken by the Review Oversight Committee.
• The Case Review Panel considers which agencies to request an Individual Management Review report from and the timescales for reports to be returned (usually four to six weeks).
• Consideration of whether additional expertise is required and whether additional panel members should be invited.
• A discussion on what additional aspects the domestic homicide or domestic abuse related suicide review is to consider where a joint review is to be undertaken. This includes where a review is to be expanded beyond the point of death.
• Finalise the draft Terms of Reference subject to any additional input from Single Points of Contacts, Chief Officers’ Groups and input from family and friends, and agreement of the Review Oversight Committee.
• Reemphasise that domestic homicide and domestic abuse related suicide reviews are collaborative, team-based processes and provide a clear outline of individual roles.

Following the meeting the Case Review Panel Chair will update family and relevant others if they have requested regular updates.

Case Review Panel Meeting Two – Is to be held once all Individual Management Review reports have been received. The remaining meetings will be scheduled at approximately four to six week intervals. Agenda items include:

• Discussion on the merged narrative chronology, identifying gaps or anomalies.
• Discuss points to be asked at a facilitated learning event. This is to include questions from families that are within scope of the review and Terms of Reference.
• Review expert presentations as needed.
• Include family input as a standing agenda item.
• Include as a standing agenda item ‘emerging themes’, encouraging Case Review. Panel members to highlight relevant research or new practice developments.
• Reiterate the victim-focused, collaborative approach to the review.

Following the meeting the Case Review Panel Chair will update family and relevant others if they have requested regular updates.

Case Review Panel Meeting Three – Papers are to include deconstructed Individual Management Review reports with each document covering responses to a specific question/ key line of inquiry. A summary of points raised and learning identified by practitioners and managers during the facilitated learning event will be provided to Case Review Panel members. The third meeting will focus on:

• Breakout rooms are to be set up where each room has a discussion on a separate question/ key line of inquiry which seeks to address:
  • whether the information is clear (does it make sense?)
  • has the question/ key line of inquiry been answered?
  • are there any new questions?
  • are there notable gaps?
  • can any learning or recommendations be derived from the information?
  • can good/ safe practice be identified?
• Breakout room feedback will be synthesised, and responses integrated to each question or key line of inquiry. These are to be circulated before the next Case Review Panel meeting.

Following the meeting the Case Review Panel Chair will update family and relevant others if they have requested regular updates.

Case Review Panel Meeting Four – Is a continuation of Case Review Panel meeting three with breakout rooms being set up to discuss the remaining questions/ key lines of inquiry. This includes questions family members have that are within the scope of a domestic homicide or domestic abuse related suicide review. The fourth meeting should also include:

• A specific discussion on good/ safe practice
• Discussions in relation to identified learning and recommendations should continue
• Revisiting the Terms of Reference and whether any points have not been completed or addressed

Following the fourth Case Review Panel meeting, the Case Review Panel Chair will prepare the draft domestic homicide or domestic abuse related suicide review report. The Secretariat will share the draft report with Case Review Panel members for discussion ahead of Case Review Panel meeting five.

The Case Review Panel Chair will update family and friends following the meeting if they have requested regular updates.

Case Review Panel Meeting Five – The fifth Case Review Panel meeting will focus on the draft report, learning, recommendations, actions any identified risks and dissemination strategies. Families may be invited to this meeting to meet the Case Review Panel and to be part of the discussion on recommendations.

A further meeting of the Case Review Panel may be necessary. This meeting will focus on any feedback received on the accuracy of the report. The Case Review Panel should be mindful that as part of the process to ensure factual accuracy and agreement within local governance structures e.g. the local Chief Officers’ Group, time will be required to ensure they have sufficient time to consider the review report. Similarly, if a family chooses to take up the offer to meet the Case Review Panel Chair to discuss the report, it is important to ensure there is sufficient time built in to do this meaningfully.

Minor changes can be agreed via correspondence but if more substantial changes are necessary then the Case Review Panel may need to meet again.

Further detail is provided in relation to the preparing of reports and recommendations at section 11.2, including learning and recommendations in relation to COPFS and the judiciary.

The structure outlined is a high-level summary which is intended to provide an overview of the process which aims to ensure that all domestic homicide and domestic abuse related suicide reviews are evidence-based, collaborative, and maintain a focus on learning, system improvement, and the experiences of victims and families. The Secretariat will support the operation of Case Review Panel meetings and as domestic homicide and domestic abuse related suicide reviews become embedded, the process will be further refined. To support the refinement of the domestic homicide and suicide review model process the Secretariat will arrange a voluntary wash-up/ de-brief session between the Case Review Panel Chair, panel members and Single Points of Contact. This is an opportunity to share any feedback on the review process – some of which may be able to be incorporated quickly while other feedback will be considered alongside feedback from other domestic homicide and domestic abuse related suicide reviews with a view to updating the statutory guidance when it is reviewed.

9.2. Individual Management Review Reports

Individual Management Review reports will be used to gather relevant information on those subject to review. Each participating agency must provide comprehensive information on the services they provided to the victim, perpetrator and relevant others including children, for the purposes of a domestic homicide or domestic abuse related suicide review. This includes any contact agencies had with the individuals before the death and in some cases for some individuals, post death. This information is to be submitted using the report template that will be provided to them by the Secretariat. The Individual Management Review report is to include a summary of:

• the nature and extent of the agency’s contact with the individual(s)
• equality, diversity and inclusion considerations
• key decisions made, actions taken, and services provided
• the rationale for professional judgments
• initial reflections or lessons identified by the organisation
• relevant information for the Case Review Panel Chair to complete the pro forma for the Core Data Set where there has been a child death.

Individual Management Review reports form a key part of the review process and should be comprehensive, factual, analytical and reflective. However, information or analysis relating to the exercise of independent professional judgement in the discharge of decision‑making functions by COPFS or the judiciary, including matters such as case analysis, prosecutorial decisions, or bail and sentencing, are out with the scope of the review and should not be provided as part of the review process.

Where the victim was registered with a GP, their (relevant) medical information is essential. GPs are expected to cooperate with the review process under their professional obligations whilst adhering to General Medical Council (GMC) guidance on confidentiality, information sharing, and posthumous disclosure. Relevant medical information in relation to the perpetrator is also important. Section 26 of the 2025 Act makes provision for such information to be shared by GPs and other relevant persons for review purposes.

The Case Review Panel Chair should ensure that where information is sought that this is precise, proportionate, and made in writing. The relevant legislative provisions should also be outlined as well as the reasons for seeking the information.

It may be necessary for mental health histories, GP notes, psychological therapy records, and any documentation of suicidal ideation or self-harm to be obtained. Such records may contain critical information relating to coercive control, stalking, or escalating domestic abuse. GP and mental health records may contain critical information relevant to domestic abuse-related suicide, including disclosures, symptoms of trauma or depression, crisis-related presentations, or previous self-harm, and should be reviewed with appropriate safeguards in place. Alternatively, arrangements can be explored for the Case Review Panel Chair to meet with e.g. the Practice Manager within the medical centre to discuss the relevant records.

Where a child or young person has died, or where a child was bereaved, information should be sought from agencies that had contact with the child and their family. This includes education, early years services, health visitors, paediatrics, Child and Adolescent Mental Health Services, child protection, social work, youth justice, voluntary sector organisations and relevant others, which provided support or engaged with the child. Reviews involving children should be undertaken in line with Getting It Right For Every Child^[3] principles, ensuring that information reflects a whole-child, rights-based and holistic view of their needs.

Domestic homicide and domestic abuse related suicide reviews will consider the child’s lived experience and how services recognised, assessed, and responded to their needs, vulnerabilities and risk of harm. Information should include developmental history, attendance and engagement with education, referrals to support services, early years assessments, and wellbeing indicators. If the child was subject to any child protection processes or multi-agency meetings, those findings are to be included. Reviews should assess whether the child was asked or had the opportunity for their views to be expressed, how cumulative concerns were identified or missed, and how adult and child services communicated.

9.3. Establishing a Timeline/ Chronology

A detailed chronology should be developed following receipt of the completed Individual Management Review report. This helps to provide a visual of known contacts, decisions, and significant events involving the victim(s), perpetrator, and relevant agencies. This forms the backbone of the analytical phase.

A standardised chronology template is to be used by all agencies. This is provided to agencies when the individual management review report template is sent to agencies. Supported by the Secretariat, the Case Review Panel Chair will collate submissions into a single merged narrative chronology, identifying overlaps, inconsistencies, and gaps.

For cases involving children, chronologies are to include multi-agency contributions, identification of cumulative concerns, clear separation of fact and professional opinion, and the inclusion of relevant school records, early years assessments and wellbeing information.

For domestic abuse related suicide reviews, chronologies are to include any mental health crisis presentations, episodes of self-harm, police attendance, domestic abuse disclosures, separation-related risk, digital abuse and any patterns of coercive control.

The final chronology is to provide a clear sequence of events and contextual information to support system-level analysis.

9.4. Animals

The presence, treatment, and welfare of animals within a household can be a significant indicator of both risk and control dynamics in cases of domestic abuse. Evidence from practice and research shows that perpetrators may harm, threaten, or neglect pets and other animals as a means of coercion, intimidation, or punishment. Victims may delay leaving an abusive relationship out of fear for the safety of their animals or because there are limited options for rehoming or temporary care.

Case Review Panels should therefore consider:

• whether animals were present in the household or otherwise connected to the victim, perpetrator, or children
• any known incidents of harm, neglect, or threats toward animals
• the emotional significance of animals to victims and children, including the role of pets as sources of comfort, protection, or attachment
• how agencies recognised, assessed, or responded to concerns about animals as potential indicators of abuse or barriers to safety planning

Information should be sought from relevant organisations such as the Scottish Society for the Prevention of Cruelty to Animals (SSPCA), local animal welfare services, or veterinary practices where there is reason to believe they hold pertinent information. These agencies may have records of injury, neglect, or behavioural signs that provide insight into the household’s dynamics and timeline of events.

Where appropriate, consideration should be given to how inter-agency communication between human and animal welfare services can be strengthened to support early identification of abuse and to ensure that future safety planning includes provision for pets and livestock.

Case Review Panels should also recognise the psychological and emotional impact on children and adults who witnessed or were aware of harm to animals. In such cases, trauma-informed analysis should explore how this affected their sense of safety, attachment, and help-seeking behaviour. Where children were present, Case Review Panels should consider the emotional and developmental significance of pets, as children may experience profound distress from witnessing harm to animals. Analysis should explore whether such harm contributed to their trauma, attachment difficulties or barriers to seeking help.

9.5. Requesting relevant information from services on perpetrator and their children

The Case Review Panel should also consider whether it is reasonably necessary to obtain information about the perpetrator’s contact with statutory and voluntary services. This includes criminal justice social work, police, housing, mental health, and substance use services etc. Where the perpetrator had dependent children or contact with children, information should where reasonably necessary be sought from children’s services regardless of whether those children were residing with the perpetrator’s partner or ex-partner. Case Review Panels should consider the perpetrator’s parenting behaviour towards their children and the extent to which services recognised or mitigated risks posed to children.

Where relevant or reasonably necessary, information relating to the perpetrator can be sought on any known history of offending, alternatives to prosecution, previous incidents of domestic abuse, controlling behaviour, crisis presentations and contact with mental health or substance use services. For domestic abuse related suicide cases, Case Review Panels should also consider in addition to the victim whether the perpetrator presented with distress, suicidal ideation or behaviour that intersected with coercive control or escalating risk.

9.6. Domestic Homicide and Domestic Abuse Related Suicide Reviews – Additional Factors

Domestic homicide and domestic abuse related suicide reviews should examine patterns of coercive and controlling behaviour where identified, including cumulative, non-linear patterns of coercion, stalking, separation-related escalation and repeat victimisation, escalation of risk and missed opportunities for intervention as well as where there were examples of good or safe practice. Reviews should adopt a perpetrator-patterned framework, systematically analysing perpetrator behaviour, service engagement, manipulation of professionals, and opportunities for earlier disruption. Domestic Homicide Reviews should consider how social, economic and cultural factors shaped the person(s) who have died, their access to safety and the effectiveness of multi-agency risk assessment and management, including how organisational culture, threshold decisions, resource pressures and lawful risk assessment practices influenced professional judgement at the time.

Domestic Homicide Reviews should explicitly examine how agencies worked together across adult, children’s and justice services, including Multi-Agency Risk Assessment Conference (MARAC), Multi-Agency Public Protection Arrangements (MAPPA), Multi-Agency Tasking and Coordination (MATAC) and other public protection arrangements where relevant, and assess the quality of collaboration rather than communication alone. Analysis should clearly separate factual findings from interpretive commentary and follow a structured approach that helps explain how events unfolded, identify underlying causes, and map the broader social and cultural factors involved.

Where children have been killed or bereaved, reviews should analyse how the child experienced domestic abuse, including the impact of coercive control within the household, behavioural and relationship changes within the family system. Children should be recognised as directly experiencing the impact of abuse rather than as passive witnesses. Reviews should examine communication and collaborative working between adult and child services, justice agencies and wider public protection structures, and how these dynamics contributed to the wider circumstances of the death. Children’s lived experience should be integrated into chronologies and systemic analysis rather than treated as an additional or peripheral factor.

Where a review includes more than one victim or where complex family structures are involved, the review should ensure that each relationship and risk dynamic is analysed in context. Consideration should be given, where appropriate and with suitable safeguards, to patterns of behaviour involving other victims, in order to inform understanding of perpetrator patterning and cumulative risk. Intersectional factors, including gender, disability, culture, socioeconomic disadvantage and immigration status, should be explicitly considered in analysing both risk and access to support.

Where a victim has died by suicide and domestic abuse was or may have been a contributing factor to the death, Case Review Panels should consider cumulative trauma, coercive control, fear, isolation, and patterns of abuse before death. Analysis should explicitly recognise coercive control as often cumulative, non-linear and psychologically destabilising, and capable of shaping the victim’s mental health, coping strategies and perceived options for safety. Case Review Panels should examine recent separation, stalking, threats, ongoing harassment, financial abuse, technology facilitated abuse or immigration-related vulnerabilities. Where relevant, reviews should also consider patterns of repeat victimisation, perpetrator manipulation of services, interference with medication or support, and the role of substance use, including drug-related deaths where intentionality may be unclear. Relevant criteria for determining domestic abuse-related suicide should be applied consistently, with recognition that domestic abuse related suicide can be multifactorial and as such, over-simplistic attribution to a single event or intervention avoided. Reviews should also consider significant events within a victim’s life and any changes or notification of change that may have had an impact on them e.g. their abusive ex-partner being released from prison, child contact proceedings, housing changes, immigration decisions, or shifts in protective measures. Intersectional factors, including but not limited to, gender, disability, culture, sexuality and socioeconomic disadvantage, should be explicitly considered in analysing both risk and access to support.

Domestic abuse related suicide review panels should explore whether agencies recognised domestic abuse as a risk factor for suicide and whether responses to any mental health, crisis presentations, self-harm or distress were adequate and informed by an understanding of domestic abuse dynamics. This should include examination of whether domestic abuse was identified within mental health or substance use assessments; whether risk assessment tools captured coercive control and escalation; whether multi agency arrangements such as MARAC or other public protection processes were considered; and how practitioner judgement was shaped by organisational thresholds, resource pressures and prevailing assumptions at the time.

Information sharing in cases of domestic abuse related suicide can be complex due to mental health confidentiality. Information sought must be justified, reasonable and proportionate. Mental health and GP records may contain key insights into risk that were not shared across agencies. Domestic abuse related suicide reviews should acknowledge practical barriers to accessing such records and clarify the lawful basis for proportionate information requests. Family members, friends and former partners may also hold relevant contextual information that agencies were not aware of or did not record. Engagement with them should be trauma-informed, carefully risk assessed and supported by local agencies, recognising the potential for conflicting accounts, ongoing perpetrator risk, intimidation or distress.

9.7. Facilitated Learning Events

Learning is central to the domestic homicide and suicide review process. Practitioners who worked directly with the victim, perpetrator and/ or children, and their managers should not form part of the Case Review Panel membership for reasons of ensuring independence in the process. However, practitioners and their managers have important and valuable contributions to make to a domestic homicide or domestic abuse related suicide review. Their experience of working with and supporting those the review is focused on provides valuable insight not only in relation to those subject to a review, but the context in which practitioners were operating.

Individual Management Review reports are an important part of how information will be collated and analysed within a review. Valuable input and expertise will also be provided through members of the Case Review Panels, but being able to hear directly from practitioners and managers offers a deeper understanding, which is further enhanced when bringing practitioners and managers together from relevant agencies to hear from those involved with the victim, perpetrator and others.

The purpose of the facilitated learning event is therefore to enable practitioners and managers involved with victims, perpetrators and children and young people to:

• share their understanding of events and agency responses
• hear the perspectives of other practitioners involved
• reflect on what happened and identify key learning points for future practice

Timing – Where a facilitated learning event is to take place, this would ordinarily be arranged for after the Individual Management Review reports have been received and reviewed. This should be within four months following a decision to establish a domestic homicide or domestic abuse related suicide review.

Preparation and Attendance – The Single Points of Contact will be the main liaison point between the Secretariat and the relevant agencies and will support the coordination of a facilitated learning event. Practitioners and managers invited to the facilitated learning event are expected to attend and come prepared to contribute meaningfully. Attendance is essential, and leaving an organisation prior to the event does not preclude participation if the individual can provide relevant insight. The Case Review Panel and Chair should consider flexible arrangements, including holding additional events where necessary, to ensure that relevant staff can engage fully in the learning process. It must be emphasised that facilitated learning events are focused on learning and not blame.

Role of the Case Review Panel Chair – Following the analysis of the Individual Management Review reports, the Case Review Panel will consider the questions and key lines of inquiry they have identified and those raised by family members which are to form part of the review. The Case Review Panel Chair and the Secretariat will attend the facilitated learning event. The Case Review Panel Chair and Secretariat will work with agencies to create the conditions for learning to be identified through open dialogue. The Secretariat will note the key points and learning identified which will be shared with the Case Review Panel for consideration alongside the wider information received as part of the review.

Supporting Practitioners – The Case Review Panel Chair and Secretariat will support practitioners before, during and after the facilitated learning event by ensuring they answer any questions those participating in a facilitated learning event, may have on the process. It is acknowledged that the death of a person that a practitioner was working with/ supporting, can be deeply distressing. Practitioners should speak to relevant colleagues within their organisation on what support may be available to them if necessary. The Secretariat can also provide information on available support such as Breathing Space.