Proposed domestic homicide and suicide review model: phase two/workshop one report

5. The Learning Identified

The learning identified is grouped under themed headings which reflect the focus of discussions throughout the workshop.

Notification of a DHSR

The case scenario reviewed for this activity concerned a woman who had died by suicide.

Groups noted that this case scenario highlighted that, whilst there may not be evidence of domestic abuse within the last 12 months, the cumulative impact of previous domestically abusive relationships should be considered.

The Chief Constable of the Police Service of Scotland and the Lord Advocate are prescribed in the Bill as the “notifying bodies”. The Scottish Ministers can make a “referral”. Group discussion reflected that the Police Investigations and Review Commissioner (PIRC) are also named as a notifying body in the Bill and could also notify in circumstances of a potentially notifiable death.

The group viewed uncertainty about meeting the criteria for a DHSR as acceptable, noting that over-notifying is preferred to under-notifying, especially in the beginning of the implementation of these reviews in Scotland.

The family members would expect to be informed about DHSRs, and the possibility of making a notification, by the police, advocacy support services, website search engine optimisation, or funeral directors. Support to access information about this was thought most likely to come via support services (bereavement, domestic abuse, or possibly social work).

The awareness that families may or may not have of information about DHSRs was discussed, and it was acknowledged that the sharing of information with families may be haphazard and not always enacted with a clear understanding that professionals should do so. It was noted that bereaved families often find each other via social media and other fora and that this may be another information giving platform.

On review of existing notification forms shared from other jurisdictions or other types of reviews, the groups were clear about the need for a notification tool that allowed for:

• the complexity of a notification regarding a suicide
• information on known relationships and persons of interest (not just referring the perpetrator)
• information on employment, volunteering and education
• information on known parallel reviews or investigations
• recognition of the relevance of pets and animal abuse
• contextual information to be included

It was agreed that it would be helpful if the level of information requested and the format for collecting this was consistent across different types of reviews, while allowing for review type variances.

The family group noted the unsuitability of forms to complete for the information they would want to share to facilitate a notification, albeit via the Scottish Ministers.

The groups would welcome clear guidance on completing a notification for the notification bodies and a referral which Scottish Ministers can in turn use to refer a death to the ROC, including an FAQ and guidance on what constitutes ‘relevant’ data to be included. For family members, this guidance would be focussed on what was required in a letter to the Scottish Ministers to request a DHSR is considered. The group representing family members were sure that families would need advocacy support to request that a DHSR is considered.

For the group representing the ROC, there was a lack of clarity regarding what constituted ‘enough’ information to facilitate an initial sift and to enable the ROC to make a decision about whether a DHSR should proceed. Furthermore, they were unclear about the role of the family at this stage and the information that they may hold. The group thought that appointing an Independent Review Chair to undertake the Initial Case Review scoping (as Northern Ireland do) might be appropriate where initial information received was limited. There were, however, also reflections that it was important to be clear about the boundaries of the role of the ROC and for them not to begin the review process, which should be the remit of the review Chair and panel.

The ROC group also thought that clear guidance with a flowchart and expected timescales would assist them in carrying out their role.

The next of kin of the deceased was discussed as a concern that should be considered, particularly in relation to a suicide, as assumptions can be made that the alleged perpetrator is the next of kin.

Setting the Terms of Reference for a DHSR

The case scenario reviewed for this activity concerned the death of a young woman who had been a looked after child and the death of her daughter who was on the Child Protection Register.

All groups partaking in this activity cited several other reviews that might be relevant to undertake in response to this case scenario. This included a:

• Child Death Review
• Child Protection Learning Review
• Death of Looked After Child Review
• PIRC Review

It was also acknowledged that the DHSR would need to be mindful of the criminal justice process.

It was cited that a principle presuming that reviews will be joined up, would be appropriate, unless there was a good reason not to.

All groups struggled to articulate which reviews should definitely take place, how they would interact (whether combined or in conjunction with) and which should take primacy. All agreed that a DHSR was appropriate to the case scenario and that this would be necessary as it was a statutory review, but that clear instruction was required regarding how different types of reviews came together and the management of processes, information and reporting.

There was overall agreement that the review’s temporal scope appropriate for the case scenario considered was a minimum of two years. Northern Ireland recommends one year within their DHR Statutory Guidance and England makes no specific recommendation on timeframes. Striking the balance between going far enough back into the history of a deceased to understand their journey and recognising that policy and practice develops over time so learning opportunities reduce, was noted as a challenge. It was noted that the policy position was that while there would be a starting position on temporal scope, that this would be varied dependent on the circumstances of the case and that if there were particular points further back in time that were considered important, these could be included without extending the temporal scope to, for example, 10 years. One group also noted that the temporal scope of a connected review would also be a consideration. The ability to capture historical contextual information, prior to the review’s temporal scope, was highlighted as important.

Groups proposed a range of lines of enquiry for the case scenario review which examined:

• Police responses
• Offender management
• Children’s Social Care interventions
• Looked after children transitioning
• Adult Social Care responses
• Pregnancy and maternity care
• Health care (mother and child)
• Substance use
• Age difference and exploitation/grooming
• Substance use and associated support
• Supported living/housing arrangements
• Cultural considerations
• Community and neighbours
• Family and friends.

Groups articulated that, in addition to the key lines of enquiry, they would expect to see the following represented within a review’s Terms of Reference:

• Information governance
• Media enquiries
• Temporal scope
• Purpose of a review
• Parallel reviews
• Family involvement/approach to engaging the family.

Establishing an effective panel for the DHSR

The case scenario reviewed for this activity concerned the death of an older man who was killed by his wife, and where there were vulnerable adult concerns.

As this case scenario concerned a couple of South Asian heritage who were practicing Sikhs, there was agreement that it was important that the panel membership responded to the need for the panel to understand the cultural and religious influences on the family.

All groups cited the importance of being able to expand the usual membership of the review panel to include experts relevant to the particular case being considered. Examples given included voluntary agencies such as Age Concern, community experts (in this case related to Sikhism), mental health, and adult support and protection.

Additional input to the panel from experts in particular issues such as violent resistance or strangulation was also noted as being helpful, although this could be achieved by guest speakers.

It was noted that it may not always be clear at the outset who the primary abuser is. Flexibility is needed to allow the panel to adapt to emerging need and gaps in knowledge. Clarity on the process for adding or changing review panel membership, as more information comes to light, was requested.

A further discussion was held about the possibility of having a family member, not associated with the case, on the panel. The benefit of this approach would be a dedicated role to ensure the victim and their family’s perspective were central to discussions. This approach would, however, need significant consideration to mitigate risks and could be resource intensive to ensure the family representatives were properly trained and supported.

The following was noted as being important inclusions within the DHSR Statutory Guidance:

• Clarity regarding who makes the final decision about the panel membership and whether this was the panel Chair, ROC or Secretariat.
• Clarity regarding the process for adding to or changing the panel membership.
• Survivor input – some guidance on the process for requesting specialist expertise.
• How communication is managed and by whom (particularly with the families).
• Guidance on responsibilities around interviewing a perpetrator (or person of interest in a suicide case).

Additional reflections and learning identified

Information sharing and data protection

Concerns were raised about the control and management of data related to the DHSR. Specifically, that:

• There must be a lawful basis for all information that is shared (except that related to the deceased).
• Clarity is needed regarding what information is relevant and proportionate to be shared with the review.
• Issues may arise if information is not relevant to the enquiry and is included (i.e. ancillary). Data dumps are unhelpful and possibly unlawful.
• Internal reviews by agencies can be the weakest part of the process regarding relevance and data should be signed off legally/in terms of data protection before it goes to review Chairs.
• Careful redaction will be required. This will bring additional service pressures on the system.
• Digital evidence (for example, police body worn video) needs particular and careful consideration.
• Secure systems are needed to assist in the movement and storage of sensitive information (for example, Diligent).

These concerns are increased when the review is concerning a suicide, and no charges have been brought against the alleged perpetrator.

It is imperative that information sharing and data protection is properly addressed within the Statutory Guidance and that there is access to appropriate advice.

It was reflected that the publication or non-publication of DHSR reports in Scotland is a live issue with Scotland yet to take a position on this, and that this may impact on the way DHSR related data is handled. This is not accurate. Scotland does have an agreed position on the publication of reports, and the retention of data and reports. This indicates that there is a current lack of knowledge amongst stakeholders about this position.

Equality, Diversity and Inclusion (EDI)

Where a child is a subject of the review, a group thought that the panel must have a child (domestic abuse focussed) advocate on the panel.

It was noted that EDI considerations should also be applied to the perpetrator’s involvement in the review.

While acknowledging that the nine protected characteristics, and their potential impact on the victim or perpetrator’s experiences and agency responses, should be considered within a review, groups highlighted the importance of also considering the socio-economic status and class of the subjects of the review, and how this intersects with other identities. Intersectionality, overall, was flagged as an important consideration within reviews.

The risk of compassion fatigue was discussed and the need to guard against this with appropriate support, challenge and training for those involved in DHSRs.

The DHSR process provides an opportunity to collect data sets for each review, and these should go beyond those set out within legal definitions (for example, the protected characteristics set out in the Equality Act 2010).

The legislation and supporting Statutory Guidance

The potential for the scope to be extended beyond deaths to focus on post death events was discussed. For example, in relation to the ongoing care of children.

An issue was identified in a lack of criteria regarding the circumstances where Ministers will overrule the ROC and instruct a review. There needs to be clarity about when and under what circumstances this will happen.

Additionally, there needs to be clarity on the role of the ROC and the case review panel – noting that they all seem to require more and more information. The process also exposed a lack of clarity regarding the nature and level of information required to enable the ROC to make decisions.

Support for the ROC

A good induction process for new members of the ROC was flagged as important.

The groups discussed the need for continuous development of the DHSR processes, allowing for fine tuning as work develops. A framework for reflective practice, enabling a continual learning loop, could be established.

For transparency and to assist in continual learning, proper recording of decisions made by the ROC was seen as crucial.

A query was raised about how the ROC and panel would receive documentation and what the responsibilities would be around storage. Use of an appropriate case management system may be a solution.

It was acknowledged that the first meeting of the ROC would require more support than subsequent meetings, as they find their feet. A consistent approach being taken to the meetings was noted as helpful.

Other

The ROC, Independent Chairs, and panel members will need good training that is regularly updated.

It was thought that there would be value in evaluating the review process as it happens (perhaps the first one) to identify lessons learned and facilitate lessons learned and continuous improvement. A suggestion for the ROC to utilise a learning log was made.

The possibility of establishing a scrutiny and management group to oversee the implementation and to ensure continuous learning was explored. While a conclusion was not reached as to whether this would be worthwhile, this is worth further exploration.

Advocacy support for families through the DHSR process was highlighted as being critical.