Fatality Review: the state of the art

Fatality Review: the state of the art

Fatality Review: The State of the Art Neil Websdale, Director, NDVFRI ICJR Orlando, January 31, 2019 Historical Origins of DVFR Public outcry over IPH Rise of second wave feminism Womens education and paid employment

New civil rights movement Increases in divorce and particularly nofault divorce Womens growing control over reproductive health Historical Origins VAWA 1994

Rise of risk societies and concern with trans-national/global risks e.g., aviation, nuclear power, medicine Victim rights revolution 1973 US Supreme Court cases David Garland The return of the victim. Colonial and revolutionary period crimes often investigated and prosecuted by victims

Historical Origins Victim Rights Act of 2004 link to listening to voices of victims in DVFR Critique of victim rights movement Undermines the right of the accused Impinges upon prosecutorial discretion

Opens the door to vengeance/negative emotion Mark Twain Most people use statistics like a drunk man uses a lamppost; more for support than illumination Stratmann & Thomas, 2016, p. 35 Dial 911 for Murder Stratmann & Thomas (2016)* argued that the introduction of 911 services much of the decrease in homicide rates

The introduction also explains the divergence between aggravated assault and homicide rates that started in the early 1970s There is an economic value to shortening response times because it reduces the time cost of emergency services Recent crime counting research Walby et al. (2015) lifting the cap on counting high frequency violent crime reveals increases in VAW since 2008

Capping UK (5), US (6), Mexico (5), Canada (3) series of more than five crimes capped at 5, even if victim assaulted 6, 10 or 13 times Challenges pacification model, self-control, etc. 2008 recession had disproportionate effects on women resources, leaving, earnings, etc Social patterning

IPH profoundly gendered but race, class, ethnicity, geo-social location also mediate About 50% of IPHs in US have prior systems contact but low collaboration, communication, coordination* About 50% female victims appear to die in relative isolation with no or few system contacts IPH stylized with telltale histories but much

knowledge remains hidden Trends Steepest decreases in the African American community BUT medical advances might be much more significant than CJ responses The IPH rate reductions coincided with improved medical interventions especially to inner city

Murder and Medicine Harris et al., (2002) - explored homicides and aggravated assaults from 1960-1999* Harris et al., estimate that without the impact of improved EMS, the 15,000-20,000 average homicides (1994-1999) would have been 45,000-70,000! Improved medical care reduced the lethality of violent assaults by 2.5-4.5%/year. Rise of

trauma centers Modern wound care, antisepsis, antibiotics, anesthesia, fluid replacement, trauma surgery, and emergency services Medical Interventions CDC The estimated number of people wounded seriously enough by gunshots to require a hospital stay, rather than treatment and release, rose 47% to 30,759 in 2011 from 20,844 in 2001

Information from more than 900 trauma centers in the U.S., also found a decrease in the death rate for victims admitted for stab wounds Source: Centers for Disease Control and Prevention's National Electronic Injury Surveillance System-All Injury Program DV Related Deaths Single and multiple homicides

Family killings Sexual competitor killings Photo by Tony Webster Domestic Violence Related Deaths Suicides of women and men Indirect deaths

Near fatalities Domestic Violence Related Deaths Bystander deaths Accidents, disappearances, and other suspicious deaths Roughly half of child maltreatment deaths occur against backdrop of battering

Telltale signs, antecedents, risk markers Prior history of IPV (weapons use; strangulation especially serial; escalating violence, attempts to control, & emotional harms; beating during pregnancy: previous attempts to kill; forced sex; entrapment; capable of killing) Separation/emotional estrangement Extreme jealousy linked to violence

Depression/suicidal potential Telltale signs, antecedents, risk markers Alcohol & drug abuse Stepchildren in the home Compromised masculinity/humiliated fury Definition of DVFR

DVFRTs identify and analyze homicides, suicides, and other deaths caused by, related to, or somehow traceable to DV Reviews are formal or informal Range greatly in depth and number Teams devise preventive interventions

Philosophy Radioactive Wolf from Chernobyl Philosophy Medical Error Deaths Sullys Landing on the Hudson DVFR Philosophy No blame and shame Accountability

Lessons from other fields Aviation, nuclear power, medicine Creating a culture of safety DVFR Philosophy No-blame and shame accountability balance

DVFR requires a paradigm shift from a culture of blame to a culture of safety Review teams therefore work with a philosophy of kindness and concern, that respects the rights of surviving family members and decedents, but that recognizes that better agency coordination might or can save lives Batterer ultimately responsible? DVFR Philosophy

Important role of culture in DV related deaths Links between racial/ethnic disadvantage and DV deaths Are we witnessing the effects of culture or the effects of concentrated poverty? Important role of gender

Note pivotal significance of race, gender, class Geographical Spread of DVFR 1995-2018, roughly 200 teams in 45 states Statewide teams in Montana, New Mexico, Kansas, Iowa, and Oklahoma Florida, Maryland, and California now have

at least 20 teams each, Arizona 13 States currently not reviewing: ID, AR, MS, IL, RI 1995: 18 Domestic Violence Fatality Review Teams 13 States 2019: Approximately 200 Domestic Violence Fatality Review Teams 45 States Forms and Organization Nowadays teams operate as multi-agency/ multi-stakeholder bodies

The Montana Review Commission travels to the communities where the death occurred, reviewing cases in conjunction with local partners, taking two days per case to do so. The Commission reviews two cases a year. The Montana Indian Country review initiative operates the same way Forms and Organization

Florida was the first highly populated state to develop a statewide DVFRT in addition to a network of county-based teams The Florida Statewide DVFRT receives information from many of the county-based teams Scope: Reviewable Cases Number and type of cases, methodologies vary

Review within teams capabilities Dangers of trying to be representative/scientific at the individual team level DVFRTs typically do not review all cases caused by, related to or somehow traceable to DV Case Types Links with DV related deaths

Single and multiple homicides; Family killings; Sexual competitor killings; Suicides; Indirect deaths; Near fatalities; Contract killings; Bystander deaths; Suspicious deaths, accidents and disappearances Team Membership Team Membership Inclusivity, creativity

Lenses of decedents/perpetrators Various perspectives dangers of fundamentalism! W.B. Yeats The best lack all conviction while the worst are full of passionate intensity Role of family, friends, neighbors, and coworkers Focus group feedback

Getting Started Use statute or other legal enabling mechanism as frame of reference Identify stakeholders to participate on the team Develop protocols Decide how the team will house documents,

send out meeting notices, and generate reports Develop confidentiality agreements for both individuals and agencies. (See ndvfri.org Documents tab and Review Teams tab) Getting Started Develop mission statements, goals, protocols, philosophies

How many cases to review in depth versus in aggregate? Case selection criteria Getting Started Select the first case(s) to review. Establish a meeting schedule that allows for maximum participation.

Will the team meet monthly, bimonthly, quarterly, biannually, or annually? How long will the meetings generally last? Team members can gather and provide documents and information related to their own agencys involvement Statutory Suggestion

Review only deaths in which the investigation is closed and there is not a pending prosecution NDVFRI team NOT permitted to lobby for legislation NDVFRI.org has sample statutes and our team can provide TA regarding elements of the law

We do not write legislation Think carefully about team subpoena power Organizing a DVFR 1. Timeline 2. Antecedents/red flags

3. Prior agency, stakeholder, and community involvement 4. Policy recommendations: What is to be done? 5. Questions Potential Data Sources Police homicide logs

Newspaper reports of homicides Crime scene investigation reports Detectives' follow up reports Transcripts/notes from interviews conducted by investigators with witnesses and other involved parties Potential Data Sources

Civil court data regarding divorce proceedings, termination of parental rights, child custody disputes, and child visitation issues (if accessible) Criminal histories of perpetrators and victims Child protective services data (if accessible) Summaries of psychological evaluations appearing in public record documents such as

police files Medical examiner reports Potential Data Sources Autopsy reports Workplace information, perhaps regarding harassment, abuse, intimidation, and stalking

Public health data e.g. emergency room data concerning protocols/procedures/hypothetical cases Shelter/advocacy outreach data (not necessarily pertaining to a specific decedent that received services) Potential Data Sources Statements from neighbors, family members, friends, workplace colleagues, witnesses and others

Drug and alcohol treatment data (again, access to confidential drug/alcohol treatment data will be limited by federal statute but superficial data about these matters may be available) Perpetrator interview transcripts if all appellate issues closed out. Be sure to advise perpetrator that interviewees know the case well Potential Data Sources Transcripts/notes from interviews by team members

Protective orders, their affidavits and service notifications School data pertaining to abuse reports (detailed access might be limited) Data Gathering Instruments & Domains The ndvfri.org website has many examples of sample instruments

Tiers 1, 2, & 3 Data Domains The fatal incident Demographics Relationship between parties

Data Domains Criminal Histories Children System involvement Physical & mental health

Additional questions Firearms Collateral Interviewing Collateral interviews are interviews with people familiar with the victim and/or perpetrator who can shed light on their lives prior to the fatality/near-death, including perpetrators and survivors in near-death reviews Rationale for collateral interviews

Understanding the lived experience of the deceased Offering family members a way to participate in the review Obtaining details absent from the documentary record Incorporating different perspectives

Contributing to team recommendations resulting from the review Preparation for the interview Know what the team wants to learn from the interview Review the documentary record; identify public, private and confidential information

Determine relationship (character lists) Select appropriate interviewers Decide on method of recording Use existing relationships to arrange contact Approaches to collateral interviews People attend team meetings

Prepare team and insure environment of respect Appointed members conduct interviews at convenience of interviewees in their homes, at a public place, by phone Appointed members interview perpetrators in prison

Questions from the team are presented and responded to in writing Know the case It will influence the questions you want to ask Youll have forensic, witness and prior criminal records that may vary from what people tell you People will assume you have some knowledge of the case

Legal issues Male Ensure appellate issues have been concluded Explain you have no legal influence and participation will not aid in early release or obtaining privileges Provide caveat regarding mandatory reporting of child abuse & other offenses

Determine whether civil issues are pending Male Perpetrators of IPH Male perpetrators desire for power, dominance, and control, thus situating such violence within the context of the overall oppression of women in a patriarchal society Conscious plot? Role of race, culture, sexual orientation

Power and powerlessness. Paradoxes Controlling behavior and directionality? Male Perpetrators of IPH Notions of intent, motive, and tactics implies too much conscious choice? In field we see a mix of batterer behavior

Some clear calculation, some more inchoate or undeveloped emotional condition Unconscious drives? Biological forces? Inexplicable forces? The Role of Family Members In a significant number of deaths victims had minimal or no contact with agencies

It was a rare case where agencies worked in concert with a battered woman prior to her demise Those closest to decedents often know most about their lives and the compromises they faced Surviving family members began to agitate for a voice at the table The Role of Family Members

Some family members want to contribute. Others do not Family members that contribute often find the experience cathartic Communicate the limits of family involvement -confidential workings of the team Persons close to the perpetrator may also wish to participate

The Role of Family Members The Montana Death Review Initiative welcomed the stepmother of a perpetrator to the table. She had been criticized because she spawned a monster. The stepmother was relieved the team treated her as a human being. She testified for four hours, providing many insights Confidentiality Not legal advice!

Nearly all states conduct fatality reviews under the protection of confidentiality statutes These laws shield the deliberations of teams from subpoena and guarantee the information cannot be used in lawsuits or for disciplining professionals handling cases Confidentiality Confidentiality guarantees vary across state and tribal lines

Initially, such statutory protections raised the possibility of authorities covering up negligence and malfeasance Agency representatives have openly admitted mistakes with a view to preventing them in the future Confidentiality Differences between public, private, and confidential information

Historical role of homicide-suicides DV victims have rights to confidentiality that survive their death. The question arises as to what information DV centers may provide a DVFRT reviewing the case of a former DV center client? Most women dying in IPHs have not resided in shelters or received services from DV centers

Confidentiality DV centers promise survivors they will not reveal any information about them without their consent, except in certain circumstances The power to consent to the release of confidential and privileged information belongs to the survivor not the center Please see: Alicia Aiken. Confidentiality

and Fatality Review: 10 FAQs. NDVFRI Bulletin, 2015. Apparent consequences of DVFR work Storer, Lindhorst, and Starr (2013) found two major changes effected as a result of DVFR: DV resources be made available for battered women with limited English proficiency (LEP)

Police learn to routinely screen for suicidal tendencies among abusers Montana Team Recommendations - creating the new strangulation law, which makes strangling a partner or family member a felony on the first offense Updating the school curriculum for kids learning about signs of dating violence

Improving the states crime victim notification program Making sure domestic violence advocates and shelters screen for mental health concerns General Changes System changes many examples, see ndvfri.org. HOPE card - Montana.

New laws/protocols/practices - many examples, see ndvfri.org Florida see the tracking of recommendations reported in the Faces of Fatality Reports (2014, 24-25; 2013, 13). General Changes Links between CCR, risk assessment, safety and accountability audits, family justice centers, and fatality review

Interagency communication (formal and informal). Many of the reports note an improvement here, although it is difficult to measure Changing the way people work DV cases General Changes Resources and reports

Opportunities to pursue new issues and perhaps grant funds Education about domestic violence Challenges We Face Teams devise preventive interventions but cannot compensate for various sociohistorical horrors Globalization of capitalism, automation, inexorable rise of disenchanting

bureaucracies, rise of much cheaper labor markets, rise of service sector affect tax bases, state infrastructure Effects families, battered women, batterers, & children The challenges of tracking outcomes of DVFR work Does the spread of DVFR imply it is useful?

We do not know the outcomes of DVFR work We need to know about: 1. The implementation of team recommendations 2. Changes in law and law-like systems

3. Team expansion The challenges of tracking outcomes of DVFR work 4. Public education and awareness campaigns concerning DV 5. Shifts in the collaboration, communication, coordination, cooperation, and integration between agencies and stakeholders

6. Changes in rates of IPV, IPH, and DV & related factors The challenges of tracking outcomes of DVFR work 7. Shifts in resources/funding allocations 8. Attitudinal shifts regarding DV/related behaviors 9. Increased access of DVFRTs to government

10. Links between DVFRT work & risk assessment and management, CCRs, safety and accountability assessments, & family justice centers New questions/issues Why doesnt he leave? Emotional isolation of perpetrators

The problematic notion of control Humiliated fury The centrality of anger The notion of intent New questions/issues

Challenging notions such as battered woman syndrome, the cycle of violence, learned helplessness, and stock scripts Through reviews battered women appear to have much more agency or resistive maneuverability Case reviews convey a strong sense of the complexity of human lives, contradictions New questions/issues

Traditional advocacy perspectives may downplay battered womens complexity Understanding battered womens agency helps us understand abuser behavior and better inform safety planning Safety planning ought always remember victims can NEVER really know what perpetrators are capable of doing Questions

Contact information: Neil Websdale Family Violence Institute Northern Arizona University [email protected]


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