Abstract
Purpose
Since 2003, all domestic violence-related homicides in Ontario, Canada have been reviewed by an interdisciplinary committee. This committee conducts in-depth analyses to help understand what may have been done differently, with hindsight, and make recommendations to prevent similar tragedies in the future. This study examined all recommendations made by the Ontario Domestic Violence Death Review Committee over a 10-year period (2010–2020).
Methods
This study undertook a thematic analysis of all recommendations provided within 219 domestic homicide case reviews. Using a multistep coding process, several recurring themes were found across 400 recommendations.
Results
Results of this study identified consistent themes related to public awareness, professional education and enhanced systems, community agency collaboration and risk assessment, safety planning, and risk management.
Conclusions
These themes parallel findings by similar research studies undertaken in the United States, parts of the United Kingdom, Australia, and New Zealand. Ongoing challenges in the implementation of these recommendations and an evaluation of the impact of this work in reducing homicides is discussed.
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References
Abrahams, N., Mathews, S., Martin, L. J., Lombard, C., & Jewkes, R. (2013). Intimate partner femicide in South Africa in 1999 and 2009. PLoS Medicine, 10(4), e1001412–e1001412. https://doi.org/10.1371/journal.pmed.1001412
Aldridge, M. L., & Browne, K. D. (2003). Perpetrators of spousal homicide: A review. Trauma, Violence & Abuse, 4(3), 265–276. https://doi.org/10.1177/1524838003004003005
Alisic, E., Groot, A., Snetselaar, H., Stroeken, T., & van de Putte, E. (2015). Parental intimate partner homicide and its consequences for children: Protocol for a population-based study. BMC Psychiatry, 15(1), 177–177. https://doi.org/10.1186/s12888-015-0565-z
Alisic, E., Vaughan, C., Morrice, H., Joy, K., & Chavez, K. M. (2022). A double taboo children bereaved by domestic homicide. The Lancet. Public Health, 7(10), e810–e810. https://doi.org/10.1016/S2468-2667(22)00228-6
Belfrage, H., & Rying, M. (2004). Characteristics of spousal homicide perpetrators: A study of all cases of spousal homicide in Sweden 1990–1999. Criminal Behaviour and Mental Health, 14(2), 121–133. https://doi.org/10.1002/cbm.577
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
Bugeja, L., Butler, A., Buxton, E., Ehrat, H., Hayes, M., McIntyre, S.-J., & Walsh, C. (2013). The implementation of domestic violence death reviews in Australia. Homicide Studies, 17(4), 353–374. https://doi.org/10.1177/1088767913494787
Bugeja, L., Dawson, M., McIntyre, S.-J., & Walsh, C. (2015). Domestic/Family violence death reviews: An international comparison. Trauma, Violence & Abuse, 16(2), 179–187. https://doi.org/10.1177/1524838013517561
Campbell, J. C., Glass, N., Sharps, P. W., Laughon, K., & Bloom, T. (2007). Intimate partner homicide: Review and implications of research and policy. Trauma, Violence & Abuse, 8(3), 246–269. https://doi.org/10.1177/1524838007303505
Chantler, K., Bracewell, K., Baker, V., Heyes, K., Traynor, P., & Ward, M. (2023). An analysis of minoritisation in domestic homicide reviews in England and Wales. Critical Social Policy, 43(4), 602–625. https://doi.org/10.1177/02610183221133052
Cook, E. A., Rowlands, J., Bracewell, K., Jones, C., & Boughton, G. (2023). Parallels in practice: Applying principles of research integrity and ethics in Domestic Violence Fatality Review (DVFR). Journal of Family Violence, 38(6), 1015–1027. https://doi.org/10.1007/s10896-023-00505-x
David, J. D., & Jaffray, B. (2022). Homicide in Canada, 2021. (Juristat, Statistics Canada Catalogue No. 85-002-X). Retrieved from: https://www150.statcan.gc.ca/n1/pub/85-002-x/2022001/article/00015-eng.htm
Dawson, M. (2017). Domestic homicides and death reviews: An international perspective. Palgrave Macmillan UK. https://doi.org/10.1057/978-1-137-56276-0
Dawson, M., Bunge, V. P., & Balde, T. (2009). National trends in intimate partner homicides: Explaining declines in Canada, 1976 to 2001. Violence against Women, 15(3), 276–306. https://doi.org/10.1177/1077801208330433
Dawson, M. & Jaffe, P. (2021). One is too many: 10 years Of domestic homicides in Canada. Report from the Canadian domestic homicide prevention initiative. Retrieved from: https://www.cdhpi.ca/sites/cdhpi.ca/files/cdhpi-report-final_0.pdf
Dawson, M., Mathews, S., Abrahams, N., & Campbell, J. (2017). Death reviews in the context of domestic homicide in low- to middle-income countries: south Africa as a case Study. In Domestic Homicides and Death Reviews (pp. 345–372). Palgrave Macmillan UK. https://doi.org/10.1057/978-1-137-56276-0_12
Dawson, M., & Piscitelli, A. (2021). Risk factors in domestic homicides: Identifying common clusters in the Canadian context. Journal of Interpersonal Violence, 36(1–2), 781–792. https://doi.org/10.1177/0886260517729404
Eastwood, O., Conroy, R., Joy, K., Chavez, K. M., Devaney, J., Frederick, J., ... & Alisic, E. (2023). “That weird kid without parents”: a qualitative analysis of identity following bereavement due to parental intimate partner homicide in Australia. https://doi.org/10.31234/osf.io/9ew2m
Fairbairn, J., Jaffe, P., & Dawson, M. (2017). Challenges in defining domestic homicide: Considerations for research and practice. In Domestic Homicides and Death Reviews (pp. 201–228). Palgrave Macmillan UK. https://doi.org/10.1057/978-1-137-56276-0_7
Fraser, C. A., Saxton, M. D., & Jaffe, P. G. (2023). Perspectives from canadian domestic violence police specialists on the challenges in providing safety planning and risk management for victims and their children. Journal of Family Violence. https://doi.org/10.1007/s10896-023-00521-x
Graham, L. M., Sahay, K. M., Rizo, C. F., Messing, J. T., & Macy, R. J. (2021). The validity and reliability of available intimate partner homicide and reassault risk assessment tools: A systematic review. Trauma, Violence, & Abuse, 22(1), 18–40. https://doi.org/10.1177/1524838018821952
Hamilton, L. H. A., Jaffe, P. G., & Campbell, M. (2013). Assessing children’s risk for homicide in the context of domestic violence. Journal of Family Violence, 28(2), 179–189. https://doi.org/10.1007/s10896-012-9473-x
Hester, M. (2007). Making an impact: Children and domestic violence. A reader (2nd ed.). J. Kingsley Publishers.
Jaffe, P. G., Campbell, M., Hamilton, L. H. A., & Juodis, M. (2012). Children in danger of domestic homicide. Child Abuse & Neglect, 36(1), 71–74. https://doi.org/10.1016/j.chiabu.2011.06.008
Jaffe, P., Campbell, M., Reif, K., Fairbairn, J., & David, R. (2017). Children killed in the context of domestic violence: international perspectives from death review committee. In Domestic Homicides and Death Reviews (pp. 317–343). Palgrave Macmillan UK. https://doi.org/10.1057/978-1-137-56276-0_11
Jaffe, P., Scott, K., & Straatman, A. L. (Eds.). (2020). Preventing domestic homicides: Lessons learned from tragedies. Elsevier Science.
Jones, C., Bracewell, K., Clegg, A., Stanley, N., & Chantler, K. (2022). Domestic homicide review committees’ recommendations and impacts: a systematic review. Homicide Studies. https://doi.org/10.1177/10887679221081788
Kourti, A., Stavridou, A., Panagouli, E., Psaltopoulou, T., Spiliopoulou, C., Tsolia, M., Sergentanis, T. N., & Tsitsika, A. (2023). Domestic violence during the COVID-19 pandemic: a systematic review. Trauma, Violence, & Abuse, 24(2), 719–745. https://doi.org/10.1177/15248380211038690
Kuijpers, K. F., van der Knaap, L. M., & Winkel, F. W. (2012). Risk of revictimization of intimate partner violence: The role of attachment, anger and violent behavior of the victim. Journal of Family Violence, 27(1), 33–44. https://doi.org/10.1007/s10896-011-9399-8
Leth, P. M. (2009). Intimate partner homicide. Forensic Science, Medicine, and Pathology, 5(3), 199–203. https://doi.org/10.1007/s12024-009-9097-5
Marsh Pow, A., Murray, C. E., Flasch, P., Doom, E., & Snyder, M. (2015). Learning from experience: A content analysis of domestic violence fatality review team reports. Partner Abuse, 6(2), 197–216. https://doi.org/10.1891/1946-6560.6.2.197
Office of the Chief Coroner. (2022). Inquest into the deaths of carol culleton, anastasia Kuzyk and Nathalie Warmerdam. Office of the Chief Coroner. Retrieved from: https://www.ontario.ca/page/2022-coroners-inquests-verdicts-and-recommendations#section-4.
Olszowy, L., Jaffe, P. G., Dawson, M., Straatman, A.-L., & Saxton, M. D. (2020). Voices from the frontline: Child protection workers’ perspectives on barriers to assessing risk in domestic violence cases. Children and Youth Services Review, 116, 105208. https://doi.org/10.1016/j.childyouth.2020.105208
Ontario Domestic Violence Death Review Committee (Ontario DVDRC). (2018). Domestic violence death review committee 2018 annual report. Office of the Chief Coroner. Retrieved from: https://www.ontario.ca/document/domestic-violence-death-review-committee-2018-annual-report
Overstreet, S., McNeeley, S., & Lapsey, D. S., Jr. (2021). Can Victim, Offender, and Situational Characteristics Differentiate Between Lethal and Non-Lethal Incidents of Intimate Partner Violence Occurring Among Adults? Homicide Studies, 25(3), 220–238. https://doi.org/10.1177/1088767920959402
Pobutsky, A., Brown, M., Nakao, L., & Reyes-Salvail, F. (2014). Results from the Hawaii domestic violence fatality review, 2000–2009. Journal of Injury and Violence Research, 6(2), 79–90. https://doi.org/10.5249/jivr.v6i2.473
Reif, K., & Jaffe, P. (2019). Remembering the forgotten victims: Child-Related themes in domestic violence fatality reviews. Child Abuse & Neglect, 98, 104223–104223. https://doi.org/10.1016/j.chiabu.2019.104223
Robinson, A. L., Rees, A., & Dehaghani, R. (2019). Making connections: A multi-disciplinary analysis of domestic homicide, mental health homicide and adult practice reviews. The Journal of Adult Protection, 21(1), 16–26. https://doi.org/10.1108/JAP-07-2018-0015
Rowlands, J., & Bracewell, K. (2022). Inside the black box: Domestic homicide reviews as a source of data. Journal of Gender-Based Violence, 6(3), 518–534. https://doi.org/10.1332/239868021X16439025360589
Saxton, M. D., Jaffe, P. G., Dawson, M., Olszowy, L., & Straatman, A.-L. (2020). Barriers to police addressing risk to children exposed to domestic violence. Child Abuse & Neglect, 106, 104554–104559. https://doi.org/10.1016/j.chiabu.2020.104554
Scott, K; Saxton, M; Reif, K; Bukhari, S; Ashbourne, D; Jaffe, P. (2022). Preventing Child and Parent Homicides: A Road Map to Implement Recommendations from the Ontario Domestic Violence Death Review Committee. Retrieved from: https://www.learningtoendabuse.ca/resources-events/pdfs/Roadmap-DVDRC-Full-Nov30.pdf
Stanley, N., Chantler, K., & Robbins, R. (2019). Children and Domestic Homicide. The British Journal of Social Work, 49(1), 59–76. https://doi.org/10.1093/bjsw/bcy024
Stanley, N., Miller, P., Foster, H. R., & Thomson, G. (2011). Children’s Experiences of Domestic Violence: Developing an Integrated Response from Police and Child Protection Services. Journal of Interpersonal Violence, 26(12), 2372–2391. https://doi.org/10.1177/0886260510383030
Stöckl, H., Devries, K., Rotstein, A., Abrahams, N., Campbell, J., Watts, C., & Moreno, C. G. (2013). The global prevalence of intimate partner homicide: A systematic review. The Lancet, 382(9895), 859–865. https://doi.org/10.1016/S0140-6736(13)61030-2
Storer, H. L., Lindhorst, T., & Starr, K. (2013). The Domestic Violence Fatality Review: Can It Mobilize Community-Level Change? Homicide Studies, 17(4), 418–435. https://doi.org/10.1177/1088767913494202
Tolmie, J., Smith, R., Short, J., Wilson, D., Koziol-McLean, J., Cram, F., Jensen, P., von Dadelszen, P., & White, D. (2017). Fifth report data: January 2009 to December 2015. Family Violence Death Review Committee, Health Quality and Safety Commission New Zealand. Retrieved from: https://www.hqsc.govt.nz/assets/Our-work/Mortality-review-committee/FVDRC/Publications-resources/FVDRC_2017_10_final_web.pdf
United Nations Office on Drugs and Crime (UNODC). (2023). Background paper on femicide review committees. Retrieved from: https://www.unodc.org/documents/commissions/CCPCJ/CCPCJ_Sessions/CCPCJ_32/CRPs/ECN152023_CRP6_e.pdf
United Nations Office on Drugs and Crime (UNODC). (2019). Global study on homicide: Gender-related killing of women and girls. United Nations. Retrieved from: https://www.unodc.org/documents/data-and-analysis/gsh/Booklet_5.pdf
Websdale, N. (1999). Understanding domestic homicide. Northeastern University Press.
Websdale, N. (2020). Domestic violence fatality review: the state of the art. In: Geffner, R., White, J.W., Hamberger, L.K., Rosenbaum, A., Vaughan-Eden, V., Vieth, V.I. (Eds) Handbook of Interpersonal Violence and Abuse Across the Lifespan. Springer, Cham. https://doi.org/10.1007/978-3-319-62122-7_133-2
Websdale, N., Town, J. M., & Johnson, B. (1999). Domestic violence fatality reviews: From a culture of blame to a culture of safety. Juvenile & Family Court Journal, 50(2), 61–74. https://doi.org/10.1111/j.1755-6988.1999.tb00800.x
Weizmann-Henelius, G., Matti Grönroos, L., Putkonen, H., Eronen, M., Lindberg, N., & Häkkänen-Nyholm, H. (2012). Gender-specific risk factors for intimate partner homicide: a nationwide register-based study. Journal of Interpersonal Violence, 27(8), 1519–1539. https://doi.org/10.1177/0886260511425793
Wilson, J. S., & Websdale, N. (2006). Domestic violence fatality review teams: An interprofessional model to reduce deaths. Journal of Interprofessional Care, 20(5), 535–544. https://doi.org/10.1080/13561820600959253
World Health Organization. (2016). Global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and against children. WHO Press. Retrieved from: https://apps.who.int/iris/rest/bitstreams/1070143/retrieve
World Health Organization. (2021). Violence against women. WHO Press. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/violence-against-women
Acknowledgements
This research has been a collaborative effort between the Centre for Research and Education on Violence Against Women and Children, London Family Court Clinic, and the Ontario Domestic Violence Death Review Committee within the office of the Chief Coroner for Ontario. This research was made possible thanks to the funding provided by the Ministry of Children, Community and Social Services (MCCSS).
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Several of the authors are members of the Ontario DVDRC. There is no other conflict of interest to declare that are relevant to this article.
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Saxton, M., Bukhari, S., Jaffe, P. et al. How to Prevent Domestic Homicides: A Qualitative Study of Recommendations from a Canadian Domestic Homicide Review Committee. J Fam Viol (2024). https://doi.org/10.1007/s10896-024-00693-0
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DOI: https://doi.org/10.1007/s10896-024-00693-0