Domestic Violence Fatality Review Essay

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In the United States, approximately 1,600 women are murdered each year by their current or former partners. Domestic violence deaths often display predictable patterns and causes. Many experts in the field believe that many of these homicides are preventable. When a woman is murdered by a partner, the public often wants to know why the woman was not protected and the homicide not prevented. A recent and increasingly popular approach to preventing these tragedies is the formation of domestic violence death (fatality) review committees (DVDRCs). The effort of a DVDRC is comparable to that seen in the airline industry in reducing aviation disasters or in the medical profession in learning from deaths occurring in hospitals under questionable circumstances. DVDRCs are interdisciplinary teams of domestic violence experts who are dedicated to understanding how and why domestic violence deaths occur through a detailed examination of individual cases. Each committee utilizes the benefit of hindsight to recommend what could have been done in their community to prevent each fatality, with the goal of preventing future deaths. There is emerging evidence supporting the utility of DVDRCs in assisting the overall effort of reducing domestic violence fatalities and domestic violence, in general, through the implementation of their recommendations.


One of the first publicly documented fatality reviews, known as “The Charan Investigation,” was conducted in 1990 in San Francisco, California. The investigation was driven by the Commission on the Status of Women at the request of the San Francisco Domestic Violence Consortium. Joseph Charan murdered his wife and committed suicide in front of numerous schoolchildren and teachers. The killing occurred 12 days after Mr. Charan received a suspended sentence for felony domestic assault and malicious mischief. Relatively soon after the official report was released in 1991, Santa Clara County in California started one of the first regularly operating DVDRCs (1994). At the end of 1994, jurisdictions in two states had committees conducting regular reviews. In 1998, nine states had jurisdictions with DVDRCs. By 2003, 27 states and the District of Columbia had committees operating or planning to operate at county or state levels, and 18 of these states had passed legislation or given directives on making the formation of DVDRCs and consistent reviews a mandatory practice. In September of 2002, the Ontario government publicized the formation of Canada’s first DVDRC through the Office of the Chief Coroner, making fatality reviews an international practice. Another important development in the field came in 2004 with the launch of the National Domestic Violence Fatality Review Initiative. The purpose of the initiative is to provide technical assistance with reviews by providing a clearinghouse, a resource center, and several other unique services.

Structure, Mandate, And Process

DVDRCs vary in their compositions, directives, and procedures, largely due to the amount of funding they receive (many operate on a volunteer basis). Most are comprised of coroners, medical and mental health professionals who specialize in domestic abuse, criminologists, prosecutors, judges, shelter staff and women’s advocates, law enforcement staff, and representatives from child protection services. The typical cases teams are charged with identifying and reviewing include intimate partner (a) homicide, (b) homicide-suicide, (c) attempted homicide followed by suicide, (d) attempted homicide followed by related accidental death (e.g., the perpetrator was killed in a car accident during a police pursuit), and (e) attempted homicide followed by related homicide (e.g., the perpetrator was killed in a police shooting). Reviewed cases may include those involving multiple deaths (e.g., familicide) or the deaths of any individuals connected to incidents of domestic violence, such as third-party interveners, friends, neighbors, coworkers, new partners, extended family members, and children. DVDRCs operate under the philosophy that the perpetrators are ultimately responsible for the deaths and do not assign blame to individuals or agencies involved in the cases under examination. Generally, a fatality review is the process by which a DVDRC uses multiagency data and interviews with families, friends, neighbors, and others to document, analyze, and report on the history of the victim, perpetrator, their relationship, and their family. Teams also track risk factors associated with lethal intimate partner violence in each case to aid in enhancing the predictability of the tragedies. They examine the effects of all interventions that took place before the deaths, consider changes in relevant prevention and intervention systems to address gaps in service delivery, and develop recommendations for coordinated community plans. Broadly, recommendations stemming from reviews address (a) increasing awareness and education of domestic violence; (b) enhancing assessment and intervention practices with victims and perpetrators; (c) improving training and policy development within target agencies; (d) increasing resource development for victims, abusers, and their families; (e) advancing coordination of services among agencies servicing at-risk families; (f) legislative reform; and (g) increasing and improving prevention programs for those at risk of becoming victims and perpetrators. DVDRCs report their findings and recommendations annually to enhance public, professional, and policymaker understanding of domestic violence death.

Current And Future Directions

To date, there has not been a systematic evaluation of the DVDRC initiative. Based on the annual reports of individual committees, there would seem to be a high level of community engagement and collaboration inherent in the process. Individual communities and states often refer to their DVDRC as a rationale for new practices or legislation. For example, in Ontario, Canada, there has been a broad-based initiative to educate friends, family, and neighbors about lethal domestic violence, in light of all the common warning signs overlooked in many homicides. Some jurisdictions monitor specific recommendations such as the Santa Clara committee highlight of the fact that there were no deaths in the 5,337 domestic violence cases referred to the district attorney’s office for prosecution in 2004. It was also noted that 2004 was the third year in a row their community had been without police-assisted suicides (i.e., “suicide-by-cop”). Many committees report that in their view, fatality reviews save lives. We can expect more empirical studies to test this hypothesis in the future.


  1. Ontario Domestic Violence Death Review Committee. (2006). Annual report to the chief coroner. Toronto, ON: Ministry of the Attorney General.
  2. Santa Clara County Domestic Violence Council. (2004). Death review committee final report. San Jose, CA: County Government Center. Retrieved from
  3. Websdale, N. (1999). Understanding domestic homicide. Boston: Northeastern University Press.
  4. Websdale, N. (2003). Reviewing domestic violence deaths.
  5. National Institute of Justice Journal, 250, 26–31. Websdale, N., Town, M., & Johnson, B. (1999). Domestic violence fatality reviews: From a culture of blame to a culture of safety. Juvenile and Family Court Journal, 50, 61–74.
  6. National Domestic Violence Fatality Review Initiative:

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