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

5. Conclusions

This section summarises the main points for consideration with regards to the proposed legislation, the development of supporting statutory guidance and supporting tools that may be beneficial. Whilst these issues are currently grouped under these headings, they may later be addressed in another way through the development process (for example, an issue currently listed under legislation might later be addressed by the statutory guidance).

5.1. The proposed legislation

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.

Omissions, lack of clarity, or where further consideration should be given were noted to relate to:

• Cases of neglect or sudden deaths not being referenced as being included or excluded;
• Whether adult children would be included in the scope of the DHSR;
• 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 need for a clear definition of suicide and which deaths by suicide fall within the scope of the review process;
• The current lack of references related to EDI as a notable gap;
• The need for direct referral routes for a DHSR to be available, which might include some specific to suicide cases;
• Clarity of roles between the Secretariat, Review Oversight Committee, chair, and panel members;
• The need for a sufficient pool of chairs as chairs should not be handling more than three reviews at once;
• Being clear that, when the Review Oversight Committee first meet to review a case, this is as initial scoping, rather than a panel meeting;
• Allowing the flexibility for the chair to inform panel membership and for the chair, panel and family to be able to suggest refinements to the review’s terms of reference;
• Ensuring there is a stage for considering what other reviews there are and where coordination is needed;
• How and who the Review Oversight Committee contact when reviewing information and making decisions;
• ‘Information’ being a broad term that may need defining to ensure consistency of understanding of what is meant by this;
• The importance of consistency of language across all direction and guidance to ensure understanding. For example, there are differences between ‘request’ versus ‘require’, or ‘encourage’ versus ‘invite’;
• Having named roles within the relevant public authorities. Consideration should be given to adding the Probation Service, Parole Board, Family Court and Armed Forces;
• Where it will be picked up in the decision-making process if a family are against a review taking place;
• Aiming for joint reviews and avoiding working through multiple terms of reference;
• How actions and decisions are fed back to others;
• What happens where the death happens in another jurisdiction;
• How, when and by who the family are notified about the intention to undertake a review;
• The potential benefits of representation and involvement of a person/persons with lived experience of fatal domestic abuse in their family on the Review Oversight Committee; and
• The Lord Advocate not being listed as a body receiving the DHSR report.

5.2. The development of supporting statutory guidance

The group noted that the following would be important to address within the statutory guidance. These points are grouped within themes.

Establishing the chair and panel

• The importance of being clear about time expectations for chair and panel members;
• Addressing where there is potential conflict of interest for a chair;
• How chairs would be allocated a DHSR – for example, whether this would involve them being on a rota and/or how their particular knowledge will be a factor;
• The experience, skills and knowledge that is required of chairs;
• The mix of panel members, including third sector specialists beyond victim support services, and whether these will be ‘pools’ of individuals who are regularly panel members. That would help to develop expertise in the process;
• Representation regarding the protected characteristics;
• The optimal size of a panel;
• Consideration of a separation of responsibilities within contributing agencies – one person to write the IMR, another as panel member;
• The independence of panel members from the case under review;
• Training and support for chair and panel members in addition to effective supervision that addresses vicarious trauma;
• What reasonable remuneration for third sector contributors would look like; and
• Costs incurred by the panel for legal advice, translation, travel etc.

Information to inform the review

• Where agencies might provide information but not participate in the review;
• Access to victim’s journals, texts, diaries etc, to assist in representing the victim’s voice;
• 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;
• That the equality data is given equal weighting to other information;
• Prompting chairs/authors to draw upon minutes of meetings as an information source; and
• Access to information on the perpetrator (particularly where the review relates to a suicide).

Engagement with family, friends and community

• Clarity about engagement of family/friends/communities – who, what, where, when, how;
• The importance of language regarding families – for example, ‘integral’ versus ‘involvement’ portray different scenarios;
• Managing the expectations of families and being clear and transparent about the scope and limitations of their engagement;
• Disclosure of information to the family about the review – treating family as equal stakeholders in the process, whilst managing any identified risks associated with sharing data;
• No hierarchy of testimony (regarding family, friends and testimonial networks relative to other sources);
• How reports can and should reflect the views of families and be written in a ‘family friendly’ format;
• The role of family still being preserved where there are joint reviews;
• Clarity around next of kin and children’s involvement, including how to represent the voice of the child;
• The involvement of the perpetrator within the review and the potential benefits and risks of doing so;
• Being mindful that the perpetrator’s family may also want to see the report; and
• The criticality of specialist advocacy support for bereaved family members. Consideration of an ‘opt out’ rather than ‘opt in’ approach to offering advocacy support.

Equality, diversity and inclusion (EDI)

• Engagement with specialist organisations to inform the analysis, findings and lessons learned;
• Clarity about what is expected practice regarding the representation of EDI in the writing of the report;
• The use of translators, access to rural communities, using different communication mediums – not just digital; and
• Acknowledging that, for some religious communities, there may be sensitivities related to suicide related stigma and shame.

The DHSR report

• Clarity about who will write the report – this needs to sit with the chair with panel input and feedback;
• Aiming for a concise report that is less than 70 pages;
• Opening the report with a description of the circumstances of the death and the reason for the DHSR;
• Including the legislation and statutory framework as an appendix at the back of report to improve its accessibility and readability;
• Avoiding the tendency towards victim blaming language/unconscious bias;
• The importance of clear and simple language and the accessibility of the report;
• The approach to anonymity;
• Ensuring the timeline of events and the narrative within the report are victim centred with every effort made to view events through the eyes of the victim; and
• Where the Review Oversight Committee deem it appropriate to make changes to the report themselves, seeking author approval for any changes.

Publication

• The principles and process informing whether a report would be made available to the public or media;
• Whether, in Scotland, the publication of reports should always be limited to those with a need to know;
• Whether there is an order/a hierarchy between who the report is shared with and when (considering Scottish Government, organisations, families); and
• The publication of group action plans to engender accountability.

Implementation of learning

• Ensuring that recommendations coming out of the review do not just relate to training alone;
• Acknowledging that change can be national and local. Guidance on setting out recommendations at agency, national and local level for chairs;
• The importance of outlining what a good and SMART^[14] recommendation looks like; and
• That fewer recommendations that are likely to support greater change can be more important than lots of recommendations.
• The order of recommendations and actions and how this might influence their success;
• How learning events can provide a good opportunity to share and act upon learning identified by the review;
• The possibility of learning and/or recommendations including or outlining the impact of actions after the death – for example, sentencing on a specific case; and
• Tracking the implementation of learning.

The review process (general/other)

• Detail on best/safe practice – for example, around violent resistance;
• Detailed guidance on reviewing deaths by suicide;
• Guidance on where the significance/specifics of a case do not immediately meet the criteria but that would benefit from a DHSR;
• Awareness of the dangerousness of the situation during the review process and the need for robust risk assessments;
• Regarding the terms of reference and temporal scope of the DHSR, instances where learning can continue after the death and that this could be reflected in the review – for example, related to the care of the children following the death;
• It will be important to continue to convey the spirit of reviews to reduce defensiveness in information sharing – openness, no blame;
• That criminal justice processes may impact on the progression of a DHSR, as might appeals;
• 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);
• The quality assurance process looking at the different forums used for capturing information, particularly from family members; and
• The statutory guidance needs to provide clarity whilst allowing flexibility.

Governance and accountability

• Consideration of fiscal accountability – i.e., the appropriate spending of public funds in a lawful way with proper accounting;
• The resourcing of DHSRs, from start to finish, acknowledging the impacts their delivery has on people’s lives;
• In reporting on the DHSRs and their themes, clarity regarding what will be deemed a success and how this will be measured;
• The identification of commonality of themes that are reported on and flexibility in relation to reporting requirements;
• The opportunity to evidence deliberative democracy^[15] through the accountability and governance arrangements; and
• How data collection can support governance and accountability arrangements to inform reporting requirements. Data could include how many people read the reports.

5.3. Supporting tools that may be beneficial

The group noted that the following tools may be beneficial to support the DHSR process:

• A minimum list of appropriate contacts for the Review Oversight Committee;
• An agreed methodology that supports consistency to the sharing of learning – this could lead to templates being used;
• Templates to guide the process overall and to support a consistent approach;
• A checklist to prompt active consideration of EDI issues;
• Additional support and training in understanding of diversity/intersectionality for panel members and the chair;
• An accessible fact sheet for family members, with simplified language, about the DHSR process and how they can contribute to this is needed. This could also offer signposting for additional support for them;
• Training on talking to children in a trauma informed way within the context of a DHSR;
• Tools to facilitate trauma informed support for children (long term);
• Template for chairs meeting the family and the conduct of the review team;
• Information on the Scottish Child Interview Model (SCIM) as a useful framework for talking to children about a DHSR;
• A template with an expected list of headings helps to aid consistency in report authors’ 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;
• Technical guidance on the editing of the report by multiple parties; and
• The quality assurance process having a framework to assess the reports against.