Fatality Reviews in Cases of Domestic Violence Research Paper

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The reviewing of cases of domestic-violence related deaths commenced in a handful of U.S. states beginning in the early 1990s. As of 2005, roughly thirty-five states conduct what have become known as fatality reviews. The term fatality review refers to the identification and analysis of cases of adult homicide and suicide where one or more parties die due to domestic violence. Reviewers seek to prevent further deaths, injuries, and abuse from domestic violence by suggesting and perhaps introducing preventive strategies involving service providers and community members at large. Reviews differ greatly by community and jurisdiction. Many reviews report aggregate statistical data or summary demographic details. Others dig deeply into fatalities, exploring the multiple and often hidden compromises faced by victims of domestic violence. A number of review teams combine both quantitative and qualitative approaches, bringing both depth and breadth to their deliberations.

Case Selection

Fatality review teams typically do not review all deaths caused by, related to, or somehow traceable to domestic violence. Rather, they select cases for review based upon the impact of the case on the community, the legal difficulties associated with reviewing a particular case, the resources of the team, and the potential the case might have for identifying innovative preventive strategies. Teams recognize that various types of cases qualify for review.

Roughly 1,000 to 1,600 people per year die in the United States as a result of intimate partner homicide. Men kill female intimates in anywhere from two-thirds to three-quarters of intimate partner homicides. In one-quarter to one-third of these cases, females kill intimate male partners. The vast majority of male perpetrators kill females after a long, highly stylized, and escalating pattern of woman battering. Conversely, women typically kill male intimates under circumstances in which their male partners have battered them, often over long periods of time. Although fatality review teams have traditionally paid more attention to the deaths of women than the deaths of men, both sets of cases display similar background characteristics and invite comparable intervention strategies.

Fatality review teams and researchers often distinguish between ‘‘single’’ and ‘‘multiple’’ forms of intimate partner homicide. In the former, the offender kills only the intimate partner. In the latter, the perpetrator kills the intimate partner and then commits suicide (homicide suicide) or kills the intimate partner and a number of family members, and then commits suicide (familicide). Men commit nearly all homicide suicides and familicides. Homicide suicide cases are particularly amenable to fatality review because there is usually no pending criminal prosecution or civil litigation that the review process might complicate.

Deaths attributable to domestic violence involve much more than intimate partner homicides. Researchers use the term ‘‘family homicide’’ to refer to that class of cases where one family member kills another (non-intimate) family member. Examples here include siblings who kill other siblings, parents who kill children, and children who kill parents. Although these killings qualify as domestic violence deaths under state statutes, they sometimes occur against the backdrop of adult intimate partner domestic violence. Fatality review teams analyze family homicides far less frequently than intimate partner homicides in part because these cases do not have the same potential for inviting intervention strategies in domestic violence cases and in part because child death review teams scrutinize a subset of family homicides (i.e., the killing of children).

A few teams have reviewed ‘‘sexual competitor killings.’’ In these cases, men kill men over a woman they sexually compete for. Most of these cases involve at least one of the male sexual competitors battering the female. Although these cases are relatively small in number compared with intimate partner killings, they serve as a reminder that domestic violence spills over into other relationships.

Research suggests that a significant number of women might commit suicide to exit violent intimate relationships. Given that 6,000 women commit suicide each year, it is possible that more women commit suicide due to domestic violence than are directly killed by intimate male partners. In recognition of this fact, a small number of fatality review teams have begun to examine women’s suicides. Evan Stark and Anne Flitcraft believe ‘‘battered women are provoked to attempt suicide by the extent of control exercised over their lives’’ (1995: 55). These researchers investigated the medical records of 176 battered women who were treated at the emergency room at Yale–New Haven Hospital. All of these women had attempted to commit suicide at least once during the study year. Over one-third of them ‘‘visited the hospital with an abuse-related injury or complaint on the same day as their suicide attempt’’ (1995: 53). The close correspondence between the battering and the suicide attempt suggested to Stark and Flitcraft that the battering may have triggered the suicide attempt. However, later research on sixteen female suicides recorded by the Bexar County, Texas, fatality review team revealed ‘‘no data yet on any abuse victim committing suicide as an apparent means of escape’’ (Thornton, Spears, and Brackley 2002: 12).

Working from data on sixty-five suicides identified by the Bexar County fatality review team, Thornton, Spears, and Brackley found twenty-seven reports of male suicide that contained some description of an intimate partner. Of these twenty-seven suicide reports, twenty-one displayed evidence of a ‘‘disturbance in the relationship’’ (2002: 12). In eleven cases the parties were estranged, in six the suicide occurred in the context of an argument, and in five cases men had a documented history of committing intimate partner violence. This preliminary research points to the role of suicidal ideations, threats, attempts, and completed acts as a control strategy in relationships involving domestic violence. Male suicide is therefore another form of death amenable to domestic violence fatality review.

The Philadelphia fatality review team examines a broad sweep of women’s deaths in order to identify the extent of fatalities traceable to domestic violence. This team analyzes intimate partner homicides but has made a highly significant contribution by highlighting the deaths of women who die as prostitutes, with HIV/AIDS, or from causes related to homelessness. Prostitutes, homeless women, and women infected with HIV/AIDS all suffer disproportionate amounts of domestic violence. Team members contend that domestic violence contributes to many of these deaths, albeit perhaps in an oblique or indirect way. The work of teams such as those in Philadelphia raise important questions about what cases teams might select for review in order to highlight the magnitude of the problems associated with domestic violence.


It might be tempting to blame and shame police officers, medical professionals, judges, probation officers, or battered women’s advocates for their failure to intervene appropriately or effectively to prevent a homicide or suicide. However, most fatality review teams recognize that the perpetrator is responsible for the death and do not attribute blame to local service providers. Teams acquired this ‘‘no blame and shame’’ philosophy from mortality review work in the fields of nuclear fuels and aviation (see Websdale 2003). In these fields reviewers soon learned that blaming individuals did not lead to open disclosure and actually reduced the likelihood of individual practitioners sharing compromising information about what might have contributed to a tragic outcome. In addition, the blaming of service professionals essentially perpetuates a style of thinking that parallels the abusive behavior of many perpetrators of domestic violence, who blame victims for much that goes wrong. Having said that reviewers seek to avoid blaming and shaming system professionals and others, they nevertheless demand accountability on the part of involved agencies and others.

Team Membership

Given that domestic violence homicides and suicides are both complex and multifaceted, many teams have been careful to develop a broad membership that reflects the diversity of service providers and others who come into contact with victims of domestic violence. Put simply, anyone involved with or affected by a domestic violence–related death might serve on a team. However, up to the present, most teams have exhibited a strong criminal justice orientation and include powerful players such as prosecutors, senior police officials, probation and parole officers and, less frequently, public defenders. Also included are victim advocates. In some states, such as Washington, victim advocates have driven the fatality review initiative. In others, such as Florida, law enforcement and criminal justice agencies have played a more important role.

In addition to criminal justice professionals and advocates, teams often include public health professionals, emergency room staff, animal control officers, school counselors, child protective services workers, batterer intervention program specialists, members of the faith community, and drug and alcohol treatment providers. Less commonly and more controversially, some teams have reached out to the community in an attempt to create a more permeable and accountable team structure to gain fresh insights into deaths. This outreach has taken two principal forms.

In Montana, for example, the death review team has interviewed family members and others close to both victims and perpetrators in an attempt to gather comprehensive data on cases. In one review the Montana team spent five hours interviewing the mother of a perpetrator of domestic homicide. Reaching out to family, friends, neighbors, and workplace associates as a means of learning more about cases is slowly but surely emerging as a key development among teams. This tendency or trajectory finds a parallel in the research literature on intimate partner homicide, where more recently researchers have used proxy-informants, those close to the victim, who might have known of specific compromises and problems not revealed by police files, court documents, medical examiner materials and the like (see, for example, Campbell 2003a, 2003b).

The second development concerns the increased discussion of the role that battered women themselves ought to play on teams. Some teams have battered women at the table in the form of victim advocates and others who once experienced domestic violence. However, although state statutes often allow for the presence of battered women on review teams, teams have been slow to include these women other than in the team’s capacity as system professionals, but this is changing. A number of teams are considering involving battered women directly in review work. For example, members of the West Palm Beach team have taken their deliberations to a group of survivors of domestic violence in order to get their feedback. This productive exercise may be the harbinger of major changes in team activity, seeking to somehow access the voices of battered women in an attempt to understand the complex compromises victims faced prior to their deaths.

Some have argued that these developments might serve to democratize teams, make them more sensitive to grassroots social and economic matters that affect battered women, and render them less bureaucratic and officious and more accountable. To the extent that domestic violence is much more than a criminal justice problem, these moves toward including survivors and the community appear promising. On the other hand, the presence of family members, victims of domestic violence, and others raises difficult ethical questions for teams about what they might share with these individuals. In addition, the involvement of family members also raises concerns about retraumatizing those close to victims (see Hauser 2005; Websdale 2005a, 2005b).

The Process of Reviewing a Case

Having identified an agency or organization to house the fatality review initiative, team members usually spend a considerable amount of time talking about how they will review cases. The nature of review often dovetails with the goals, purposes, and philosophical orientation of the team. The review process differs by team and is shaped in part by resources, levels of participation by various members, and the nature of any statutory guidelines. Members often take turns chairing or co-chairing teams. These individuals usually have the connections to orchestrate meetings, arrange for the flow of relevant information to the table, and have some political clout in the local domestic violence arena. Rotating chairs and co-chairs also limits burnout.

Notwithstanding certain difficulties with various types of private or confidential information, teams usually draw from some or all of the following: police homicide logs; newspaper reports of homicides; crime scene investigation reports; detectives’ follow-up reports; transcripts of interviews conducted by investigators with witnesses and other involved parties; data from prior protective orders; affidavits for protective orders; notices of service of protective orders; presentence investigation reports (probation); parole data including notification of victims; civil court data regarding divorce proceedings, termination of parental rights, child custody disputes, and child visitation issues; criminal histories of perpetrators and victims; child protective services data; summaries of psychological evaluations appearing in public record documents such as police files; medical examiners reports; autopsy reports; workplace information, perhaps regarding harassment or abuse; public health data, including emergency room data; shelter/advocacy outreach data; school data pertaining to abuse reports; statements from neighbors, family members, friends, workplace colleagues, witnesses, and others; and drug and alcohol treatment data.

Agency representatives and others bring their respective information to the table. Sometimes this is copied and circulated beforehand, other times it is analyzed only during review meetings. Some teams use documentary evidence only as a touchstone for ascertaining what they need. Teams that adopt this strategy sometimes destroy that documentary evidence at the close of their deliberations. Team members often present information deriving from their respective agency files, summarizing and interpreting those data as they proceed. Discussions ensue based upon the array of evidence presented, and detailed syntheses of at times disparate sources of data emerge.

Many teams find it helpful to generate a timeline of the case, a linear chronology that maps the primary events before the homicide in varying degrees of detail. They might also identify specific red flags, or warning signals, in the case that may or may not have been picked up by risk assessment instruments. Most teams address the nature and extent of interagency involvement and coordination in the case. Far fewer teams scrutinize the involvement of family, community members, and others prior to the death. Most teams complete their work by addressing the question of what is to be done. This question takes the form of recommendations for the development of more solid preventive interventions. More recently teams have focused on how to implement these recommendations.

In addition to thinking about the information to be gleaned from reviews, team members often think carefully about the way cases are reviewed. Of paramount consideration here are developing a climate that honors victims and their families and working to provide a safe and supportive climate for reviewers and those who work with teams. This means considering the emotional toll on reviewers and others and developing protocols that address these difficulties. Teams often reflect upon the culture they create, the language they use to talk about cases, the photographs members may or may not be asked to view, and the inevitable differences in perspective that surface during such challenging work.


Whether or not fatality review statutes shield team deliberations and findings, most teams are careful to protect sensitive and confidential information from the public eye. Most teams understand the difference between public, private, and confidential information and work within these parameters, taking care not to break the law or infringe upon people’s rights to privacy and confidentiality. In order to bring agency professionals to the table, it proved imperative in many states to develop protective statutes that rendered deliberations immune from subpoena and various forms of legal discovery. Such statutory shields ensure teams access to much, although not all, sensitive and confidential information. These confidentiality guarantees allow team members to come to the table in an open and honest manner.

The criticism of providing confidentiality shields is that they increase the likelihood of a cover-up. Such cover-ups might occur in cases where there is gross negligence or malfeasance. However, while it may be the case that confidentiality guarantees shield teams from civil suits and other legal or disciplinary actions, it is nonetheless the case that civil suits can still take place and any negligence or malfeasance challenged through tort law.

The need for confidential information speaks to the desire of many teams to produce thorough, comprehensive, and detailed reviews that maximize the opportunity to highlight systems failures and the like. However, it is also the case that perfectly thorough, detailed, and comprehensive reviews result from the analysis of public record data alone (see Thompson 2005). These reviews usually involve the examination of homicide suicide cases or other closed criminal cases where there are no pending civil or criminal legal issues, including appeals.

Fatality Review and Other Preventive Interventions

Domestic violence fatality reviews emerged alongside and as a part of a number of multi-agency and interdisciplinary initiatives in the field of domestic violence. In a number of states (e.g., Florida) fatality review teams arose out of existing coordinated community responses to domestic violence. In some states they arose in a review climate established by the work of multi-agency child fatality reviews. Fatality reviews also dovetail nicely with safety and accountability audits. These audits involve working closely with agencies and examining their modes of operation in minute detail. In a sense, safety audits scrutinize institutional ways of life that constrain and limit effective responses to domestic violence. Audits work with everyday procedures in police departments, the courts, and other agencies to improve communications and sharpen system effectiveness. Fatality reviews examine the everyday procedures, paper trails, and human practices through the lens of the death rather than everyday practice. If audits scrutinize everyday ways of providing services, fatality reviews approach service delivery through the rare but potent event of a death.

Although it is too early to say whether fatality reviews actually reduce domestic violence deaths, injuries, and abuse, it is clear that teams across the country report major improvements in inter-agency communication, the emergence of novel practices, an increased awareness of the significance of domestic violence as a social problem, and the development of increased understanding and appreciation among service providers. Fatality reviews also contribute to increasingly sophisticated appreciations of risk in local, statewide, and national contexts. In this sense fatality reviews and safety audits contribute to safety planning for victims of domestic violence and the coordinated and thoughtful delivery of services.

See also:


  1. Campbell, Jacquelyn C., et al. ‘‘Risk Factors for Femicide in Abusive Relationships: Results from a Multisite Case Control Study.’’ American Journal of Public Health 93, no. 7 (2003a): 1089–1097.
  2. ———. ‘‘Assessing Risk Factors for Intimate Partner Homicide.’’ NIJ Journal, Issue 250 (2003b): 14–19.
  3. Hauser, Jacquelyn. ‘‘Commentary on Websdale.’’ Violence Against Women 11, no. 9 (2005): 1201–1205.
  4. Stark, Eva, and Anne Flitcraft. ‘‘Killing the Beast Within: Woman Battering and the Female Suicidality.’’ International Journal of Health Services 25, no. 1 (1995): 43–64.
  5. Thompson, Robi. ‘‘Confidentiality and Fatality Review,’’ 2005. National Domestic Violence Fatality Review Initiative.
  6. Thornton, Jo E., William Spears, and Margaret H. Brackley. ‘‘Suicides Associated with Intimate Partner Violence: Perpetrator Suicides Underrecognized.’’ Fatality Review Bulletin (Winter 2002): 12–13.
  7. Websdale, N. Reviewing Domestic Violence Deaths. National Institute of Justice Special Research Bulletin on Intimate Partner Homicide, 2003.
  8. ———. ‘‘Battered Women at Risk: A Rejoinder to Jacquelyn Hauser’s and Jacquelyn Campbell’s Commentaries on R and B.’’ Violence Against Women 11, no. 9 (2005a): 1214–1221.
  9. ———. ‘‘R and B: A Conversation between a Researcher and a Battered Woman about Domestic Violence Fatality Review.’’ Violence Against Women 11, no. 9 (2005b): 1186–1200.

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