Domestic Fatality Review Boards

last updated November 1, 2006

Domestic fatality reviews examine domestic violence related deaths including the events leading up to the death(s) in order to determine what lead to the homicide(s). The goal of the project is to uncover holes or gaps in the various government systems’ responses to domestic violence.  The review process is predicated on the knowledge domestic violence is often an escalating crime and that by addressing domestic violence which results in low level injuries we can prevent fatalities.  By identifying missed opportunities for intervention and points at which intervention was not effective, the reviews prompt improved identification, intervention and prevention efforts in future cases.  The approach of the process is that of working toward system improvement and not placing blame for the death. The review process is a vehicle to identify gaps, barriers and shortcomings in the government response to domestic violence and propose solutions.

The review teams are comprised of representatives from government agencies, including prosecutors, public defenders, judges, police, medical examiners, emergency room doctors, court psychologists, corrections or probation officers, child protection workers, school social workers, etc. The teams also include strong representation from domestic violence advocates and from the community. 

Starting a Fatality Review Process

Starting a review process requires a considerable amount of preparation.  A team needs to agree on a method of reviewing cases, a shared philosophy about domestic violence, and a membership policy. In order to fully examine the events leading up to a homicide, access to confidential data is important. Fatality Review teams often seek legislative authority to access information protected under data privacy laws.  Establishing mechanisms to protect confidentiality in the review process is important. Each team member should be instructed on keeping the case materials and the information discussed in the meetings confidential.  The Hennepin County Fatality Review team starts each meeting with its members signing a confidentiality agreement.

Case Review Process

Selecting cases for review is a critical component to the review process. Selection methods vary between groups. The Hennepin County Fatality Review team has elected to not review cases until all direct litigation (i.e. criminal trial, direct appeals) have been completed and or at least a year has passed since the homicide. This waiting period allows for agency representatives to engage in the review process without compromising an ongoing case and with the distance to examine the case, and their agencies role in it, objectively.  After a case is selected for review, a staff member identifies records that might be critical to understanding the case. These may include:

  • Prosecutor file
  • Probation file (perpetrator and victim and significant others)
  • Pre-Sentence Investigation
  • Prison records (perpetrator and victim)
  • Medical records (perpetrator and victim)
  • Police Records on current and any former cases (assaults, etc) and of calls to the address
  • Child Protection records  
  • Juvenile Court records
  • Juvenile Court records for any child who was a victim or witness
  • Drug treatment records
  • School records
  • Civil Records (Orders for Protection, Divorce, etc)
  • Arrest records
  • Criminal history
  • Domestic Abuse Service Center Records
  • Domestic abuse program records
  • Psychological evaluations and mental health records
  • Family Court documents and any “Orders for Protection”
  • Criminal Court Records
  • Medical Examiner’s Office Records
  • Newspaper articles

Using the records, the staff member compiles a chronology of events leading up to the fatality.  The chronologies identify the source of the information. When appropriate, an advocate who worked with the victim may be contacted and through an advocate, the victim’s family.  Copies of the chronology are provided to each team member. Additionally team members are selected to have reviewed the original records and to present and/or explain significant information from the files to the group. Using the chronologies and the presentations, the group identifies key case observations and missed opportunities for intervention that may have prevented the homicide and make recommendations based on the issues identified. The team also identifies successful interventions. It also identifies issues that requires further investigation  The focus of the process is on the government systems’ response to domestic violence.


Members of the team take the recommendations back to their agencies for implementation. The key case observations, missed opportunities for intervention, and recommendations are also compiled and periodically published.  In preparing reports, review teams need to be conscious of protecting the confidentiality of the cases.   The reports include public recommendations to government agencies on improving their response to domestic violence, along with the factual basis for that recommendation. An example of a pilot report is available here. The periodic reports, by providing the status of prior recommendations, also allow for holding government agencies accountable for showing improvement. An example of a periodic report, the 2007 Hennepin County Fatality Review Team Report, is available here. Also, the 2008 United Nations expert group report entitled "Good practices in legislation on violence against women" includes information on collecting statistical data of domestic violence cases (Section 3.B). For the Russian version of the recommendations of "Good practices in legislation on violence against women, click here.

For more information on Fatality Review teams:
National Domestic Violence Fatality Review Initiative;
Hennepin County Fatality Review Team;
Washington State Coalition Fatality Review;
New Jersey Domestic Violence Fatality Review
County of San Diego Health and Human Services Agency Domestic Violence Fatality Review Team.