How team reviews can help prevent domestic violence deaths

Using philosophies similar to those of the NTSB, approximately 200 Domestic Violence Fatality Review teams have been formed since the 1990s

2017 marks the 30th anniversary of Domestic Violence Awareness Month, launched nationwide in October 1987 as a way to connect and unite individuals and organizations working on domestic violence issues and raise awareness for those issues. 

Intimate partner violence accounts for 15% of all violent crime and 19% of domestic violence involves a weapon. On a typical day, more than 20,000 phone calls are placed to domestic violence hotlines nationwide. For more information, the National Resource Center on Domestic Violence offers a variety of educational materials.

Reprinted with permission from DOJ Office of Justice Programs Diagnostic Center blog.

By Neil Websdale

The National Transportation Safety Board’s (NTSB) comprehensive, professional and independent investigation of plane crashes has greatly improved the safety of U.S. commercial aviation.

Building expert teams to analyze complex cases and lives is crucial to preventing fatalities.
Building expert teams to analyze complex cases and lives is crucial to preventing fatalities. (Photo/Pixabay)

Teamwork among airlines is common as they share vital crash data. Accident reconstructions contribute to new life-saving safety procedures by identifying the role of small, unchecked errors that multiplied prior to a crash. As a result, deaths per passenger-mile flown over the last 40 years have diminished greatly – proving the positive impact critical questioning and collaborative reviews can have on safety procedures and protocols.

Flight crews have also come to recognize the life-saving potential of cockpit teamwork. In the aviation industry, it is accepted practice for junior pilots to question the decisions of their seniors. Captain Sullenberger explained the collaborative nature of aviation risk management: “You take a team of experts and make them into an expert team.”

Using philosophies similar to those of the NTSB, approximately 200 Domestic Violence Fatality Review teams have been formed in 44 states since the 1990s.

These teams have no regulatory or enforcement functions. They build case timelines and explore the circumstances of a domestic violence death or near death.

The role of Domestic Violence Fatality Review teams

Teams examine the role of agencies, stakeholders and community members and the degree of communication, collaboration and coordination among them.

Using the deceased's life as a central frame of reference, they recommend preventive interventions, intentionally avoiding blaming or shaming individuals, agencies or stakeholders.

By including different experts (e.g., law enforcement, victim advocates and prosecutors), teams optimize opportunities to learn about and share the way their systems handle domestic violence cases.

Team reviews often reveal how domestic violence victims perceive services as confusing, alienating, dangerous or irrelevant rather than helpful and potentially lifesaving. Many victims perished without accessing domestic violence services; a fact we ought to take seriously.

Other victims experienced various system interventions (e.g., advocacy, arrest of suspected abusers, orders of protection) seemingly to no avail. In cases with substantial system contacts, teams usually find numerous missed intervention opportunities.

Domestic violence cases as community challenges

The most promising reviews analyze the complex ways a case flows through systems and identify opportunities to better collaborate, improve communication and transform case handling practices.

Such reviews re-frame domestic violence cases as community challenges rather than criminal justice problems. The reviews increase the social connectivity between state and civil society, reinforce the rule of law and identify new ways to reduce the number of domestic violence fatalities.

Teamwork is more than just working together; it includes critical questioning, constructive criticism and a commitment to constant improvement. Building expert teams to analyze complex cases and lives is crucial to preventing fatalities. Working together to review deaths and near deaths caused by, related to or somehow traceable to domestic violence has the potential to uncover intervention opportunities and reduce fatality rates.

The National Domestic Fatality Review Initiative is dedicated to domestic violence fatality review. It is funded by the Office on Violence Against Women (OVW), a branch of the U.S. Department of Justice. Working closely with project partners and OVW, the initiative integrates fatality reviews into the broader national initiatives to combat violence against women. For more information, visit

This article was originally shared on the U.S. Department of Justice, Office of Justice Programs (OJP) Diagnostic Center Consider the Evidence blog.

About the OJP Diagnostic Center
The OJP Diagnostic Center works with law enforcement to address persistent and emerging public safety problems using evidence-based strategies. The purpose of the OJP Diagnostic Center is to ensure resources are available to state, local, and tribal law enforcement agencies to champion law enforcement officer safety and wellness; reduce crime (particularly violent crime and crime involving gangs and drugs) and make communities safer. Since 2012, the OJP Diagnostic Center has worked with over 60 communities on a wide range of public safety topics. Learn more at Follow @OJPDC for the latest information on criminal justice topics.

Neil Websdale is Director of the National Domestic Violence Fatality Review Initiative.

Recommended for you

Copyright © 2021 Police1. All rights reserved.