The Potential and Peril of Domestic Homicide Review
First posted on the 3rd May 2023 on the University of Sussex's School of Law, Politics and Sociology's research blog, LaPSe of Reason.
Domestic homicides – killings by either a former or current intimate partner or a family member – are a significant problem, both globally and in England and Wales, where there were 373 victims of a domestic homicide in the three years to March 2021. Of these victims, nearly three quarters are women and just over a quarter are men. Most commonly the killer is a man.
Not unsurprisingly, these killings – and increasingly domestic abuse-related deaths by suicide – are a cause for concern, for both a victim’s loved ones and their community and for campaigners, policy makers and researchers.
One way of responding to domestic abuse-related deaths – a term I use to capture both domestic homicides and deaths by suicide – is to build a picture of what someone who was subjected to domestic abuse experienced before they were killed or died by suicide and then try to learn from it. In doing so, the hope is that any learning can be used to improve responses to domestic abuse and so, potentially, reduce domestic abuse-related deaths in the future.
Since 2011, in England and Wales such learning is undertaken through a national ‘Domestic Homicide Review’ (DHR) system. DHRs are a type of statutory review, but while the DHR system is national in scope, in practice it is delivered locally because each DHR is commissioned and run in the local area where a victim died.
As a process, DHRs bring together a range of stakeholders after a domestic abuse-related death. Stakeholders can include organisations (like the police, health or social services, or domestic abuse services) that had contact with a victim, the (alleged) perpetrator, and/or any children, as well as people who knew them (sometimes called ‘testimonial networks’, like family, friends, neighbours, and colleagues). During a DHR, stakeholders are meant to come together in a spirit of accountability (not blame), to share what they knew, build a chronology of events, and then identify learning about gaps or issues with practice, policy, or systems. Having identified learning, stakeholders should then work together to make recommendations for change. Usually, the product of these deliberations is a DHR report that is anonymised and published.
To date, DHRs have largely been seen as a positive development and a way to better respond to domestic abuse and enable prevention. Supporting this, the learning from DHRs have led to an improved understanding of the circumstances of domestic abuse-related deaths. We also increasingly understand the types and limits of the recommendations that are being made.
However, as a system, process, and product, DHRs remain something of a ‘black box’, because we know relatively little about how they work. My PhD thesis was an attempt to open this black box and was inspired by my practice experience (I have commissioned DHRs as a local authority domestic abuse lead and have also led them as an independent chair). To frame my thesis, I drew on Sara Ahmed’s work on use and sought to examine what DHRs are understood as being for, what is used in any by DHRs, and how are DHRs themselves used.
Given our limited understanding of DHRs, I used a mixed methods approach to generate as rich a dataset as possible. I analysed 102 DHRs that had been submitted for quality assurance in 2018 (DHRs must be signed off a national quality assurance panel before they can be published) and, to hear from stakeholders, ran a web-based survey with 117 respondents and undertook 40 interviews.
My overall research question was:
How do DHRs operate as a technology to produce knowledge?
I then explored specific research questions which addressed the assumptions and norms in DHRs, decision making, how stakeholders try and make sense of domestic abuse-related deaths, and lastly, the possibilities in terms of change.
Simply put, my findings were, whatever the ambition or hope for DHRs, they are in fact shaped by complexities and tensions that arise from the operational, discursive, and symbolic practices involved. These complexities and tensions mean that while DHRs have potential as a way of making sense of domestic abuse-related deaths and bringing about change, they can also be perilous. This peril comes about because how DHRs are conducted can vary and, most notably, they may not always be well led, may not engage all stakeholders, centre victims, and/or bring about meaningful change.
To explore these complexities and tensions, I examined DHRs across five domains:
1. How DHRs are established As a type of statutory review, you might think DHRs have stable foundations and a robust framework for delivery. That’s partly true, not least because DHRs are only possible because the state first established them and then provided statutory guidance to guide their conduct. However, I found that DHRs’ foundations and framework are not as stable as you might think. This instability is for several reasons, encompassing how domestic abuse is sometimes not a priority, the absence of consistent national and local oversight, as well as a lack of investment in ensuring DHRs are both functioning well and useful.
2. What DHRs are for Compounding this instability, despite often being taken-for-granted (they are about learning right?), I found that DHRs are better understood as having multiple purposes which reinforce each other. These purposes include DHRs being a way to bring stakeholders together to collaborate in reviewing a domestic abuse-related death, take accountability through learning, and then working to bring about change. There are also the purposes of ensuring that the family of a victim are kept central (with possible benefits, either in terms of their experience of loss and/or being able to contribute to change) and, critically, telling a victim’s story (in a way that keeps them central to the process, as a form of memorialisation). However, I found that there can be differences in how these purposes are understood, meaning some may not be sought or alternatively may be prioritised over other purposes. Critically, if one purpose is not achieved, others can be affected or be at cross-purposes. For example, if bringing stakeholders together is not done in a way that means everyone can take part, then accountability is less likely.
Better understanding how DHRs are established and what they are for, including complexity and tension in these respects, are important findings. In short, DHRs can be contested and are consequently contingent as a system.
Critically though, this also means the conditions are in place for DHRs as individual case examinations to be done in very different ways. As a result, the process of delivering a DHR, as well as the product produced, might also vary. Something my findings generated evidence for too:
3. Practices in DHRs (including what is used by and in DHRs) I found that, to build a picture of what happened, a variety of stakeholders, some of whom have little or no experience of DHRs, need to be engaged. Yet, there is relatively little training available and this, compounded by a lack of clarity over the skills, experience and knowledge required, means stakeholders may be more – or less – supported or able to participate. As part of engagement, these stakeholders also need to feel they can gather and share information openly. Here too there are challenges, reflecting stakeholder confidence or willingness to share information. Finally, if DHRs are to tell a victim’s story, it is necessary to try and understand someone’s experiences, including trying to take their perspective as much as possible to think through how practice, policy, and systems did or did not work. Here, ensuring testimonial networks are integral is critical – especially family, given they can share information about a victim, and ask questions about their experiences, which may not be available to or occur to organisations. Yet, the extent to which victims are central, and family are treated as integral, vary. Thus, the practices of DHRs are not consistent.
4. DHRs as relational Ultimately, because different stakeholders are brought together in a DHR, they are a collective endeavour. Reflecting this, DHRs have been described as a way of achieving ‘dialogic democracy’ by Neil Websdale. While I generated evidence that this dialogic democracy can be achieved, and how this could happen, I also found that it can be difficult in practice. Importantly, if dialogic democracy is not achieved, that can prevent some or all stakeholders engaging in a DHR or mean some stakeholders do not participate in a helpful or productive way.
5. DHRs as a site of action Clearly, if DHRs seek to bring about change in response to learning, then they need to lead to action. Positively, I found that DHRs can and do lead to action, sometimes across multiple levels, from individual changes (like professionals changing how they think about domestic abuse), to changes within or between agencies (in terms of things like practice and policy, or joint working arrangements), or societal change (like increased awareness). Yet, at the same time, I also found that the actions generated by DHRs could differ in terms of quality and/or whether they were accomplished. In other words, just because a DHR was able to build a picture of someone’s experience, and generate learning, this did not always lead to change.
Taken together, this means that what is used by and in DHRs, and how they are then used, are also contested.
In summary, my PhD provides evidence for the complexity and tension with and within DHRs and shows how this can affect there doing, findings and impact. But what does this mean?
First, it means DHRs can be perilous because their potential to account for individual domestic abuse-related deaths can be underused and, at worst, misused. Effectively, DHRs may end up ‘containing’ domestic abuse-related deaths and ‘de-risking’ the state and organisations because of limits to who is involved, the information collected, the learning generated, or the changes proposed. DHRs can also responsibilise or blame victims too. Such under- or misuse is detrimental to stakeholders, in particular family, and the story told about a victim and their killing or death.
Moreover, my findings also show how responses to domestic abuse-related deaths can be symbolic. That is, DHRs may be a way of being seen to act rather than necessarily acting. Such a conclusion flows from the extent to which the numerous weaknesses of DHRs, as a system, process, and product, have been manifest over the ten or more years of their existence, and yet have been left largely unaddressed (i.e. DHRs have been neglected by the state, although the promise of reform is on the agenda).
Yet, despite these perils, DHRs also have potential. That potential is because DHRs can be used to achieve collaboration and accountability, during which testimonial networks (principally family) are seen and treated as integral, while also telling a victim’s story and making change. Most notably, this potential can be achieved despite the complexity and tension, and in the face of relative neglect, which I have described above. Such achievement speaks to the hope and ambition that is implicit and perhaps necessary within this work.
So, how do we move forward? Perhaps the contradiction that DHRs have potential and yet bring peril is something we cannot avoid. But by being aware of it we can seek to prevent or at least minimise the risks. With that in mind, to offer some ways forward, my PhD makes recommendations for policy, practice, research, and theory. In different ways, all my recommendations turn on the question of how we individually and collectively keep the victim central as we seek to make sense of and respond to domestic abuse-related deaths. One way of doing that is to try and ensure that DHRs deliver justice, be that procedural justice (in terms of how they are done) or outcomes justice (in terms of what they achieve). Afterall, after a domestic abuse-related death, an attempt to do justice to a victim and their story is surely the least we can do.
You can access my PhD via Sussex Research Online.
 My focus in the PhD was on how knowledge was generated about victims, which means I did not directly explore approaches to perpetrators. Nonetheless, while my focus was on victims, it is important not to lose sight of a perpetrator’s actions and responsibility.  There is the potential that many of the issues I identified in my thesis could be addressed, including updating the statutory guidance; requiring training for independent chairs; bolstering local and national oversight; and introducing a national repository. Quite what this reform agenda looks like, and what it achieves, remains to be seen.