Testing Scotland's proposed domestic homicide and Suicide review model: phase one report and SG response

4. Summary of themed discussions

4.1. Theme 1: Identifying when a DHSR is required and instigating a DHSR

Group 1 considered the scope or criteria for undertaking a review

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

The possibility of a review would cover a range of situations where:

• there was, or appears to have been, abusive behaviour within a relationship (e.g. abuse of a partner or ex-partner); and
• that behaviour has, or may have, resulted in the death of the abused person or contributed to their suicide.

It was noted that the scope of the review process, as informed by the consultation process, is broader than that of the current definition of domestic abuse which amounts to criminal conduct as outlined in the Domestic Abuse (Scotland) Act 2018.

The person who experiences the abusive behaviour needs to be, at the time of the behaviour, one of the following -

• the partner or ex-partner of “the perpetrator”;
• the child of “the perpetrator”;
• the child of the partner or ex-partner of “the perpetrator”; and
• a young person living in the same household as “the perpetrator”, or in the same household as “the perpetrator’s” partner or ex-partner.

The types of deaths that are covered by the Bill’s proposed review mechanism are:

• those killed by a partner or ex-partner;
• someone killing their children or the children (of any age) of their partner or ex-partner;
• violent resistance where a victim of domestic abuse kills their abusive partner/ex-partner;
• someone killing young people who live in the same household as them or their partner/ ex-partner;
• domestic abuse related suicide; and
• connected deaths of children and young people^[5] (those who die as part of a domestic abuse related death (or a near-miss) but who may or may not be related to the victim or perpetrator) (example given of a young person at a friend's house being killed whilst on a play date).

The situations where a review might take place would not be limited to ones where a link between abuse and death has been established with certainty.

The definition of a 'domestic abuse death' does not cover a range of scenarios where other family relationship existed between the abuser and victim. For example, the system of reviews would not apply where a child kills a parent, or a brother kills a sister.

However, the Scottish Government is committed to expanding the system of reviews to other family relationships where the death was a so called 'honour killing'. It states that this will be taken forward once work on developing a policy definition of so called ‘honour based’ abuse has been completed.

The group’s reflections

The flexibility of the proposed legislation with its enabling power was viewed as a particular strength, as was the existence of the Review Oversight Committee.

It was noted that cases of neglect or sudden deaths^[6] are not referenced as being included or excluded. Clarity is required regarding this. Whether adult children would be included in the scope of DHSR was queried.

Additionally, existing proposals do not allow for addressing multiple perpetrators. This is of particular importance where there is so called ‘honour-based’ abuse. While there is a stated commitment to expanding the system of reviews to include this, concern was raised about this gap being present at the outset.

The group noted that the following would be important to address within the statutory guidance:

• Detail on best/safe practice – for example, around violent resistance;
• Clarity but flexibility;
• Anonymity of final reports and access to them;
• No hierarchy of testimony i.e. professional testimony would not be given a greater weighting than testimony from family, friends, community;
• Access to information on the perpetrator (particularly where the review relates to a suicide);
• Guidance on reviewing suicide cases; and
• Family involvement including children of the deceased.

Group 2 considered the decision-making process regarding whether to undertake a DHSR

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

The Review Oversight Committee receives written notification from Chief Constable of Police Scotland or the Lord Advocate. The referrer must provide the Scottish Ministers with a copy of the notification.

Scottish Ministers also have power to make a written referral or to overrule the committee decision not to undertake a review (example given of family escalating a case).

Ministers may also receive a notification from families or an advocate on behalf of a family requesting a review. Ministers will be able to refer this into the Review Oversight Committee for consideration.

The referral should include such information as the person making it possesses or controls which they consider likely to be of assistance to the committee for the purpose of its consideration.

Notification can be revoked by the referrer where they believe the death is not a reviewable death and give reasons for this (e.g. if new information came to light).

The Review Oversight Committee decision as to whether to undertake a review would be based on:

• Satisfying itself that the death is a reviewable death, and then if satisfied;
• the likelihood of a review identifying lessons which would improve practice in safeguarding and promoting the well-being of those affected by abusive domestic behaviour; and
• whether any relevant public authorities or voluntary organisations were, or could have become, involved in the circumstances leading up to the death.

Factors to be given regard to in assessing the above are noted as:

• the extent of the apparent connection between the abusive behaviour and the death (this would be most relevant to either suicides or some connected deaths);
• the information which the review will be able to have at its disposal; and
• the extent of the connection which both the person who has died, and other person(s) involved, have to Scotland (since if, for example, a relationship mostly took place abroad, the opportunities for earlier intervention within Scotland would have been limited).

The committee has information-gathering powers which it may need to exercise when considering whether to undertake a review.

The Review Oversight Committee decision does not have to be unanimous; it can be a majority decision. Alternatively, the chair may decide to defer a decision to Scottish Ministers, or to seek advice from them to inform a decision.

The Bill includes a power for the Lord Advocate to pause or end a review where the Lord Advocate deems this necessary in order to prevent potential prejudice to or in light of an investigation or criminal proceedings or a Fatal Accident Inquiry.

The group’s reflections

The importance of the Review Oversight Committee being clear on what a notification is, was highlighted. Referrals may come from a variety of sources and it was stressed that they could come directly from the community i.e., family, friends, employer etc. All referrals, including for example, suicides, would go through a consideration process which may include gathering further information before a determination was made.

The group queried who the Review Oversight Committee are linking in with at a local level and whether information comes in to them via SPOCs^[7] nationally.

The initial case review should have a step added for reviewing what other reviews may be being undertaken on the case being considered and where coordination is needed.

There is a need to understand what impacts the decision making may have – for example, related to the gap of reviews for familial abuse/so called ‘honour-based’ abuse.

The query was raised about instances where a family are against a review and whether this would be picked up in the Review Oversight Committee decision making process.

It was noted by some that the review landscape was busy and that the ideal scenario would be for joint reviews, where circumstances allowed, and avoiding working through multiple terms of reference.

Actions and decisions will need to be fed back to others (e.g., child protection committees).

A clear process for determining whether a death is a suicide and meets the criteria for a review will be important to aid decision making.

Further queries were raised for consideration, including:

• What if the death happens in another jurisdiction?
• How is information captured by other agencies if a person discloses they are a victim of domestic abuse? How can/does this inform decisions?
• How, when and by who are the family notified? and
• How and who do the Review Oversight Committee contact when reviewing information and making decisions?

It was reflected that there may need to be a minimum list of appropriate contacts for the Review Oversight Committee. National public protection arrangements could inform this. For example, Scottish Government Multi-Agency Public Protection Arrangements (MAPPA).

There may also need to be guidance on where the significance/specifics of a case do not immediately meet the criteria but that would benefit from a DHSR.

Group 3 considered the establishment of the review’s chair and panel

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

The Review Oversight Committee establishes the review panel tasked with carrying out the review.

The Review Oversight Committee selects a chair from a pool of panel chairs appointed by the Scottish Government.

The Review Oversight Committee would also be able to:

• establish a Case Review Panel to carry out a joint review of more than one death;
• instruct a panel to carry out its review in conjunction with another form of review being carried out by someone else.

Chairs – the requirement is to have a pool of at least three chairs, they will ‘bring their own unique expertise, e.g. knowledge and experience of policing and domestic abuse or of the parole board’.

Panel members – appointed on ad hoc basis, as the committee determines, ‘people who have valuable insights to offer but who will be able to do this alongside their everyday lives and work’.

The Review Oversight Committee set the review’s terms of reference.

The group’s reflections

Concern was raised that chairing a review can be a lengthy process and the availability of a chair may be limited. The importance of being clear about time expectations for chair and panel members was highlighted.

In some instances, there could be a potential conflict of interest for a chair. The process for deciding upon a chair must be alert to this.

The minimum three chairs as set out in the Bill would likely not be enough. There is a need for at least four chairs as chairs should not be handling more than three reviews at once.

The group queried how chairs would be allocated a DHSR and whether this would involve them being on a rota. Allocation based on their particular knowledge also needs to be a factor.

Chairs should have a broad base of relevant experience. The requirements of a chair adopted in England and Wales are the right ones. However, the chair also needs to be able to successfully promote active engagement with the process and have the ability to write analytically. Particular expertise can be provided through panel members and invited others.

Regarding the panel, the group noted that:

• A panel needs to have a strong mix of members, including third sector specialists beyond victim support services;
• Representation regarding protected characteristics is important;
• Consideration should be given to the optimal size of a panel – too small versus too big – and how this relates to the review’s terms of reference;
• ‘Pools’ of individuals who are regularly panel members from agencies would help to develop expertise in the process;
• Separation of responsibilities from agencies would add value and reduce individual workloads – one person to write the Individual Management Review (IMR)^[8] or equivalent, another as panel member;
• Independence of panel members is critical, ensuring they have not been involved with the case under review;
• Training and support for chair and panel members is important – both before and during a review – in addition to effective supervision that addresses vicarious trauma;
• Consideration should be given to what reasonable remuneration for third sector contributors would look like; and
• The panel may incur costs for legal advice, translation, travel etc.

There needs to be clarity of roles between Secretariat, Review Oversight Committee, chair, panel members. In particular:

• The Review Oversight Committee will draft the review’s terms of reference while retaining facility for chair, panel and family to suggest refinements;
• Noting that the Review Oversight Committee establishes the review panel, the chair should still have the flexibility to invite experts to meet with the panel to address gaps in knowledge and understanding; and
• When the Review Oversight Committee first meet to review a case, it is important to distinguish this as initial scoping, rather than a panel meeting.

Regarding the terms of reference and temporal scope of the DHSR, there may be instances where learning can continue after the death and this could be reflected in the review – for example, related to the care of the children following the death.

The group queried when family involvement began and how. Detailed guidance would be beneficial.

Guidance on joint reviews and role of family still being preserved would also be helpful to all involved in the process.

It was proposed that the Review Oversight Committee would benefit from representation and involvement of a person/persons with lived experience of fatal domestic abuse in their family.

Templates are needed to guide the process and to support a consistent approach.

4.2. Theme 2: Conducting a DHSR

Group 1 considered effective information gathering to inform the review.

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

Duty on named public authorities to co-operate in reviews.

“Relevant public authority” means —

(a) a local authority,

(b) a health board constituted under section 2(1)(a) of the National Health Service (Scotland) Act 1978,

(c) a special health board constituted under section 2(1)(b) of the National Health Service (Scotland) Act 1978,

(d) the chief constable of the Police Service of Scotland,

(e) the Scottish Police Authority,

(f) the Lord Advocate,

(g) the Scottish Courts and Tribunals Service,

(h) the Scottish Ministers in the exercise of their functions under the Prisons (Scotland) Act 1989,

(i) Community Justice Scotland,

(j) Social Care and Social Work Improvement Scotland,

(k) the Scottish Social Services Council.

Co-operation includes participating (if asked to do so) in a review, as well as providing such information or assistance as the Review Oversight Committee or the relevant Case Review Panel reasonably considers necessary to allow them to fulfil their functions.

Other people and organisations (e.g. private and third sector organisations which had contact with the victim) could be required to provide information in their possession.

Scottish Ministers, the chair of the Review Oversight Committee and Case Review Panel chairs will be able to, by notice in writing, require a person to provide them with information which the person holds and which is considered necessary for the carrying out of a review. Organisations which are made subject to a requirement to provide information would be able to participate more fully in a review if they were content to do so but would not be compelled to do anything beyond providing the requisite information.

This duty to provide information is subject to the general law, including data protection legislation.

‘In relation to information-sharing, it is not merely about stakeholder confidence: the creation of a statutory obligation to provide information facilitates a lawful basis for processing under section 8(c) of the Data Protection Act 2018 and Article 6(1)(c) and/or (e) of UKGDPR. Given those parameters, a non-legislative model was not considered a viable option from a Scottish perspective.’

The group’s reflections

The group queried whether there should be named roles within the relevant public authorities There was a view that consideration should be given to the competence to add the Parole Board for Scotland, and Armed Forces whilst recognising that the inclusion of the Armed Forces would require exploration with the UK Government due to it being a reserved matter. There was some reference to bodies that form part of the English model as part of the discussion about comparative work elsewhere and ensuring that those bodies replicating those roles within Scotland were also included – for example the probation service and family court.

‘Information’ was noted to be a broad term that may need defining to ensure consistency of understanding of what is meant by this.

Consistency of language is important across all direction and guidance to ensure understanding. Also, when making requests to partners to give information, there are differences in ‘request’ versus ‘require’, or ‘encourage’ versus ‘invite’.

There is a need to reflect where agencies might provide information but not participate in the review.

Victim’s journals, texts, diaries etc, can be a source of valuable information and assist in representing the victim’s voice. However, who gives consent and provides access to these?

Additionally, the review may need access to underlying reviews/reports – for example, a Serious Incident Report or a Probation review – and access to other reviews – for example, other DHSRs conducted.

Criminal justice processes may impact on the progression of a DHSR, as might later appeals. Also, there may be information that comes to light during a DHSR that may need to be reported to/passed to police Scotland/ Crown Office and Procurator Fiscal Service (COPFS) to be worked through/investigated.

It will be important to continue to convey the spirit of reviews to reduce defensiveness in information sharing – openness, no blame.

Group 2 considered equality, diversity and inclusion.

The current proposals

There is no reference within the current legislation to equality, diversity and inclusion (EDI) and the statutory guidance, which one would expect to address EDI, has not yet been created. The Scottish Government has, however, undertaken an Equality Impact Assessment (EQIA) and considered whether the provisions outlined in the Bill could constitute conduct prohibited by the Equality Act.

The EQIA highlighted that domestic homicide is a gendered crime and therefore people who may particularly benefit from the Bill’s provisions related to DHSRs are women. The EQIA acknowledged that the enabling powers of the Bill provide the opportunity to potentially widen the scope in the future to include so called ‘honour killings’.

Overall, the EQIA identified no significant negative impacts associated with the policy content of the Bill and the Scottish Government has concluded that no changes to the Bill details are necessary as a result.

The group’s reflections

The group highlighted the current lack of references or guidance related to EDI as a notable gap.

Feedback from England and Wales is that proper consideration of EDI within reviews is often a gap. Information about EDI is often missing from agency reports and chairs/panels are not getting the information required to undertake related analysis. A critical element of a review is understanding how the relevant protected characteristics impacted on the individual and case.

It is important that the equality data is given equal weighting to other information. There should be a requirement for this to be understood as an integral part of the review (by the chair and panel members).

The review needs to engage with specialist organisations as this will inform the analysis, findings and lessons learned. England and Wales have had positive experiences of this approach within reviews.

The approach to EDI, including the engagement of specialist organisations should be built into the statutory guidance, as well as being clear about what is expected practice regarding the writing of the report. A checklist to prompt active consideration of EDI issues would be helpful.

It was noted that some agencies may not be recording EDI information. The review process provides an opportunity to reinforce that equality data should be captured and recorded.

At times the review may reveal a need for specific support or for ways of gaining information. For example, the use of translators, access to rural communities, using different communication mediums – not just digital.

The quality assurance process should look at the different forums used for capturing information, particularly from family members.

There are sensitivities that need to be considered when it comes to the report – for example, the accessibility of the report, or the approach to anonymity.

Understanding of diversity/intersectionality is important for panel members and the chair. Additional support and training may be required to ensure this is in place. This includes the ability to articulate EDI information in reports in a meaningful and proportionate way. The chairs also need to be aware of the cultures of organisations and how they may have had an impact.

Group 3 considered the involvement of family, friends, community.

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

Ministers may also receive a notification from families or an advocate on behalf of a family requesting a review. Ministers will be able to refer this into the Review Oversight Committee for consideration.

Family members will have the opportunity to meet with the review chair to discuss the review report.

Family members are central to the review and will be kept updated throughout the whole process if they choose to be.

It is important to have the facility for families to escalate a case if they consider a review should be undertaken but the Review Oversight Committee reach a different conclusion.

The joint review approach is intended to reduce duplication and reduce the burden on family members and stakeholders engaging in multiple reviews in addition to a potential criminal investigation.

Involving children and young people in the review process, if they choose to participate, will help give a voice to those who have been affected by domestic homicide and suicide. However, it is essential that children’s participation in a review is done in a person centred, trauma-informed and age-appropriate way. It is also acknowledged that, depending on the age and stage of children, it may not be appropriate for them to participate in a review. If they do participate it will be essential that they are supported to do so before, during and after a review. The support for children and young people relates to the Bairns’ Hoose approach to delivering child protection, justice, and health support and services to child victims and witnesses of abuse and harm. The overall vision of a Bairns’ Hoose in Scotland is that all children in Scotland who have been victims of or witnesses to abuse or violence, as well as children under the age of criminal responsibility whose behaviour has caused significant harm or abuse, will have access to trauma-informed recovery, support and justice.

The group’s reflections

Families make a very important contribution to reviews because they know the victim best. It is important to recognise that the term ‘family’ covers a whole range of relationships, and families may have different, even opposing views of some matters.

It would be risking an over-simplification to view the perpetrator’s family as being automatically on the side of the perpetrator.

In addition to families, the DHSR should consider including information from colleagues, friends, and wider social networks (for example, hairdresser, driving instructor). It was noted that gathering information from friends and these other sources was important as their perspectives and potentially different insights could be useful information for the review.

The wording regarding families is important – for example, ‘integral’ versus ‘involvement’ portray different scenarios.

It is important to manage the expectations of families and be clear and transparent about the scope and limitations of their engagement. An accessible fact sheet for family members about the DHSR process and how they can contribute to this is needed. This could also offer signposting for additional support for them.

Disclosure of information to the family about the review is an important consideration. Families should be treated as equal stakeholders in the process, but any identified risks associated with sharing data properly managed. It is not appropriate to ask families to sign non-disclosure agreements.

The involvement of the perpetrator within the review needs to be at the discretion of the chair and panel, taking account of the potential benefits and risks of doing so. A further consideration is that, in some cases, the families of perpetrators may continue the abuse towards the victim’s family.

It was noted as important to acknowledge that, for some religious communities, there may be sensitivities related to suicide related stigma and shame.

There have been positive steps in England and Wales to try and better represent the voice of the child within the review, acknowledging that a lack of involvement can lead to further trauma. Involving children is often dependent on their guardians and it is likely that some work will be needed to assist adults around the child to understand the benefits.

The group reflected that it is difficult to legislate about the involvement of communities and families within reviews. However, the statutory guidance can provide:

• Clear guidance for the chairs and review teams;
• Clarity about engagement of family/friends/communities – who, what, where, when, how;
• How reports can and should reflect the views of families and be written in a ‘family friendly’ format;
• Clarity around next of kin and children’s involvement – families may remain cautious, but attempts should still be made to put engagement into practice; and
• Guidance on how to represent the voice of the child.

The group noted that the following tools would assist with positive engagement of family, friends and communities:

• Training on talking to children within the context of a DHSR;
• Trauma informed interactions with children – tools to facilitate support for children (long term);
• Fact sheets for families with simplified wording;
• Templates – how they are involved, timelines;
• Sign posting information for support; and
• Template for chairs meeting the family and the conduct of the review team.

Specialist advocacy support was viewed as critical for bereaved family members and that this recognised that there is not a ‘one size fits all’ model of support for families. The group suggested an ‘opt out’ rather than ‘opt in’ approach to offering advocacy support might be appropriate.

It was highlighted that various models might provide a useful framework for talking to children about a death and about a DHSR, two of which are described below:

• The Scottish Child Interview Model (SCIM) used whilst conducting investigative interviews with children. The SCIM joint interviews are tailored to the individual needs of the child or young person and are based on trauma informed principles.^[9]
• The Bairns’ Hoose model will provide children and young people across Scotland with access to trauma-informed recovery, support and justice.^[10]

4.3. Theme 3: Facilitating learning from a DHSR

Group 1 considered reporting on the DHSR.

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

The panel prepare the report – ‘While it is for the Case Review Panel as a whole to prepare the report, this does not mean that it needs to be “drafted by committee” – it could, for example, be prepared by one member of the panel on behalf of them all, or by those providing their administrative support, and endorsed by the panel as a whole.’

There are certain things which must be included in a report, but it is open to the panel to include such other information as it sees fit. The things which must be included are -

• a timeline of what the panel considers to be any key events prior to the death;
• information about any missed opportunities for intervention;
• the panel’s conclusions;
• its reasons for reaching those conclusions; and
• any recommendations it has as a result.

If the panel is unable to agree a unanimous report, the report must reasonably reflect the points of disagreement.

Once the panel has prepared a report, the chair of the panel must submit the report to the Review Oversight Committee for quality assurance and finalisation.

The Oversight Committee decide whether modifications are required to the report before accepting it. If they are required, the committee will be able to decide whether to make these itself (which may be possible in, for example, the case of minor corrections) or whether to direct the panel chair to resubmit an amended report (for example, because the information that is missing is not within the committee’s knowledge). Where a report is resubmitted, the same process of approval with or without modifications, or a further direction to make changes, can occur.

The group’s reflections

A template with an expected list of headings helps to aid consistency in report author’s approaches. The template should address the purpose of the review, all reasons for contact, EDI, the action plan and recommendations. It is important that the report framework allows the information to flow.

Authors could be prompted to draw upon minutes of meetings for anything outstanding and for inclusion.

Longer reports are less likely to be read - the aim should be for a concise report that is less than 70 pages.

The reality is that the review panel or administrative support will not write the report – this needs to sit with the chair with panel input and feedback.

Where the Review Oversight Committee deem it appropriate to make changes to the report themselves, author approval should be sought for any changes.

Recommendations coming out of the review should not just relate to training alone. The review provides a good opportunity to identify the evidence for systemic change, both nationally and/or locally.

The perpetrator’s family may also want to see the report and the panel should be mindful of this.

The timeline of events and the narrative within the report need to be victim centred with every effort made to view events through the eyes of the victim.

The legislation and statutory framework are included at the start of the report in England and Wales. Including this as an appendix at the back of report would improve its accessibility and readability. Clear and simple language is also important.

The report should open with a description of the circumstances of the death and the reason for the DHSR.

Fewer recommendations that are likely to support greater change were deemed to be more important than lots of recommendations, some of which may be meaningless and unimpactful.

Technical guidance on the editing of the report by multiple parties would be useful.

The quality assurance will itself need a framework to assess the reports against.

Group 2 considered sharing and acting on learning.

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

Once approved, the report is shared with:

• Scottish Ministers;
• the organisations where learning, recommendations and actions have been identified;
• family members – given opportunity to meet and discuss the report with the panel; and
• in cases involving a young person or adult at risk, the Care Inspectorate.

A case review report may require people to respond to recommendations. Those people (including organisations) will be provided with a copy of the report. ‘This will, in practice, be discussed with the organisations to ensure the recommendations are clear and achievable.’

The oversight committee can choose to publish a report (or part of it) but only where consent has been given by the Lord Advocate. However, in every case, the committee has to publish (either in the report if it is published, or separately) such information as it considers appropriate about the recommendations made in the report. Published reports must not include information which would or might identify living individuals unless the individual has given their consent.

The group’s reflections

The report is not the end point of the DHSR – the recommendations, actions as a result of these, and the follow up on these is where the change occurs.

The group noted the difference between learning versus recommendations and queried whether it is possible to have one without the other.

It was highlighted that the order of recommendations and actions may be important and influence their success. Families may focus on actions and their implementation, which reiterates the importance of getting these right and ensuring they are achievable and impactful. Clear communication with families on what the review will /can achieve is important for managing expectations.

This group also discussed the balance of the detail of recommendations versus the number of recommendations – how implementable, meaningful, systemic they are.

Learning events for professionals were noted to provide a good opportunity to share and act upon learning identified by the review.

The Lord Advocate was not listed as a body receiving the report and the group queried whether this should this be in place to prompt a requirement to engage with the Crown Office and Procurator Fiscal Service (COPFS) and their processes (for example, Fatal Accident Inquiries (FAI)^[11]). Are there any differences between DHSR recommendations and FAI recommendations? What is the interaction with these?

In England and Wales, the Coroner often waits for the review’s conclusion, although not always, so that the inquest process can be informed by this. This is particularly important for suicide cases. Scotland may wish to think about how this approach is promoted, given the different legal set-up.

Learning and/or recommendations could include or outline the impact of actions after the death – for example, sentencing on a specific case.

Recommendations can be poorly articulated at times (this has been experienced in England and Wales and other jurisdictions), so outlining what a good and SMART^[12] recommendation looks like will help to avoid this.

An agreed methodology that supports consistency could be used to share learning – this might lead to templates being used.

The circumstances regarding when a report is not published need to be clear. There is experience of family members wanting publication of the report but then later regretting this when they experience the negative consequences of the publication. The wider group discussed whether, in Scotland, the publication of reports should always be limited. This would be quite a different approach to that in England and Wales but there may be real benefits to only sharing the information with those who have a clear interest. In particular, the risks associated with publication would be reduced. It was noted, however, that where agencies do not see the report leading to the recommendations and action plans, it may be difficult for them to implement change when the context is not understood. Consideration could be given to limiting the sharing of the report to those with a need to know. This might include researchers who can assist with broader learning.

The group felt that action plans should be published and that this would engender accountability and processes to check the progress of change against stated timelines.

Consideration is needed on who gets a copy of the report and when. Is there an order/a hierarchy between who the report is shared with and when (considering Scottish Government, organisations, families).

Group 3 considered accountability and governance arrangements.

The current proposals

Related information taken from the proposed legislation and supporting Explanatory Notes and Policy Memorandum, was shared with the group and included the following.

This group also looked at the powers and responsibilities set out in a separate handout (see Appendix 3).

The Bill will require the Scottish Ministers to lay regular thematic reports in Parliament. Biennial thematic reports will include the following:

• Common themes and key learning points emerging from recommendations in individual reports;
• Any actions taken as a result of recommendations and where known, the impact of those actions;
• The number of notifications of deaths received which were suspected to fall within the scope of the domestic homicide and suicide review model, broken down by Lord Advocate notifications, chief constable notifications and Ministerial notifications, and between homicides and suicides;
• The number of cases considered for review by the Review Oversight Committee broken down between homicides and suicides;
• The number of decisions not to undertake a review and the reasons for this, broken down between homicides and suicides;
• The number of reviews commenced, and the number completed, broken down between homicides and suicides; and
• Any other information the Scottish Ministers consider appropriate.

The group’s reflections

A DHSR is not a paper exercise, and all processes need to be mindful of the time required to undertake a review.

There is a need to consider national versus local learning and buy in. It is important to track the implementation of learning.

Evidence of fiscal accountability – i.e., the appropriate spending of public funds in a lawful way with proper accounting – will be important.

DHSRs will need to be properly resourced, from start to finish, acknowledging the impacts their delivery has on people’s lives.

In reporting on the DHSRs and their themes, what will be deemed a success and how will this be measured? Where themes arising from reviews are reported, mechanisms are needed to identify their commonality. Reporting requirements should allow flexibility around what can be included.

There is an opportunity to evidence deliberative democracy^[13] through the accountability and governance arrangements.

There is a need to be conscious of the risk of and take steps to avoid the tendency towards victim blaming language/unconscious bias, as well as unawareness of the dangerousness of the situation (antagonising perpetrators).

Learnings from the DHSRs, overall, can inform safety planning.

The statutory guidance will need to cover:

• Guidance for chairs on setting out recommendations at agency, national and local level;
• Guidance on the minimum data set that can be used for identifying common themes; and
• Guidance on the mechanism for setting out common themes.

Accountability and governance arrangements can be supported by data collection in a timely manner to inform reporting requirements. Data could include how many people read the reports.