I’ve titled this blog ‘what makes a Domestic Homicide Review?'. On one level, the answer is fairly obvious. The purpose of a review is set out in Statutory Guidance, alongside several requirements ranging from the appointment of an Independent Chair to quality assurance. But in this blog, I am less interested in the technical aspects, important though they are, and instead want to talk about what makes a good review.
It’s an important question that I find myself asking more and more. To some extent, that is because of my recent experience. For five years, I was a Local Authority Strategic Lead, which included responsibility for commissioning reviews. Now, as an Independent Chair, I lead them. If anything, the question of what makes a good review is going to loom larger in my life. In September I’ll be starting a PhD looking at how reviews work, and whether they are effective.
But as that’ll take a few years… what’s pushed me to write this blog now? Well, I’m blogging in response to a review. I won’t identify the review here, because the chair doesn’t have an option to reply. But as I read the review, I grew more and more frustrated. I felt it singly failed to engage with the victim’s experience and, if anything, was blaming. After reading it, I tweeted about my reaction. I had a fair number of responses back, echoing or adding to what I said. So, for me, this blog is a chance to develop my thoughts a bit more and add to the growing conversation about the practice of reviews.
What then makes a good review? In my experience, a good review needs to have a heart and be informed, fearless, expansive and ambitious.
First off, a review needs to have a heart. Put into the language of the Statutory Guidance “the narrative of each review should articulate the life through the eyes of the victim (and their children)”. Each review is unique. But by the end of every review I’ve been involved in, a common thread is that I've had some sense of those involved. Getting that sense takes time and it can be hard. Sometimes it’s been based on information directly from a victim (like texts, social media or diaries), but more often it relies on the accounts of family and friends. Whatever its extent or form, gaining that sense of someone is a privilege. It’s also important because it provides a vital lens. Frankly, I don’t think you can conduct a review into a homicide without seeking to really try and understand, as best you can, the life of the person who has died. That’s because taking the time to try to understand someone’s lived experience inevitably changes your perspective. It's becomes much harder to look away from what happened, the decisions they made and the options they felt were available. Likewise, if you are spending time with someone’s family or friends - hearing how they describe a person who was dear to them, as well as the questions they are asking about what happened - then you are likely to want to try and find answers. So, the process of trying to get a sense of those involved is critical. And when done well, it means a review can hold the victim at its centre, inoculating it against the trap of being and reading like just another report. But sadly, this doesn’t always happen. I have read too many reviews that treat someone’s lived experience as cursory, or don’t seem to think about it at all. Karen Ingala Smith wrote a powerful blog where she called out a review last year for writing someone (in this case Christina Spillane) out of the narrative of their own death. She was spot on. None of us should be satisfied with a review that does that.
Reviews also need to be informed so that any analysis and recommendations are meaningful. First and foremost, a review needs to robustly engage with domestic violence and abuse. As the chair of a review is responsible for guiding the process, surely that means they should have a deep and up-to-date knowledge of this issue. Yet reading some reviews I am left questioning whether that is the case. Sure, no one chair is going to be an expert in every area of domestic violence and abuse, but they must be able to lay claim to some specific expertise. It is not enough to simply passport over from a senior role in an organisation and assume you can do the job. There’s a question here for all of us who chair reviews about our own values and professional development. But the Community Safety Partnerships (CSPs) that commission reviews need to think carefully about who they are choosing to be chairs and making sure they fit the bill. Sure, the Statutory Guidance lays out the skills and expertise required to be a chair. But how many CSPs really grapple with this, or check out the quality of a prospective chair’s reviews and the feedback they have received from the Home Office quality assurance panel? It also means that CSPs need to recognise that, as in so many areas, cheapest and quickest is rarely the best option.
Being informed isn’t just the responsibility of the chair. A good review draws on a range of expertise, from specialist domestic abuse services, through to representatives who can help explore equality and diversity issues, housing and mental health to name a few. Having a panel made up of representatives who can bring the right range of knowledge to the table is critical. And while those review panel members bring their own expertise, they should ideally have a basic knowledge of domestic violence and abuse too. If they don’t, they need to take the time to deepen their knowledge, which includes being willing to hear from experts. So, having a strong, independent voice from the specialist domestic abuse sector is important. Where a review needs it, it should also seek input from specialist services that can help identify and explore any additional barriers people may face. Doing so can be particularly important in ensuring that reviews substantively engage with what helps and hinders access to services for Black and Minority Ethnic (BME) women, victims with a disability, Lesbian, Gay, Bisexual and Trans (LGBT+) or male victims. The role of organisations like AAFDA, which can support families to engage with, and contribute to, the review process is also vital. Chairs, local commissioners and partnership leads need to make sure they encourage and support the contribution of specialist(s). That means recognising that any contribution takes time and resource. It also means thinking carefully about how to manage this in practice. After all, it can be hard to sit in a room and tell the people commissioning your service that they have got something wrong.
This leads nicely to why reviews should be fearless. Despite huge progress, it seems to me that there is still a discomfort in naming domestic violence and abuse, as well as articulating its links to other forms of violence against women and girls or how gender works in our society. That extends to reviews as much as anywhere else. As a result, sometimes it seems that reviews are afraid of stating the obvious or rely on euphemism. At other times, reviews don’t stop to consider social and cultural attitudes towards domestic violence and abuse. Indeed, it is striking how many reviews only engage with social and cultural attitudes when someone is from a minority community. I won’t say more on this for now because that’s a whole conversation in its own right and others are already exploring this issue. Suffice to say, a good review will try and describe a victim’s experience of domestic violence and abuse as best as possible, as well as naming those forms of abuse that are often unacknowledged, like stalking or sexual violence.
Being fearless also means being clear about who is responsible for the homicide, as well as describing their behaviours and decisions. That raises a whole host of challenges, because it involves trying to engage with a perpetrator and their family. There is the very real risk that a perpetrator may try and use the review as yet another tool to abuse by minimising their actions or blaming the victim. But, where possible, interviews with perpetrators and their families may help identify critical learning, or at least enable the review to paint a picture of that perpetrator’s attitudes and beliefs. That’s important because we need to do more to understand the use of violence and abuse by perpetrators, who are usually men. We also need to understand what it is about our professional practice, systems and society at large that at best allow perpetrators to operate and, at worst, provide a conducive context for their behaviour.
Reviews should also be expansive. What do I mean by that? Well, while reviews seek to understand the specifics of a homicide, they also need to consider what any learning might mean for the wider coordinated community response. If there is learning for a team or agency: great, address it. But the review also has an opportunity to ask whether that same learning might apply more broadly and if so, what needs to happen. That kind of thinking is essential if reviews really are going to try and reduce the likelihood of future homicides. Sadly, this is not always the case. I can think of plenty of reviews that seem to act merely as a management tool. That is, they effectively package up and file away a case, de-risk agencies or assure (professional) stakeholders that the job is done rather than asking more expansive questions. A single domestic homicide does not stand alone. Apart from the fact that domestic homicide is tragically and shockingly a weekly occurrence, for every victim of homicide there will be countless others who have had similar experiences, faced the same barriers or used the same services. The lessons from these most extreme of cases have a wider relevance that must be identified, mapped and considered. So, a good review will look at an individual case but go beyond it, and ask hard questions about the wider partnership, its priorities and the allocation of resources.
This leads on to my last point: reviews should be ambitious. Reviews are about a homicide. We need to honour the person who has died. In undertaking reviews, we are asking families and friends to engage with a process that is likely triggering and time consuming. We are also asking them to trust us. So, we need to pay that trust back by doing our best to answer their questions. Once we have gathered the information for a review, we then need to use it to take every opportunity to reduce the likelihood of future homicides by improving services for victims and their families, while also getting better at holding perpetrators to account and intervening earlier.
Of course, reviews also incur time and resource costs for agencies and professionals. Their participation needs to be recognised and supported so that they feel able to engage. While the ‘no blame’ aspect of reviews can be challenging, I believe it is vital to ensure agencies and professionals participate in an open rather than a defensive way. But the quid pro quo should be that their participation is reflective and transparent, and they are willing to take the actions necessary to bring about real change, rather than settling for the appearance of it or second best.
Taken together, all this means reviews need to be ambitious. They should make recommendations that look beyond simplistic, punitive or process-driven responses, and ask more broadly: what can we start, stop or change to reduce the likelihood of this happening again?
As you might have guessed from reading this blog, I spend a fair amount of time wrestling with these issues in my work as a review chair. At the end of every review, I hope I have done my best. But I can always look back and identify what I might have done differently or what I have learned. Reviews are a process at both an individual and collective level. In a perfect world, we wouldn’t need to conduct them. Sadly, we are nowhere near that place. So, reviews are a tool. To borrow a phrase from Frank Mullane of AAFDA, they should illuminate the past to make the future safer. If that’s the case, the least we can do is try to do them as well as we can.