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

7. Summary findings and government response

“Having an opportunity to reflect upon the proposed model with colleagues who have experience of undertaking reviews in other national contexts has been extremely helpful. It has affirmed many of the elements of the new model, while also helping to strengthen key aspects of our approach to ensure that the new model and supporting processes will work as intended.”

7.1. Proposed legislation: Findings

Scope

(a) Inclusion of cases of neglect or sudden death;

(b) Inclusion of adult children;

(c) Inclusion of honour-based killings; and

(d) Addressing multiple perpetrators (particularly relevant where there is honour-based abuse).

Definitions

(a) Clear definition of ‘suicide’ and which deaths by suicide fall within the scope of the review process;

(b) Clear definition of ‘information’; and

(c) Consistency of language across all directions to ensure understanding.

Roles

(a) Clarity of roles between the Secretariat, Review Oversight Committee, chair, and members;

(b) Named roles in public authorities; and

(c) Inclusion of Probation Service, Parole Board, Family Court, and Armed Forces.

Process

(a) Reference to Equality, Diversity, and Inclusion (EDI);

(b) Existence of direct referral routes;

(c) Maximum three reviews per chair at any one time;

(d) Clarity around the initial notification review by the Oversight Committee;

(e) Flexibility to suggest refinements to the review’s terms of reference;

(f) Stage to consider joint reviews;

(g) Who will the Review Oversight Committee interact with in the process; and

(h) What happens when a family is against the review being undertaken.

7.2. Proposed legislation: Scottish Government response

Scope

(a) Cases of neglect or sudden death are not within the current scope of the model. There are existing review processes that include such cases and at present there is no intention to use the enabling power in the Bill to include these deaths within the model.

(b) Adult children of the ‘victim and/ or perpetrator’ are included within the legislation.

(c) The Scottish Government has committed to including so-called ‘honour’ killings in the model using the enabling power. Work is required to develop a policy and legal definition.

(d) The legislation already makes provision for multiple perpetrators but this will be detailed in the statutory guidance.

Definitions

The significance and clarity of language used in the proposed legislation, and throughout the learning review, is recognised. Where relevant, definitions will be provided as part of the legislative provisions. Other definitions will be captured through the statutory guidance or other review specifications.

Roles

(a) Clarity of roles will be established through the statutory guidance, as well as the job descriptions associated with each role.

(b) The existence of a Single Point of Contact (SPOC) within each agency is currently being explored.

(c) The inclusion of the suggested agencies is currently being considered, and the enabling powers would allow for future amendments to the list of relevant public authorities.

Process

(a) EDI will be a key aspect of the statutory guidance.

Points (b) to (e) are to be specified through the Statutory Guidance detailing how domestic homicide and suicide reviews will be undertaken.

(f) Joint reviews will be considered during the initial review undertaken by the Review Oversight Committee.

(g) The work of the Review Oversight Committee will be facilitated by the Secretariat for the learning review.

(h) The Oversight Committee Chair will seek to understand why a family do not wish a review to proceed. However, it is likely a review would still proceed if deemed appropriate. This will be managed sensitively.

7.3. Statutory guidance: Findings

Chair and panel

(a) Clarity around time expectations for chairs and panel members;

(b) Conflicts of interest;

(c) Allocation of chairs;

(d) Knowledge, experience and skills required for chairs;

(e) Panel members and panel size;

(f) Representation of protected characteristics;

(g) Responsibilities within agencies contributing to the review process;

(h) Separation of panel members from the case being reviewed;

(i) Training and support for chairs and panel members, as well as supervision for vicarious trauma;

(j) Remuneration for third sector organisations; and

(k) Costs incurred by the panel for legal advice, translation, travel etc.

Informing the review

(a) Circumstances where agencies might provide information but not participate in the review process;

(b) Access to victim’s journals, texts, diaries etc, to assist in representing the victim’s voice;

(c) Access to other underlying reviews/ reports, such as a Serious Incident Report or Probation Review;

(d) Equal weighting to equality data and characteristics;

(e) Prompt chairs to draw upon minutes of meetings as an information source; and

(f) Access to information on the perpetrator, particularly where the review refers to a suicide.

Engagement with families, friends, and communities

(a) Clarity about the engagement of family/friends/communities;

(b) Managing expectations and being clear and transparent about the scope and limitations of families’ involvement;

(c) Disclosure of information to the family about the review and treating the family as equal stakeholders in the process;

(d) No hierarchy of testimony;

(e) The importance of language regarding families;

(f) Reports should reflect the views of families and be written in a ‘family friendly’ format;

(g) Preserving the role of the family when there are joint reviews.

(h) Clarity around next of kin and children’s involvement, including how to represent the voice of the child;

(i) Involvement of the perpetrator within the review and the potential benefits and risks of doing so;

(j) Being mindful that the perpetrator’s family may want to see the report; and

(k) Criticality of specialist advocacy support for bereaved family members and consideration of an ‘opt out’ rather than ‘opt in’ approach to offering advocacy support.

Equality, Diversity, and Inclusion (EDI)

(a) Engagement with specialist organisations to inform the analysis, findings and lessons learned;

(b) Expected practice regarding the representation of EDI in the report;

(c) The use of translators, consideration of access in rural communities and different communication mediums; and

(d) Acknowledging that, for some religious communities, there may be sensitivities related to suicide and associated stigma and shame.

Report

(a) Clarity about who will write the report and that the chair will be the author, while the panel will provide input;

(b) Concise report (less than 70 pages);

(c) Opening the report with a description of the circumstances of the death and the reason for the review;

(d) Including the legislation and statutory framework as an appendix at the back of report to improve its accessibility and readability;

(e) Clear and simple language to make the report accessible;

(f) Avoiding the tendency towards victim blaming language/unconscious bias;

(g) Ensuring the timeline of events and the narrative within the report are victim-centred, with every effort made to view the events through the eyes of the victim;

(h) Approach to anonymity/pseudonymity; and

(i) In circumstances where the Review Oversight Committee would deem it appropriate to make changes to the report themselves, it would be necessary to seek author approval for any changes.

Publication

(a) Clearly establish and communicate the principles and process informing whether a report would be made available to the public or the media;

(b) Consideration as to whether, in Scotland, the publication of reports should always be limited to those with a need to know;

(c) Consideration as to whether there is an order/hierarchy between who the report is shared with and when; and

(d) Consideration to the publication of group action plans to engender accountability.

Learning

(a) Ensuring recommendations from the review do not relate only to training;

(b) Change can be national and local, and guidance should be provided on setting out recommendations at agency, national, and local levels;

(c) SMART recommendations and tracking their implementation;

(d) The quality of recommendations is more important than the quantity;

(e) Guidance on establishing the order of recommendations and actions;

(f) The use of learning events; and

(g) Learning and/or recommendations outlining the impact of actions after a death that has been reviewed.

Governance

(a) Consideration of fiscal accountability, e.g., the appropriate spending of public funds in a lawful way with proper accounting;

(b) Resourcing of reviews from start to finish, acknowledging the impacts their delivery has on people’s lives;

(c) In reporting on DHSRs and their themes, ensuring clarity regarding what will be deemed a success and how this will be measured;

(d) The identification of commonality of themes that are reported on, and flexibility in relation to reporting requirements;

(e) The opportunity to evidence deliberative democracy, whereby political decisions should be the product of fair and reasonable discussion and debate among citizens, through the accountability and governance arrangements; and

(f) Consideration to how data collection can support governance and accountability arrangements to inform reporting requirements, e.g., data on how many people read the reports.

Miscellaneous

(a) Inclusion of detail on best/safe practice, e.g., for violent resistance;

(b) Inclusion of detailed guidance on reviewing deaths by suicide;

(c) Guidance on where the significance/ specifics of a case do not immediately meet the criteria, but that would benefit from a review;

(d) Awareness of the dangerousness of the situation during the review process, and the need for robust risk assessments;

(e) Consideration in the terms of reference and temporal scope of the DHSR of 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;

(f) The importance of conveying the spirit of reviews to reduce defensiveness in information sharing, and that it is about openness, not blame;

(g) Awareness that criminal justice processes may impact on the progression of DHSRs; and

(h) Information that that comes to light during a DHSR that may need to be reported to Police Scotland/ Crown Office and Procurator Fiscal Service.

Supporting tools

(a) A minimum list of appropriate contacts for the Review Oversight Committee;

(b) A methodology that supports consistency to the sharing of learning;

(c) Templates to guide the process and to support a consistent approach;

(d) A checklist to prompt active consideration of EDI issues;

(e) Additional support and training in understanding of diversity/ intersectionality;

(f) An accessible fact sheet for family members, with simplified language, about the DHSR process and how they can contribute to this if needed. This could also offer signposting for additional support;

(g) Training on talking to children in a trauma informed way within the context of a DHSR;

(h) Tools to facilitate trauma informed support for children (long term);

(i) Information on on the Scottish Child Interview Model (SCIM) as a useful framework for talking to children about a DHSR;

(j) Technical guidance on the editing of the report by multiple parties; and

(k) A framework for Quality Assurance.

7.4. Statutory guidance: Scottish Government response

Chair and panel

A Workforce and Training Task and Finish Group has been established under the Taskforce governance structure to undertake the work required to develop the appointment, performance, and training specifications for the membership of the Review Oversight Committee and Individual Case Review Panels, as well as other relevant roles that will be operating in the context of the Domestic Homicide and Suicide Review Model for Scotland. The points (a) to (k) regarding the establishment and support of the panel and chairs will all form part of the discussions of the group.

Informing the review

An Information Governance Delivery Group has been established to develop a national framework and protocols for the appropriate application of information governance in the development and implementation of the Domestic Homicide and Suicide Review Model for Scotland. The findings of the workshop will be addressed through the work of the group, as well as the Statutory Guidance and additional guidance for chairs of reviews.

Engagement with families, friends, and communities

Families, friends, and communities are recognised as being integral to the review process and their involvement is being woven throughout the Statutory Guidance.

Dedicated training for chairs and panel members is also being developed to ensure that engagement with families, friends and communities is approached with sensitivity and respect, and that interactions are person-centred and trauma-informed.

It is equally important to ensure that families, friends and communities contributing to the review process are clear about why, how, when, and where this would happen, and that support is available before, during, and after they interact with the review.

The Case Review Panel Chair will be a point of contact for families during the review process and will ensure they are being listened to throughout the review process. The role of advocacy to strengthen the support and to advocate for families is also being considered.

Involvement of the perpetrator within the review process is also being carefully considered.

Equality, Diversity, and Inclusion (EDI)

(a) Specialist organisations are expected to inform the analysis of findings from the review reports, as well as the approach to implementing learning.

(b) Expected practice regarding the representation of EDI in the report will be set out in the report writing guidance, and through the training that will be offered to chairs.

Points (c) to (d) will be set out I further detail in the wider Statutory Guidance. Stigma in relation to suicide within some religious communities is recognised and will be handled sensitively.

Report

(a) The chair of the Case Review Panel will be the sole author of the report, which will be written with input from panel members. This will be set out in the Statutory Guidance in more detail.

Points (b) to (g) are to be addressed through the guidance that will be developed to support the writing of clear and concise domestic homicide and suicide review reports, as well as the additional training that will be offered to chairs and panel members.

(h) The approach to anonymity/ pseudonymity of published reports sits within the remit of the Information Governance Delivery Group under the Taskforce. The Group is considering how to ensure that any report published is risk assessed and compliant with the common law duty of confidentiality towards the deceased, and data protection legislation, should living individuals be referred to in the report.

(i) The Review Oversight Committee needs to ensure the report meets the high standards expected by undertaking a quality assurance check. Any amendments that are deemed necessary will be discussed with the author of the report (the Review Panel chair), who will be responsible for implementing the changes agreed.

Publication

For points (a) to (d), the adoption of a standard for the publication of reports is being progressed by the Information Governance Delivery Group. A series of options will be proposed to the Domestic Homicide and Suicide Review Taskforce for consideration. In all circumstances, the process adopted will aim to ensure transparency and accountability in relation to learning, while ensuring compliance with the common law duty of confidentiality towards those who have died, and data protection legislation for the living individuals referred to in the report.

Learning

Points (a) to (e) will be addressed through the Statutory Guidance for undertaking domestic homicide and suicide reviews, and the training of chairs and panel members.

(f) The various groups under the Taskforce governance structure agreed that the approach to individual reviews could be complemented by facilitated learning events as a powerful opportunity for collective reflection among professionals.

(g) The Criminal Justice Modernisation and Abusive Domestic Behaviour Reviews (Scotland) Bill makes provisions for providing information on the impact of learning and recommendations after a review has been undertaken.

Governance

(a) Fiscal accountability processes and appropriate monitoring of spending will be embedded throughout the learning review.

(b) Aspects of this work are being taken forward by the Workforce and Training Task and Finish Group, with recognition of the vicarious trauma that can be associated with such reviews, and the development of a support framework for those involved in the review process.

Points (c) to (d) will be reflected in the approach to making Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) recommendations, and the guidance to this effect.

(e) The principles of deliberative democracy have underpinned the development of Scotland’s Domestic Homicide and Suicide Review Model to date, and it is expected that this will continue to be an important aspect of the model.

(f) The use of data will be an important aspect of the review model and will be a means to help to shape and inform change.

Miscellaneous

(a) The inclusion of references to best practice is currently being considered.

(b) The Domestic Abuse Related Suicide Group is developing a framework that will support the Review Oversight Committee in its considerations of reviews of domestic abuse related suicide. The framework will be included in the Statutory Guidance.

(c) The flexibility allowed by the model and proposed legislation would enable the Review Oversight Committee to consider whether such cases could generate learning.

(d) A risk assessment methodology will be developed and embedded in each stage of the review process.

(e) Consideration is being given to the inclusion of learning in relation to actions following relevant deaths.

(f) This is an underpinning core function of domestic homicide and suicide reviews. This will be communicated to those involved in reviews.

(g) A protocol is being developed with Police Scotland and COPFS to ensure that the review can take place in parallel with criminal justice processes without interference.

(h) The Information Governance Delivery Group is considering all the legitimate reasons for processing data.

Supporting tools

All the supporting tools suggested have the potential of ensuring there is clarity, consistency, precision, and accountability within the domestic homicide and suicide review process. The creation of such tools will be considered at the right stage of the model’s development, and as part of the discussions with the various groups established under the Taskforce governance structure.