Sharing the learning from Domestic Homicide Reviews
So, this is my first blog after a summer break. Having recently completed two Domestic Homicide Reviews (DHRs), publication is on my mind.
When it comes to the publication of reviews, the Statutory Guidance is straightforward. Once completed, reviews should be published by the commissioning Community Safety Partnership (CSP). That makes sense, right? By sharing a review, people can understand what happened and, critically, what needs to change to reduce the likelihood of a similar tragedy happening in the future.
Yet, anyone who has gone looking for a published review knows that finding them can be difficult, frustrating and occasionally impossible. Even when a review has been found more often than not it stands alone, with the Overview Report and Executive Summary having simply been placed online on a CSP's website.
Why might that be? Well, let’s start with what we know: while there is limited research out there, what is available highlights a potential bottleneck when it comes to getting reviews completed and published. Nicky Stanley, Khatidja Chantler and Rachel Robbins went looking for reviews which had been published between July 2011 and June 2016. They found nearly 150. That sounds OK, until you remember that at the end of 2016 the Home Office said that in excess of 400 reviews had been completed since April 2011. That tallies with some findings by Eamonn Bridger, Heather Strang, John Parkinson and Lawrence Sherman, who looked at (heterosexual) intimate partner homicides between April 2011 and March 2013. As part of their research they set out to identify whether the associated review had been completed and if it was available online. By 2015 (when they completed their study), nearly half had not been published, while a little over 5% had not been completed. That was despite at least two years passing since the homicides had occurred.
So, both pieces of research suggest that there are delays happening with either the completion and/or publication of reviews. That chimes with my experience, and may seem familiar to readers too.
As someone who has previously commissioned reviews for a local authority, and now as an Independent Chair, I know all too well that reviews take time. Most will likely take more than the six months required by the Statutory Guidance. As challenging as that can be for everyone involved, there may be any number of good reasons. Those could include:
Allowing the criminal trial to conclude or in order to manage issues with other parallel reviews that might be running at the same time.
Engaging with family or friends.
The complexity of the case, perhaps because of extensive agency contact.
The time it can take between submitting the finalised review to the Home Office for quality assurance and getting it back (which in my experience can take a least three to five months from start to finish).
Even when a review is completed, there can often be a long wait for it to be published. That too could be entirely appropriate. A CSP may be working with a family to manage the process of publication, including avoiding dates that are sensitive. Or it may, in exceptional circumstances, decide not to publish: the statutory guidance recognises that publication may not be appropriate if there are “compelling reasons relating to the welfare of any children or other persons directly concerned in the review”.
The problem is, we don’t really know what is going on. Allowing for the issues summarised above, many reviews are probably getting completed and published as quickly as possible. But it’s likely that some reviews are simply taking too long. What’s more, in some cases, reviews aren’t being made available and it’s unclear why. Looking in my own near neighbourhood, no reviews have been published in West Sussex at the point at which I published this blog. That’s despite the local authority receiving a Freedom of Information (FOI) request (not from me!) in 2015 and committing to publish the two reviews that had been completed at that time by December 2015. It still hasn’t happened.
Regardless of timeliness, it can be hard to know when a review has been published. More often than not, CSPs don’t seem to do much to mark the publication of a review, with most placing the Overview Report and Executive Summary (and perhaps the Home Office Quality Assurance letter and an action plan) on their website and leaving it at that. So, unless you are actively looking for it, you probably won’t know a review is there. While that meets the letter of the Statutory Guidance, I don’t think it meets the spirit of the review process. How can we honestly say we are really trying to learn lessons, apply them and prevent future homicides if our publication strategy is to merely slip out a review? At best that could generously be described as a reactive communications strategy. I don't think that's good enough, and certainly shouldn't be the default position. And I say that as someone who previously commissioned reviews for a local authority. In that role I think I and my colleagues did a good job of disseminating learning among professionals. But with hindsight I regret not pushing harder at times for a more proactive communication strategy, ideally one developed with the agreement of the victim's family, so we could share learning more widely including into local communities.
All in all, I believe our collective approach to completion and publication is potentially a barrier to what we are trying to achieve. My last blog was about what makes a good DHR. The timely completion and publication of a review is a critical part of what I said then; it’s the logical conclusion to the attempt to do reviews as well as we can and to share the learning as widely as possible. None of that is possible if the story told by a review goes unheard. There is also a risk that a lack of transparency around the time reviews take could undermine people’s confidence in the process. Most importantly, publication can be difficult for family and friends. While everyone will react differently, it’s not unreasonable to think that a long delay in publication is going to cause distress, anxiety or frustration.
Collectively we need a better picture of how reviews are working, including the time they take and a focus on getting them completed. When they are completed we also need to be ambitious in their publication, balancing the need to disseminate learning with the wishes of the victim’s family.
One solution would be for CSPs to be required to report on reviews in their jurisdiction and their progress, including: reviews that have started, are ongoing, and those that have been completed or submitted to the Home Office for quality assurance but have not yet published. That would at least mean that CSPs kept a regular eye on the review(s) they are responsible for and asked questions if timelines appear to be slipping. At the same time, it would also start to highlight those CSPs where delays are routinely occurring, particularly if this is for a specific reason (for example, repeated issues with timeliness, if reviews keep failing to get through quality assurance, or where there are issues with publication).
Another sensible response would be to make reviews more accessible. I’ve previously argued that there should be an expectation that CSPs take a review and turn it into a practical document that can be used by professionals in day to day practice. This could be taken further by producing learning briefings, running dissemination events and integrating learning into existing training. As an example, when I worked at Brighton & Hove City Council and East Sussex County Council we started experimenting with different ways of sharing learning. To accompany the last couple of published reviews we produced one-page learning summaries and longer briefings that could be more easily shared and used at workshops and briefing sessions. Other CSPs have done the same, including the Safer Leeds Partnership. Meanwhile, others have tried to pull together learning across a number of reviews (like Newham), something that a number of Police & Crime Commissioners (PCCs) have tried as well (Avon & Somerset, the West Midlands. Whichever way it happens, the focus should be on disseminating the learning as widely as possible.
We also need to get serious and develop a repository for reviews. The NSPCC already maintains a national case review repository to make it easier to access and share learning from child deaths at a local, regional and national level. Adopting a similar approach to DHRs would be fairly straightforward and have real benefits. Hopefully this is something that will come out from the recent Domestic Abuse Bill consultation.
But that’s for the future. So, in the meantime, I’ve decided to do what I can to help and will be collating a list of reviews as they are published. As a starter, these are reviews that I am aware of that were published in August 2018:
Chorley and South Ribble Community Safety Partnership – case of David
Safer Somerset Partnership and Safer Communities Torbay – case of Eleanor
It’s a small list for now. And it will inevitably be partial. So, if you know a review has been published, please let me know.