Domestic Violence Death Review Committee

Annual Report to the Chief Coroner.

2004

a. Purpose of the DVDRC 2

b. Why is there a need for a DVDRC process? 3

c. Case Reviews and Recommendations 4

d. Statistical Analysis 7

e. DVDRC Subcommittee on Risk Assessment 8

f. Government Announcements and Initiatives 8

g. Review and Report Limitations 9

a. Awareness and Education 31

b. Assessment and Intervention 38

c. Resources 46

Recommendations from the First Annual Report of Case Reviews, 2002 64

The Domestic Violence Death Review Committee (DVDRC) is a multi-disciplinary

reports the results of domestic violence fatality investigations to the Chief Coroner. In

2003, the committee presented the first annual report to the Chief Coroner of cases

occurring during the year 2002. Since then, the committee has continued reviewing and

reporting on cases that have occurred between the years 2002 and 2004. An average of 26

homicide cases per year occurred between 2002 and 2004, with an average of 34 deaths.

However, the number of reviews conducted each year represents less than half of all

domestic violence cases.

When it was first formed, the committee determined that it would review cases only

when they had been completed before the courts, or when there was no accused because

the perpetrator had died as well. In the first report, we reviewed and reported on 11

occurrences and 24 fatalities—eight of the cases were homicide–suicides and two of the

cases had multiple homicides. This report reviews nine occurrences and 11 fatalities, only

two of which were homicide–suicides. However, our statistical analysis of antecedent

information about the victims and perpetrators, used to help identify risk factors in these

kinds of fatalities, is cumulative.

cases. In eight of the nine cases, the perpetrator was male. Of the nine cases, four

involved child custody and access disputes, an issue not identified in our last review

report. In addition, two of the homicides involved non-custodial parents murdering their

children. The reviews have become increasingly more complex, particularly with respect

to those cases involving perpetrators killing children of the relationship and those with

multiple system involvement, such as criminal and family justice, child welfare

protection, and health services.

An important concern to the DVDRC as a result of our review is the extent to which

these homicides appear both predictable and preventable, based on an analysis of wellknown

risk factors. In eight out of nine cases, the homicide appeared both predictable and

preventable. In the majority of cases reviewed, ten or more risk factors associated with

potentially lethal violence were present in the circumstances.

1 Section 15 (4) of the Coroners Act, R.S.O. 1990, c.37, as amended

2 "Primary victim" is the intended target of the domestic violence, the partner or ex-partner, although in two instances the deceased

were children whose deaths were the result of the violence in the lives of their parents.

1

The purpose of the committee, as outlined in its Terms of Reference, is to assist the

Office of the Chief Coroner of Ontario in investigating and reviewing deaths of persons

that occur as a result of domestic violence, and making recommendations to help prevent

such deaths in the future. Initially, the cases referred to the committee were all homicides

involving the death of a person and/or her or his child(ren), committed by the person’s

partner or ex-partner from an intimate relationship. We have expanded the terms of

reference with respect to the cases referred to the committee to include those occurrences

where there has been a failed attempt on the life of the primary victim and his/her

child(ren) and where the perpetrator had died, either by suicide or homicide.

The mandate of the committee is to help reduce domestic violence generally, and

domestic homicides in particular, by:

recommendations to address these concerns;

of domestic violence fatalities and their circumstances;

recommendations for effective intervention and prevention strategies;

and awareness of the issues, and conducting and promoting further research where

appropriate.

Between 1998 and 2002, three major coroner’s inquests into domestic violence-related

killings have been held in the province of Ontario. The first inquest was held in 1998, and

focused on the deaths of Arlene May and Randy Iles. May was killed by her estranged

boyfriend, Randy, who then committed suicide. During more than four months of

testimony, jurors heard from 76 witnesses and returned with 213 recommendations

intended to make the system more responsive to the needs of women and children

experiencing domestic violence. The second inquest, held in January 2001, examined the

events leading up to the domestic homicide of the Luft family of Kitchener. In July 2000,

William (Bill) Luft killed his wife, Bohumila, and their four children before taking his

own life. The most recent inquest was held between October 2001 and February 2002,

after the domestic homicide–suicide of Gillian and Ralph Hadley of Pickering in June the

previous year.

2

The major themes emerging from these inquests on domestic violence include:

violence resources and responses;

of the response system;

especially children exposed to domestic violence;

in Ontario;

domestic violence fatalities and the responses to it.

Our review and assessment of cases continues to re-enforce the perspective that these

themes emerging from inquests are still valid. There is a continuing need to address each

of them if we are to achieve the goal of preventing deaths in similar circumstances.

Such reviews, whether by inquest or committee reviews, are necessary to answer the

question of "why" deaths from domestic violence occur. Trying to answer the question of

"why" is essential in any process directed to prevention. Generally, death investigations

are directed to answering who died, when and where it happened, what the cause of death

was, and whether it was as a result of homicide, suicide, accident, natural causes, or

undetermined. But to answer why the death occurred and what can be done to prevent it

in the future requires a more extensive inquiry into the constellation of circumstances that

lead to the death.

When deaths result from accidents or even natural causes, as a society we ask why the

death occurred. When someone dies in a motor vehicle collision, we ask whether there

was a problem with the driver or the road conditions, or a failure of some part of the

vehicle. When there is an airplane crash, in addition to inquiring whether there was pilot

3

systems approach is that humans will make errors in even the best organizations. These errors are recognized as the consequences of

problems that predate the errors. Thus, to reduce the number of errors, changes must be made to the workplace or the system. Adverse

events occur because of either active failures on the part of individuals, or latent conditions within the system or process that

contribute to or create the circumstance where the error occurs. Active failures include unsafe acts committed by people who are in

the craft or other systemic conditions that contributed to the failure or error leading to the

disaster and deaths. Such disasters, usually resulting in a massive number of fatalities,

lead to some form of inquiry directed to trying to answer why it happened. Similarly,

hospitals continuously engage in morbidity and mortality reviews. They increasingly

apply the same kind of systems analysis developed in the aeronautics industry to

determine whether the management of the patient’s malady or course of treatment could

be improved. To make the necessary changes to avoid such deaths in the future, the

overarching question in these inquiries has to be, Why did the death occur?

However, when the fatality results from domestic violence, the question is rarely asked

from a systemic paradigm. Undoubtedly, nothing is more complex and difficult to

understand than human relations. In the context of trying to understand the circumstances

that lead to these kinds of fatalities, inquests such as the ones mentioned above have

helped to some limited extent in addressing the question "why." While each of these

lengthy and costly inquests resulted in a number of important recommendations, there

continue to be a significant number of such fatalities in Ontario from which more could

be learned. However, without a significant realignment of resources, it is impossible to

conduct such extensive inquiries in all such fatalities. Alternatively, only by intensively

examining the circumstances of these deaths, with the benefit of the various expert

perspectives represented on committees such as the DVDRC, can we try to learn as much

as possible in trying to answer "why."

In the context of domestic violence fatality reviews, the deaths being examined are

always first and foremost attributable to the actions of the perpetrator. In addressing the

question "why," however, the application of a non-fault finding systems analysis assists

in the examination of those systems—such as justice, health, and social services—with

which the victims and perpetrators were involved prior to the fatalities.

In our first report, we found that the issues identified and the resultant recommendations

fell into one of three broad categories. Our review of the cases forming the basis of this

report can again be grouped into the same categories:

direct contact with the patient, such as slips, lapses, fumbles, mistakes, and procedural violations, without assigning blame or finding

fault. Latent conditions comprise the underlying system factors that contribute to the potential for active failures.

4

First, there continues to be a need to generally heighten awareness and provide education

about domestic violence. Also, it is important to ensure that domestic violence education

and approaches. Ontario is the most racially, ethnically, and linguistically diverse

province in Canada. Therefore, all public education should strive to meet and impact the

broadest possible audience. In every case reviewed, family members, friends, neighbours,

co-workers, and/or professionals had some knowledge of the escalating circumstances

between the perpetrators and victims. However, these individuals did not appreciate the

significance of the situation, the information or warning signs available to them, or what

to do about it. Accordingly, many of the recommendations address the need for targeted

public awareness and professional educational programs that teach about the signs of

domestic violence and the risk factors leading to potentially lethal consequences.

Second, there is a need to have appropriate tools available to those who work with

victims and perpetrators of domestic violence to better assess the potential for lethal

violence in their lives, and corresponding access to appropriate services and programs. As

an example, victims may need access to safety planning and perpetrators may benefit

from access to counselling programs.

Third, adequate resources are required to institute programs that will help to ensure

victim safety and reduce the perpetrator’s risk.

While there may be increasing public awareness and professional training concerning

domestic violence, the cases we reviewed this year highlight the need to expand this

awareness and training and make the necessary links to appropriate action. In many of the

cases we reviewed, the indicators for domestic violence were present and even

recognized. However, there seemed to be a lack of referrals and/or interventions which

focused on safety planning for victims and treatment or other programs for perpetrators.

In the majority of the reviewed cases, there were ten or more risk factors associated with

potentially lethal violence present in the circumstances. Throughout our case reviews, we

identified multiple opportunities for intervention by family, friends, co-workers, and

employers. More importantly, front-line professionals such as family doctors, lawyers,

and child welfare and protection workers, as well as more specialized domestic violence

services such as police and shelters for abused women also had opportunities for

intervention.

4 "Cultural Competence" is a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among

professionals that enable effective work in cross-cultural situations. "Culture" refers to integrated patterns of human behaviour that

include language, racial, ethnic, religion, or social groups. "Competence" implies having the capacity to function effectively as an

individual and an organization within the context of cultural beliefs, behaviours, and needs presented by consumers and their

communities. (Cross, T. et al., 1989)

5

Many of the recommendations in this section address the need for ongoing training of

professionals to not only identify the risk of violence in the lives of those they deal with,

but also what to do about it. Once the risk is identified, the professional, child protection

worker, co-worker, or employer has to know how to effectively intervene with the

appropriate referrals. Simply put: if you can say when it is likely to occur, you should

also know what to do about it.

Last year, the committee reported on the need to have appropriate risk assessment tools

for use by those who deal with victims and perpetrators of domestic violence to identify

those who have a high likelihood to act violently. We note that a pilot project involving

be used by police services throughout the province. If individuals charged with offences

involving domestic violence and considered high risk as a result of an assessment are

released, there needs to be continuing vigilance and follow-up if breaches occur.

Recommendations in this area focus on the need for police services to institute dedicated

high-risk case management units to supervise and monitor the case until completion.

A number of the cases we examined involved bail releases. It was apparent that the

sureties in several of these cases were inappropriate for many reasons, including:

to meet the obligations of being a surety.

Several of the recommendations address the need to ensure that sureties are appropriate

to the seriousness of the undertaking.

As the concept of risk assessment becomes better understood, the committee feels it is

important for community professionals to recognize that these assessments should not be

limited to use by professionals involved in the criminal justice system. Every sector needs

to use these tools when clients reveal domestic violence in their lives. Healthcare

providers in hospital and community settings are well placed to gather critical

information after victims or perpetrators present physical injuries or mental distress as

6

symptoms. As well, shelters should adopt the use of standardized risk assessment tools

for intake so those who require immediate assistance receive it.

Two of the cases reviewed involved a parent killing children as a form of punishment or

revenge against the other partner during the separation. Several of the recommendations

are directed to the need for child welfare and protection services to use a domestic

violence assessment process that takes into account the dynamics of the violence in the

family. A number of other recommendations address the need for a greater understanding

by police about the enforcement of Family Court Orders. There is also recognition of the

need for greater communication between the criminal justice and family law process.

Further, there are recommendations directed to the need for Family Court judges to have

assessment reports prepared by qualified assessors with domestic violence training

available to them when deciding matters of child access—particularly in cases were one

of the parties has a history of domestic violence.

As noted in last year’s report, and it bears repeating, adequate resources are required to

ensure victim safety and reduce perpetrator risk. All programming and services require

resources to become operational. These resources include, but are not limited to:

children exposed to domestic violence.

One of the cases reviewed this year highlighted the need for adequate resources to

provide access to these kinds of services and responses in northern and more remote or

rural areas. Of particular concern in this year’s review is the need for resources to train

and provide the tools for those engaged in protecting children where there is violence in

the lives of their parents.

In 2004, the DVDRC reviewed nine domestic violence cases involving homicides. There

were 11 deaths, since two of the cases involved a homicide–suicide. Two of the cases

involved homicides of toddlers by their fathers who were targeting their estranged spouse

by killing their child. Both of these cases involved criminal and family court proceedings

in which there were criminal charges and conflict over access to children. The majority of

homicides involved married couples who were Canadian citizens with children. Eight of

the nine cases involved male perpetrators. In the one case of a female perpetrator and

7

male victim, there had been a previous history of his violence in the context of this

intimate relationship.

In our second year, we were able to review current cases as well as combine data with the

previous year, which produced a more sizable total of 20 cases. In our analysis, we found

common risk factors associated with the domestic violence and risk assessments

literature. The most common factors found in the nine cases reviewed in 2004 as well as

the overall common factors for 2003 and 2004 combined appear to be an actual or

pending separation, prior history of domestic violence, and a perpetrator who had made

threats to harm himself or his partner in the past. A history of depression, alcohol abuse,

and stalking behaviour appear to be present in at least half of the cases. Four of the nine

cases in 2004 involved child custody and access disputes, in contrast to this issue not

being identified in our 2003 review.

An important concern to the DVDRC is the extent to which the homicides reviewed

appear predictable and preventable with the benefit of hindsight and the analysis of wellknown

risk factors. In eight out of the nine cases from 2004, the homicide appeared both

predictable and preventable. In seven out of nine cases, at least seven or more risk factors

were clearly identifiable in the history of the family circumstances. For the two years

combined, 12 out of 20 cases (60%) had at least seven or more known DV risk factors

associated with lethal violence. A proper risk assessment had been done in only one 2004

case, but unfortunately this assessment did not lead to a coordinated safety plan and risk

management strategy.

As a result of the case reviews this year, the subcommittee observed that there is a lack of

coordination and follow up of domestic violence cases, and a lack of continuing

vigilance—particularly in the justice system—pending completion of the case. When

serious injury or death occurs, the unacceptable but common response is that the case fell

through the cracks. Unfortunately, a number of the tragic cases that result in fatalities

occur when the perpetrator is subject to a bail order or the victim has obtained a

restraining order. As a result, the focus of attention of the subcommittee this year has

been on the need for a process to provide some measure of safety to victims, a process

that would help limit the risk. This section of the report describes a basic case

management framework, and provides a preliminary examination of a number of

different approaches that have been used by various communities in an effort to manage

high-risk cases.

Unlike inquest recommendations that deal with the individual circumstances of a

person’s death and the advancement of public safety, there is no follow-up process to

ascertain specific responses to the recommendations contained in the DVDRC report.

8

However, it is noteworthy that subsequent to the release of our first report, in 2004 the

Ontario government announced a $66 million Domestic Violence Action Plan to address

domestic violence. The stated objective of the program is to enhance existing domestic

violence programs and services and to implement new initiatives by placing a new

emphasis on prevention and community support for abused women and their children.

The government announced that one goal of the program was to identify women and

children at risk earlier in the process, and to that end $5.9 million would be spent on

training, research, and conferences. Professional and service providers would be trained

to intervene early and offer appropriate response, information, and supports. Further,

training materials were to be developed to help front-line workers, professionals, family,

friends, and neighbours detect early signs of abuse. In addition, $4.9 million was to be

made available for a four-year public education and prevention campaign to help

communities play an active role in ending violence against women and girls.

Another declared goal was to strengthen the justice response to domestic violence by:

restraining orders and breaches; and

tested in two jurisdictions in the province.

Many of the DVDRC recommendations in this report speak to the need to implement the

announced initiatives, and it will be for others to assess the commitment of those in a

position responsible to do so.

The individual case reports and data summary collection forms that form the basis of our

case reviews and analysis have not been released to the public. All of the information

obtained as a result of the coroner’s investigation and provided to the Domestic Violence

Death Review Committee has been subject to the confidentiality and privacy limitations

imposed by the Coroners Act of Ontario and the Freedom of Information and Protection

of Privacy Legislation. Unless and until an inquest is called with respect to the specific

death, the confidentiality and privacy interests of the deceased, as well as those involved

in the circumstances of the death, still prevail. Accordingly, the individual reports, as

well as the review meetings, remain private and protected. Each member of the

committee has entered into and is bound by the terms of a confidentiality agreement that

9

recognizes these interests and limitations.

The DVDRC’s terms of reference direct that the committee, through its chair, report on

an annual basis to the Chief Coroner the trends, risk factors, and patterns identified as a

result of its review, and make appropriate recommendations to prevent deaths in similar

circumstances. The recommendations in this report, while generalized, result from the

review of the facts of the specific cases before the Domestic Violence Death Review

Committee. Each reviewed case resulted in recommendations specific to that case, which

were then distilled for the purpose of this report. This report’s recommendations, as with

the last report, may not be seen by some to cover as broad a spectrum of issues as those

produced as a result of the domestic violence inquests and the report of the Joint

recommendations should not be seen in any way to diminish or detract from the

importance of the earlier recommendations of those other processes. Indeed, this report’s

recommendations and any future reports of the committee should be seen as

supplementary to them.

The cases summaries in Chapter 2 are provided only to give the reader a general sense of

the circumstances that led to the fatalities and issues that assisted the committee in

formulating recommendations. They do not represent all the detail available or all of the

issues necessarily observed by the DVDRC during the reviews. Further, the following

caveat forms part of each case review and applies to this report as well:

This document was produced by the DVDRC for the sole purpose of a

R.S.O. 1990 Chapter c. 37, as amended. The opinions expressed do not

necessarily take into account all of the facts and circumstances surrounding

the death. The final conclusion of the investigation may differ significantly

from the opinions expressed herein.

10

This case of homicide occurred in the spring of 2002. The deceased male victim, age 48,

and the female perpetrator, age 34, had been living in a common-law relationship for

approximately four years prior to the homicide. They lived in a small northern Ontario

community in a three-bedroom trailer. They had one child together, however the

Children’s Aid Society had removed the child from their home the previous fall. They

had other children from previous relationships, however they were estranged. The male

victim was employed as a truck driver and he also worked as a self-employed mechanic.

The female perpetrator was unemployed and had been unable to hold any employment

due to her alcohol problems. She had been in various treatment programs over the years,

and she had attempted suicide on several occasions. The weekend of the homicide, they

had been together redecorating their trailer in the apparent hope of regaining custody of

their child. She stabbed him to death at their residence sometime during the weekend of

heavy drinking.

The couple shared a very violent relationship and both had a long history of alcohol

abuse. They were both well known within their community and to the local authorities for

their violent behaviour toward one another. She had frequent contact with the local

women’s shelter, however she was volatile and threatening and she terrified other

community members. Both spouses had been subject to charges of assault and other

violent offences toward one another. The perpetrator in particular had a long history of

violence. She had been arrested 22 times for offences involving domestic violence, often

using weapons such as knives, hammers, and broken beer bottles. In an earlier

relationship, she had stabbed her then-boyfriend. With respect to the victim in this case,

she had stabbed him on two prior occasions. The charge was withdrawn in the first

instance because the victim refused to cooperate with the prosecution, and the second was

still outstanding at the time of his death. Due to their violent relationship, some in the

community openly speculated about which one would kill the other first.

The victim had as violent a past as did the perpetrator. He was known to have a violent

temper. Approximately ten days before the homicide, he had been involved in an

altercation with one of his spouse’s uncles that resulted in her uncle being hospitalized

and the victim being charged. At the time of his death, both the victim and perpetrator

were facing criminal charges of violence and were on bail. She was on a recognizance of

bail with respect to the alleged earlier stabbing of the victim, but without a term of noncontact

with the victim. He was on bail for the offence against her uncle. Both were

enrolled in a domestic violence counselling program, but they had only attended a couple

of times.

On the day of the homicide, the perpetrator argued with the victim. No one else was

11

present in the home. As the argument escalated, the perpetrator stabbed the victim in the

upper chest with a sharp knife or similar object, cutting deeply into his chest. Due to the

nature of the wound, he bled to death within minutes. She covered his body with blankets

where he lay on the kitchen floor, and she then continued to drink to excess and consume

prescription medication. She was charged with second-degree murder. She subsequently

pled guilty to the offence of manslaughter, and in addition to one and a half years of pretrial

detention, she was sentenced to a further eight years.

This case involves the homicide of a woman by her husband. The victim and perpetrator

had been married for approximately ten years. They had two children together. The

victim was well educated and had become very successful in her position with a large

international corporation. Her husband, on the other hand, had been unemployed for most

of the marriage, and while he attempted to find jobs, he had been largely unsuccessful.

The victim and perpetrator’s marriage began to deteriorate, and in the spring of 2002 they

separated. He had unfounded suspicions that his wife was having an affair. At one point,

Children’s Aid Society was called because the children had been seen wandering around

the neighbourhood and appeared to be un-kept and unsupervised. They were, at the time,

in the perpetrator’s care. Upon separation, the victim and children moved in with her

father, and the perpetrator eventually moved in with his mother and sister. Initially he had

remained in the matrimonial home, but he found it too expensive to manage.

Between the time of separation in the spring and the homicide in the fall of 2002, the

perpetrator made several attempts to get back together with the victim. He made excuses

to see her and sent her emails requesting that she and the children come home. She

refused. They did agree between themselves as to the terms of custody and access to the

children. However, during the fall of 2002, they began to have disputes over the division

of assets. While the perpetrator had hired a lawyer, the victim did not feel she needed

one. She continued to meet directly with her husband to try and resolve the disputes,

notwithstanding having several people tell her that he had made threats against her life.

His sister called the victim at one point and told her that he had said that he if he found

her with someone, he would kill her. He told a counsellor he had been seeing that he was

afraid he would snap and strangle her to death. The counsellor called her and warned her

of the threat. When told of these threats, she did not convey any sense of concern.

The husband suffered from depression, and at the treatment centre where he was

receiving additional counselling, he had completed workbook sketches showing him

killing his wife. The workbook also contained written messages expressing thoughts of

rage against her because of his belief that she would get everything and he would be left

12

with nothing.

One Saturday, they had agreed to meet at her place of business to discuss the sale of the

matrimonial home. She had told her father that she was going to work and planned to

meet her husband to speak with him. The perpetrator had the children that weekend and

had left them in the care of his mother while he went to meet the victim. When he came

home from the meeting, he went immediately to his room where he was later found to

have attempted suicide. An ambulance was called and he was taken to hospital where his

self-inflicted injuries were found to be non-life threatening. Later the next day, after the

victim had failed to return to her father’s home, a relative went to her office and found

her dead. She had been stabbed multiple times in the front and back, and her throat was

slashed. The perpetrator pled guilty to second-degree murder.

This case involves the killing of a two-year-old girl by her father during the course of an

on-going dispute and separation from his spouse. At the time of the killing, he was on

probation for an assault involving her mother and had a restraining order. The perpetrator

and his wife had two daughters, the victim aged two and her sister aged four. Their

marriage had been rocky from the beginning. Over time, the perpetrator became

increasingly abusive and threatening toward his wife. He would physically block his

wife’s movements throughout the house and occasionally physically restrain her. He

threatened that if she called the police, he would say that she hit him and that she too

would be charged. She believed his threats and therefore did not involve police until the

final assault against her, which led to him being charged and removed from the home by

police. He was released on bail with a term of no contact. Even though he complained

bitterly that the charge was unwarranted, within a few months he pled guilty and was

placed on probation, but without any requirement for counselling.

Earlier, when the marriage had begun to fail, his wife had sought support and counselling

from several organizations, including Catholic Family Services and a local women’s

centre. She encouraged her husband to go to counselling with her, but he refused to go.

At the group counselling, she was able to assess her own situation to the degree that she

knew the relationship was abusive and that her husband was controlling her and

intimidating her. She took steps to contact a family law lawyer and began the process of

separation. While in the process of separating, they continued to cohabit in the same

residence, on the advice of their family lawyer. That situation continued until the assault

reported to the police and he was removed from the home. At that point, the Children’s

Aid Society became involved with the family due to police notification of children in the

home where there had been an investigation of domestic violence. Only the mother was

interviewed. She was deemed to be a fit and loving mother, and as such no risk to her

children. The father was not interviewed or assessed. The file was closed and no further

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action was taken.

Initially, custody and access to the children was arranged through an intermediary,

however eventually that arrangement broke down because of his abusive behaviour.

Supervised exchanges then took place through a family access centre. Even then, access

centre staff documented that the perpetrator would act inappropriately during these

exchanges. He would ask to see his wife, notwithstanding that he was not permitted to by

the terms of probation and a restraining order. He would be seen peering into her car in

the parking lot. At one point, he refused to hand over the children because he believed he

saw her with another man in her car. Further, he had been breaching his restraining order

for several months. On the advise of her lawyer she reported the breaches, but no action

was taken by the police. He was seen stalking her in parking lots and at the children’s

school. He would attend the school and remove the children without his wife’s

authorization. Eventually it came to the point where, with the consent of the school,

arrangements were made to home-school the children.

On the last exchange, after the mother dropped off the children at an access centre, the

perpetrator picked up his two daughters and drove to a neighbouring community where

he made his way to a secluded rural area. He parked his vehicle on the side of the road

and took his two-year-old daughter to a spot beneath a tree where he slashed her throat

with a knife and left her there to die. She was found to have died of a combination of

hypothermia and blood loss over several hours. After abandoning her, he made his way

with his other daughter to visit an acquaintance. When asked, he told the acquaintance

that the baby was ill and with her mother. Then he telephoned the access centre and

informed the staff that he would be keeping the children overnight as his car had broken

down and he was unable to return them. The staff of the access centre told him that the

police would be notified if the children were not returned. The mother of the victim was

at the centre to pick up her children when her estranged husband called to say he would

not be returning them. The police were notified, but no action was taken at that time,

notwithstanding an existing family court order confirming the terms of custody and

access. The mother went home without her children. The next day, he left his surviving

daughter on the road across the street from her grandparent’s home. When he did not

returned his other daughter, police were again notified. The following day the mother

went to the police station and it then became a missing person investigation. The

perpetrator later revealed the location of the little girl’s body.

The perpetrator pled guilty to second-degree murder and was sentenced to life

imprisonment with parole eligibility set at 18 years.

In this case, the father of a two-year-old boy killed him in the midst of an attempt to kill

14

the child’s mother. At the time of the attack, the perpetrator, age 36, was on a bail release

for charges of assault and threatening to kill his spouse, age 39.

The couple had only been together for a few years. Initially they lived in Toronto, but

after the birth of their son they moved to a small town outside of the greater Toronto area.

The allegations of assault and threatening death incident involved the perpetrator

claiming that his spouse had cheated on him with another man. While choking her, he

was alleged to have stated, "If I catch you cheating on me I’ll kill you and the other

man." He had been abusive in the past, all stemming from jealousy, but these earlier

incidents went unreported. In an earlier relationship with another woman, the perpetrator

had been convicted of assaulting her with a weapon when she said she was leaving him.

He assaulted her repeatedly with a belt and told her that she could not hide from him, that

he would find her. He spent four months in custody for that offence.

When the perpetrator was arrested for the assault and threatening death charges, his

spouse asked her father to help him get out on bail so he would not lose his job and

would be able to continue to support them. Her father had a criminal record, and he

enlisted the help of another young woman in order to be approved as a surety. They lied,

telling the court that he was her father and that he had sufficient assets to qualify. The

court approved the two of them and released the perpetrator on bail with a number of

conditions, two of which required that he not enter the home occupied by his spouse and

child, and that he have no contact with them, except as permitted by a Family Court

Order. Notwithstanding the court order, he constantly contacted his spouse. He would

stalk her, later calling to tell her that he knew where she had gone and what she had done.

When she told him that she had a copy of the release order and that he was breaching it,

he told her he did not care what it said, that no court order would stop him. His spouse

did not report the breaches, declaring later that she was "too scared of him to do

anything."

The police who investigated the assault and threatening death charges referred the case to

the local Children’s Aid Society when they found an infant in the home. The CAS

investigated the welfare of the child. On finding that the house was clean, the child well

cared for by his mother, and the perpetrator was out of the house, the CAS concluded

there was no immediate threat. Their file was closed.

On the day before he was to return to court to deal with the charges, he called his spouse

several times to try to have her accept him back. She refused and told him that she was

afraid for herself and her child because of his violent behaviour. She told him that he

needed help. He demanded to know what she was going to testify to in court, and stated

that he believed that she would try to get him into trouble because she was probably

involved with another man. After she hung up the telephone on him, she prepared her son

for bed. As she sat on the couch with the child while he drank from a baby bottle, the

perpetrator let himself in the back door and attacked her with a hammer. He struck her in

the mouth, knocking out several of her teeth. After she fended off another blow, he

15

grabbed his son by the neck and began to strangle him. She tried to pull him away from

the child, but being unable to, she ran from the house screaming for help. He carried his

son into the kitchen where he stabbed him twenty times in the chest with a butcher knife.

He left the child in a pool of blood on the kitchen floor, threw the knife into the sink, and

fled the house. He was later arrested for first-degree murder of his child and the

attempted murder of his spouse. He was found guilty of both offences and sentenced to

life imprisonment.

The father of the spouse and the young woman he had enlisted to deceive the court in

order for them to be approved as sureties for the release of the perpetrator were both

found guilty of perjury and sentenced to periods of incarceration.

This is a case of homicide committed by a woman’s estranged husband. At the time of

the homicide, the perpetrator was on a bail release for the charges of assault and

threatening to kill his spouse, with a term of no contact with her. His adult daughter and

her husband were the named sureties and he was required to reside with them. He later

killed his wife in circumstances similar to those that had resulted in the outstanding

charges and bail release. Several weeks after his arrest and release, he followed his wife

to a store. He waited in his motor vehicle in the parking lot for her to exit the store. When

she did so, he forced her into the van and began to beat her with a wrench. She escaped

from the van. As she ran through the parking lot, he ran her down with his van, killing

her.

The victim had married the perpetrator at an early age; he was eight years older. They

were married in January 1980, and he was violent with her from the beginning. In their

first year of marriage, the victim left the perpetrator after he choked her. She fled to a

shelter but he found her and took her home. Again, in 1984 he choked her to the point

that she lost control of her bodily functions. These incidents went unreported. At the time

of the homicide, the perpetrator was 52 years old and his wife 44. He had an elementary

school education and worked as an unskilled labourer. He had a long history of

marihuana and alcohol abuse. He had recently been prescribed sleeping pills and

antidepressants. His family physician had given him a referral to a psychiatrist, but he

had yet to be seen. Even his friends described him as being a bully, a jealous person and

very controlling, especially around his wife. His children were fearful of him. In the past

he had made threats to kill other family members because he believed they were stealing

from his father.

The events that gave rise to the charges of assault and threatening death and his bail

release occurred in early 2002. The perpetrator convinced the victim to go for a drive

with him in the country. She had dyed her hair the previous day, and it was his belief that

16

she had done so to attract other men. While he was driving, he punched the steering

wheel and he threatened to strangle her. He stopped the vehicle and threatened her again.

Believing that he was going to kill her, she fled from the vehicle. She ran to a nearby

house where she was able to call police. After his arrest, the victim moved into a shelter,

still fearing for her life. She later found a job, but the day before she was to have started it

she was killed. She had purchased a cell phone and gave the number to her children. She

started to receive telephone calls from the perpetrator while she was in the shelter. She

reported these breaches of the bail order to the police. The police had planned to arrest

the perpetrator for these breaches, however it did not occur before he killed her. Further,

his daughter, concerned about his having made contact with her mother, also planned to

revoke her surety for his bail release, however before she did he killed her mother.

The perpetrator was described as being very upset and depressed after he was charged.

He was taken to a treatment centre for substance abuse and detoxification, but checked

himself out within a few hours. In the days leading up to the homicide, the perpetrator

drank heavily, increased smoking of marijuana, and complained to friends that his wife

only wanted his money. At one point he checked into a hotel and took an overdose of

medication in an apparent attempt to kill himself, but a family member rescued him. At a

bar the evening before he killed his wife, the perpetrator asked a friend he had been

drinking with to play a song about suicide. Later, when he left the bar, he told his friend

that he would not be seeing him again.

After he killed his wife, the perpetrator fled the jurisdiction, checked into a hotel, and

again attempted suicide by drug overdose. He was discovered by police, arrested, and

hospitalized. After recovery, he pled guilty to second-degree murder. He was sentenced

to life imprisonment with parole eligibility set at 14 years.

This is a case of homicide–suicide. The victim and perpetrator had been married for 15

years and had one child, a daughter. The perpetrator was a police officer with 22 years

experience. He had been known as a well organized, quiet spoken officer. He had been

involved in an altercation while on duty several years earlier that had a significant impact

on him, and he subsequently transferred to court officer duties. He had an obsessivecompulsive

disorder and was very focused on finances and his pending retirement within

the next several years. The victim, who had several jobs over their marriage, was on

disability after sustaining a blood clot while working. The marriage had shown signs of

failing, and the couple separated at one point in 1995. During this time, the couple

attended marital counselling. Approximately three months later they resumed their

marital relationship.

In December 2003, the victim advised her husband she wanted a divorce. According to

17

friends, he told them he had no idea that such a thing would happen and he felt betrayed,

hurt, and vulnerable. The victim had told him that she felt they were not compatible and

that he was self-centred and controlling. She went to a lawyer and started divorce

proceedings, which he was very upset about. He was quite concerned about the impact

that the separation and divorce would have on his retirement and pension. They continued

to reside in the same home. The perpetrator’s lawyer advised him to go for mediation at

family court. According to his friends, he pleaded with her to work out their problems

and once again she agreed to go for counselling, but it failed. The victim became upset

with him for mentioning the pending divorce at the counselling session in the presence of

their daughter, contrary to his agreement not to tell her until after the holidays.

On the day before he killed his wife and himself, the perpetrator took his daughter to

medical appointments and later made inquiries at work about health and dental benefits

after the marriage break-up. When he returned home, he told his wife what her

entitlements would be and then he left the house upset, returning later. The next morning,

although off-duty, the perpetrator returned to the station and retrieved his firearm from

his locker. He drove back home and went inside to the bedroom where he shot the victim,

killing her, and then turned the gun on himself. Their daughter, who had been in her room

using her computer, heard the shots and ran to her parent’s bedroom where she found her

mother dead in bed and her father dead on the floor.

In this case, a husband, age 30, killed his wife, age 31, at a time when they had agreed to

separate, yet were still living in the same residence. They had been married for almost

five years, although it was described as being stormy throughout. There were no children

from the relationship. They argued constantly about financial issues. While there were

considerable verbal exchanges, there was no reported or known history of physical abuse

in the relationship.

The husband worked as a truck driver and the wife started working in the business of

promoting nightclubs. Her activity caused her to spend considerable time away from

home at clubs and she became involved in the drug scene—both using and selling illicit

drugs. She also started to engage in extra-martial affairs with other men. Family and

friends, on the other hand, knew her husband as a quiet person who did not go to clubs

and was not involved in the drug scene. He had no criminal record or prior police

involvement.

Due to their differing lifestyles, they grew apart. They decided, after numerous arguments

in the fall of 2002, to separate but agreed to continue living together in the matrimonial

home and to share the responsibility of maintaining the residence while readying it for

sale. During this time, the husband became reacquainted with a woman he had known

18

from the time he was a teenager. They began to see each other, and the relationship

developed to the point that he was spending some nights at her residence. They began to

discuss marriage plans. Other nights he would sleep on a couch at his matrimonial home.

On the day before the wife was killed, she visited her mother, upset about money issues

and the separation. She and her mother discussed how she could get a divorce and what

would happen with the assets of the marriage. She returned home after meeting with her

mother, stopping first to purchase cleaning supplies to work on the house. When she

returned home, an argument with her husband developed over the sale of the house,

division of the assets, and their finances. At some point, after speaking to a friend on the

telephone, the wife went to bed and the husband retired to the couch for the night.

According to an interview given to the police by the husband, admitting to killing his

wife, he kept saying to himself in the morning, "why is she doing this to me?" He felt he

"had no other option." He got a hammer, went into his wife’s bedroom, and while she

slept, struck her several times in the head, killing her. He left her body in the bed, left the

house, and spent most of the next week at his girlfriend’s residence. Immediately after the

killing he took a number of steps to try to conceal his responsibility and construct an

alibi.

The mother of the deceased became worried after not having heard from her for almost a

week. The mother went to the house where she found her daughter dead in her bed. When

the police interviewed the husband, he confessed to killing his wife. He was charged with

first-degree murder and later pled to second-degree murder and was sentenced to life

imprisonment with parole eligibility set at ten years.

In this case, the perpetrator, age 25, shot the victim, age 23—his girlfriend and mother of

his child—with a handgun, and then shot himself. Both died from a single gunshot to the

head. They had an on and off relationship over a six year period, largely because of the

perpetrator’s extended periods of incarceration. He had an extensive record for crimes of

violence and drug offences. He had been released on bail five days before the homicide–

suicide. One veteran police officer described him as a "gun-toting drug dealer." The

victim did not have any criminal history.

The perpetrator had been in custody for a drug-related offence. He had originally been

detained, but after approximately eight months in custody, he was released on consent as

a result of evidentiary problems. He was released on a substantial cash bail. His father

was approved as surety, even though he had a criminal record. He was to reside with his

father and not be away from that residence without being in the company of his father.

He was also not to be in possession of any firearms. In addition to the term of this

recognizance prohibiting his being in possession of a firearm, the perpetrator had a prior

19

conviction for an unlawful use of a firearm—an occurrence involving the shooting of

another victim left paralysed—that included a life-time prohibition as part of the

sentence.

As a result of the abuse in her life and his most recent incarceration, the victim did not

want to have any more contact with him. She feared for the safety of her child and

herself. Shortly before his release, he told the victim that when he got out of jail he was

going to kill five people. She believed that she would be one of those people, but made

no report to the police at that time. Her sister’s boyfriend reported that the perpetrator had

threatened to kill the victim and her child, and that she was always afraid of him.

On the day that the perpetrator was released, notwithstanding the release order, the

perpetrator’s father—his surety—drove him to the victim’s apartment. Her apartment was

in a different city from that of the father, where the perpetrator was to reside. Upon his

unexpected arrival, he declared his intention to reside there with her and the child. When

he left to go to visit a friend, who the victim knew was holding the perpetrator’s guns, she

fled with her child to a friend’s apartment. Two days later the victim phoned both the

police and the local shelter to seek help in dealing with the perpetrator. No details were

provided about the police call, and when queried, the police had no record of it. The only

shelter record indicates she told them he had made threats, that he had just been released

from jail, and that she wanted to get out of the apartment. She was told that the shelter

was full and was given the phone numbers for other shelters in the city. Shelter staff also

suggested that she call the Children’s Aid Society for support and assistance. She found

shelter at her sister’s apartment.

The perpetrator found out where she was staying and called her repeatedly. The next day

the perpetrator called the apartment and spoke to the victim, stating he wanted to visit his

daughter. The victim tried to put him off with a number of excuses. She asked him to

wait for her mother to be at the apartment at the end of her work day. He phoned back

continuously via a cellular telephone. The victim told him that she was afraid to be alone

with him, and considered ways to let him see the daughter without her being directly

involved. Finally she told him that she would call him back in five minutes. She then

called 911 and remained on the line. The perpetrator, speaking over his cellular phone,

arrived at the apartment door just as two police officers, who had been dispatched,

arrived at the building. Just after he gained entry to the apartment, while the victim was

still speaking with the 911 operator, the police officers arrived outside the apartment

door. On discovering the police were at the door, he said "I can’t believe you called the

police on me." He then produced a 9mm handgun. He shot the victim in the head in front

of her daughter and sister, and then turned the gun on himself. The police had no chance

to act to prevent the shooting.

20

The victim and the perpetrator had known each other for several years. In this case, the

perpetrator beat the victim to death in the hall of his rooming house after a day of heavy

drinking. She would visit the accused for days at a time, largely for the purpose of

drinking alcohol. During these drinking sessions, arguments would occur between the

two that would result in the victim being physically abused by the perpetrator. Following

these drinking bouts over the past three years, the victim was seen with various physical

injuries ranging from blackened eyes, facial cuts, and a broken shoulder and wrist. Both

the perpetrator and victim would say these injuries resulted from her falling and/or

bumping into objects. The police and her family suspected abuse, but her refusal or

inability to disclose due to her lack of memory inhibited intervention other than to

administer to her injuries.

She had been married for 26 years to another man and was the mother of two boys. Her

alcoholism led to her leaving her husband, although they remained in contact. He knew of

her drinking habits and relationship with the accused, but did not want to divorce the

victim because of financial factors. Over the years of her relationship with the

perpetrator, various incidents of violence involving the victim occurred at or near his

home. Many incidents went unreported to the police. On one occasion where she did

complain to police, the charges were later withdrawn at her request and he entered into a

peace bond for 12 months.

On the day of her death, the perpetrator, who was undressed from the waist down, was

seen straddling the victim, who was also semi-clothed, banging her head repeatedly on

the floor in the hallway of the rooming house. When police arrived, her naked body was

found on the floor in the perpetrator’s room. She had died of closed head injuries. He was

convicted of manslaughter and sentenced to ten years in prison.

21

In 2004, the DVDRC reviewed nine domestic violence cases that involved homicides.

There were 11 deaths, since two of the cases involved a homicide–suicide. Two of the

cases involved homicides of toddlers by their fathers who were targeting their estranged

spouse by killing their child. Both of these cases involved criminal and family court

proceedings in which there were criminal charges and conflict over access to children.

Since the inception of the DVDRC in 2003, the committee has primarily reviewed cases

cleared by the court in the previous year. In our first year of operation, we reviewed more

homicide–suicides because there was no court involvement in these matters. In 2003, we

reviewed cases principally from 2002. In 2004, we reviewed cases from 2003. These

complex and time-consuming reviews have limited our ability to complete this process

for every available case. As indicated in Table 1, the number of homicide cases per year

between 2002 and 2004 has averaged 26 cases, with an average of 34 deaths. In

reviewing nine cases, the DVDRC limited itself to a thorough analysis of slightly over

one-third of the available cases for 2004. Over the past two years, approximately 40% of

the available cases were reviewed.

For the cases reviewed in 2004, eight out of nine cases involved a male perpetrator and

female adult victim who was the primary target of the domestic violence. The term

primary target is used since the actual homicide victim was a child in two of the cases. In

one case, access to the adult victim was limited by supervised exchanges for children, and

in the other cases a court order forbade any contact. The overall data from Ontario

domestic violence homicides, shown in Table 1, suggest that males as perpetrators and

women as victims represent approximately 80% of the cases, a four-to-one ratio. This

percentage and ratio is comparable to other DVDRC’s findings in the U.S. and the

national homicide data according to Statistics Canada.

22

27

35

25

1 (F)

9

15 deaths

homicide/suicide

1 attempted

homicide/suicide

1 attempted

homicide/homicide

25

29

19

10

8 deaths

homicide/suicide

5 attempted

homicide/suicide

26

40

21

4 (F)

1 (M)

14

15 deaths

homicide/suicide

1 attempted

homicide/suicide

The data presented for 2004 represent nine cases. The summary tables that follow provide

an overview of these cases, as well as an accumulated picture from the totals of 2003 and

2004 (20 cases = 11 from 2003 + 9 from 2004). Table 2 provides an overview of victim

and perpetrator background information. The majority of the cases involved Canadian

citizens who were married couples with children. As mentioned above, eight of the nine

cases involved male perpetrators. In the one case of a female perpetrator and male victim,

there had been a previous history of his violence in the context of this intimate

relationship, but no self-defence was raised in the criminal proceedings. Both for 2003

and 2004, background information suggests that the perpetrator most likely had a

criminal record (ten out of 20 cases), had made previous threats/attempts at suicide (nine

out of 15 cases), and had experienced significant life changes such as job loss (18 out of

19 cases).

Table 3 provides an overview of the nature of the cases. Two of the nine cases were

homicide–suicides. Four out of the nine cases involved stabbing as the cause of death,

which is comparable to 2003 data. Firearms were used in two out of nine cases in 2004

and six out of 20 cases (30%) for the two years combined. It may be interesting to note

that in the U.S., over half of female domestic violence homicide victims (54%) are killed

23

Table 4 provides an overview of the common risk factors associated with the domestic

violence literature and risk assessments. Table 4 highlights the most common factors

found in the nine cases reviewed in 2004, as well as the overall common factors for 2003

and 2004 combined. The most consistent factors appear to be an actual or pending

separation, prior history of domestic violence, and a perpetrator who had made threats to

harm himself or his partner in the past. A history of depression, alcohol abuse, and

stalking behaviour appear to be present in at least half of the cases. Four of the nine cases

in 2004 involved child custody and access disputes, in contrast to this issue not being

identified in our 2003 reviews.

An important concern to the DVDRC is the extent to which the homicides reviewed

appear predictable and preventable with the benefit of hindsight and the analysis of wellknown

risk factors. In eight out of nine cases, the homicide appeared both predictable and

preventable. As an illustration of this fact, we reviewed the number of known risk factors

in 2004 cases. These results are illustrated in Figure 1 and suggest that in seven out of

nine cases reviewed in 2004, at least seven or more risk factors were clearly identifiable

in the history of the family circumstances. For the two years combined, 12 out of 20 cases

(60%) had at least seven or more known domestic risk factors associated with lethal

violence. A proper risk assessment had been done in only one 2004 case, but

7 We acknowledge the assistance of Mr. George Goodall, a graduate student in the Library and Information Science program at the

University of Western Ontario, in the development of the database and data analysis.

24

NOTE: The information reported is only relevant to the perpetrator and domestic partner

Gender

89% female

11% male

(n = 9)

11% female

89% male

(n = 9)

95% female

5% male

(n = 20)

10% female

90% male

(n = 20)

Age when

incident

occurred

(years;

adults only)

Min = 22

Max = 48

Median = 39

(n = 9)

Min = 24

Max = 65

Median = 39

(n = 8)

Min = 19

Max = 81

Median = 39

(n = 20)

Min = 20

Max = 89

Median = 43

(n = 19)

Type of

relationship

between

victim and

perpetrator

Legal spouse —

Common-law partner —

Other —

(former partner/current

friend)

(n = 9)

66%

11%

22%

Legal spouse —

Common-law partner —

Estranged boyfriend/girlfriend–

Boyfriend/girlfriend —

Divorced —

Estranged legal spouse —

Other —

(former partner/current friend)

Same-sex partner —

(n = 20)

50%

15%

10%

5%

5%

5%

5%

5%

25

Length of

relationship

(adults

only)

< 1 year 0%

1–10 years 78%

11–20 years 11%

20–30 years 1%

(n =9)

< 1 year 5%

1–10 years 55%

11–20 years 10%

20–30 years 30%

(n =20)

Children in

common

(adults

only)

0 22%

1–2 66%

3+ 11%

(n = 9)

0 30%

1–2 45%

3+ 25%

(n = 20)

Residency

status

(adults

only)

Canadian citizen

— 100%

(n = 9)

Canadian citizen

— 100%

(n = 9)

American citizen

— 0%

Canadian citizen

— 84%

Immigrant/

Refugee

—16%

(n = 19)

American citizen

— 5%

Canadian citizen

— 80%

Immigrant/

Refugee

—15%

(n = 20)

26

Employment

status

(adults only)

Disability —

0%

Employed parttime

— 29%

Employed fulltime

— 43%

Retired — 0%

Unemployed

— 29%

Welfare — 0%

(n = 9)

Disability

— 12%

Employed parttime

— 0%

Employed fulltime

— 50%

Retired — 0%

Unemployed

— 25%

Welfare —13%

(n = 8)

Disability

— 6%

Employed parttime

— 29%

Employed fulltime

— 41%

Retired — 6%

Unemployed

— 18%

Welfare — 0%

(n = 17)

Disability

— 5%

Employed parttime

— 0%

Employed fulltime

— 58%

Retired — 5%

Unemployed

— 26%

Welfare — 5%

(n = 19)

Criminal

history

(adults only)

Yes 14%

(n =9)

Yes 56%

(n = 9)

Yes 12%

(n = 20)

Yes 50%

(n = 20)

Prior

counselling

(adults only)

Yes 50%

(n = 8)

Yes 33%

(n = 6)

Yes 27%

(n = 18)

Yes 44%

(n = 16)

Threats or

attempted

suicide

(adults only)

Yes 0%

(n = 8)

Yes 83%

(n = 6)

Yes 0%

(n = 18)

Yes 60%

(n = 15)

Significant

life changes

(adults only)

Yes 78%

(n = 9)

Yes 89%

(n = 9)

Yes 81%

(n = 19)

Yes 94%

(n = 20)

27

Type

Homicide 77%

Homicide–suicide 22%

(n = 9)

Homicide 45%

Homicide–suicide 45%

Multiple homicide–suicide 5%

Multiple homicide 5%

(n = 20)

Cause of death

Stabbing 44%

Gunshot 22%

Beating 22%

Other 11%

(Beating and hit by vehicle)

(n = 9)

Stabbing 40%

Gunshot 30%

Beating 15%

Strangulation 5%

Poisoning 5%

Other 5%

(Beating and hit by vehicle)

(n = 20)

Actual or pending separation 7 78% 16 80%

Other factors that increased risk 7* 78%* 10 50%

Prior history of domestic violence 7 78% 12 60%

28

Escalation of violence 6 67% 10 50%

Prior threats to kill victim or threats

with a weapon

6 67% 9 45%

Obsessive behaviour (including stalking

the victim)

6 67% 11 55%

Depression (or other mental health or

psychiatric problems)

6 67% 13 65%

Perpetrator unemployed 5 56%

Excessive alcohol and/or drug use 5 56% 10 50%

Child custody or access dispute 4 44% 4 20%

Control of most or all of victim's daily

activities

4 44% 9 45%

Extreme minimization or denial of

spousal assault history

4 44% 4 20%

* Comments on "other factors" include: health conditions, perpetrators isolation, lack of risk management by professionals, lack of

risk assessment or safety plan; breaching court orders, requested stress leave due to depression, statements to co-workers about

intentions, gambling addiction; perpetrator was isolated from his friends and family; violence with others; domestic violence with

former partners; chronic and severe substance abuse including prescription drugs and non-prescription drugs and alcohol; level of

physical violence is above "common assault" and involves weapons of opportunity; events of violence involved little precipitating

factors; both victim and perpetrator were living with a relationship of violence; emotional abuse, distress over disruption of retirement

plans, and financial issues caused by pending divorce; perpetrator has relationship with new partner; financial factors; continued cohabitation

after intention for separation.

29

10+ factors

56%

7-9 factors

22%

4-6 factors

11%

1-3 Factors

11%

30

In the case reviews of domestic violence deaths in the year 2002, we looked at three

major subject areas of potential intervention. One of the subject areas addressed

increasing awareness of and education about domestic violence. In every case that was

examined, family members, friends, neighbours, and/or professionals had some

knowledge of the escalating circumstances between the perpetrators and victims. Some

did not recognize the warning signs, nor did they act upon them. Many of 2002–2004

cases showed the continuing need to target culturally competent public awareness and

education

It has been proven that community alliances are critical to optimal success. In many

communities, support for awareness and education on domestic violence initiatives has

been received from community-based violence against women (VAW) services, police,

victim services, family and children counselling services, and the private sector working

together as a team.

There appears to be increasing public awareness of and professional training about

domestic violence. However, the cases we reviewed this year highlight the need to

expand this awareness and make the links to appropriate action. In many of the cases we

reviewed, the indicators for domestic violence were present and even recognized, but

there seemed to be a lack of any referrals and/or interventions focussing on safety for

victims and treatment for perpetrators. In short, people know how to recognize the

occurrence of domestic violence but do not know what to do upon this discovery. Public

awareness campaigns need to emphasize steps that may be taken such as where/who to

call (Assaulted Women’s Helpline—a Provincial crisis line available 24 hours a day,

seven days a week—or distress centres) when they think there may be a domestic-related

crisis brewing. Ideally, the process of raising awareness should be embedded in the

public education system so students learn about these issues early in their lives before

their transition to adulthood.

In most cases we reviewed, there were at least seven or more risk factors associated with

potentially lethal violence. It is important to understand that domestic violence occurs

along a continuum. This continuum includes minor and isolated incidents, progressing to

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an overall pattern of behaviour over time within the relationship. This overall pattern of

behaviour suggests a high likelihood of repeat violence, dangerous behaviour, and even

the potential for life-threatening harm. Throughout our case reviews, we again found

multiple opportunities for intervention by friends and family, by front-line professionals

such as family doctors, and by more specialized domestic violence services such as police

and shelters for abused women. When properly done, risk assessments offer a number of

benefits to the victims, as well as inform victims of the potential danger they are in. The

assessment process also gives the assessor an opportunity to provide victims with direct

services or referrals to services available that promote safety and help reduce the risk.

Victims of domestic violence need information about risk factors for lethality and what to

do about them. In one case of attempted homicide–suicide, the surviving victim

suggested that she and other victims needed to have more information about what kind of

the services are available; she had no idea what was available. In another case, the

surviving spouse of an attempted homicide–suicide seemed totally overwhelmed and felt

like she was basically on her own due to her lack of knowledge and trust in the system.

She advised that the perpetrator had caused such fear in her life that, even after he was

gone, she still felt his controlling influence. These cases also help illustrate that waiting

for decisions by the justice system, whether during family, criminal, or child protection

proceedings, can leave some victims vulnerable, unprotected, and without support

throughout the process due to lack of information about how to access services.

In a number of cases, we observed that professionals might have in fact minimized the

danger victims were in because they focused exclusively on other factors, such as mental

health and alcoholism issues involving the victims and perpetrators. Problems in other

areas of adjustment may escalate the risk offenders present and magnify the vulnerability

of individual victims.

Individuals in the workplace have a unique opportunity to observe the impact of domestic

violence on victims, or to observe the perpetrator’s disconcerting behaviour. Both

employers and co-workers have a potential role and responsibility to provide support and

either seek out or help activate appropriate community interventions. In the same manner

in which a workplace culture can foster caring through resources such as employee

assistance programs that tend to focus on mental health and alcohol-related problems,

domestic violence needs to be recognized as a significant issue requiring intervention.

In one of our cases, there were many warning signs of an employee’s escalating distress

in the context of a known prior mental health diagnosis that might have led co-workers

and supervisors to intervene. In response to high-risk cases, friends, neighbours, family,

and co-workers have an essential role to play as part of a wider community coordinated

response. We do not intend to place an extraordinary responsibility on individual citizens,

but hope that an enhanced awareness on the part of the public will be joined by a growing

sensitivity on the part of professionals and community agencies in activating an

appropriate response to the domestic violence in the lives of their family members,

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friends, neighbours, fellow co-workers, and employees.

All public education recommendations include the fact that any domestic violence

training must be done within an integrated anti-oppression framework, which is inclusive

of race, class, ability, sexual orientation, age, and religion.

violence against women and child welfare sectors must work together in situations

where there is violence against women. It also ensures that perpetrators are held

accountable to the fullest extent possible within the parameters of each sector’s

mandate.

the most effective ways to intervene in domestic violence cases. Currently,

assessment focuses primarily on the mother’s ability to protect her children. There is

minimal focus, if any, on intervening directly with the offender on risk reduction and

containment, and assessing if access should be permitted, particularly if the abuser

remains untreated.

violence issues, including the risk factors for potential lethality, should be provided to

Family Court judges so they have the necessary information prior to making decisions

regarding custody and access to children.

welfare sector to ensure that best practices and standards of care for interventions are

maintained.

level in acting to locate, interview, and assess abusers to safely intervene in ways that

enhance the safety of mothers and children and to hold abusers accountable.

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level in interviewing women at risk and how to connect them to support systems in

the community to enhance the safety of mothers and children.

In all the cases we reviewed involving children, the child welfare sector was involved and

had a key role to play in assessing risk to mothers and their children. Opportunities

existed to provide safety planning for both mothers and their children, make referrals to

supportive violence against women services (VAW), help decrease their isolation, and

respond to their ongoing need for assistance and protection, particularly when faced with

custody and access issues. As a result of its role and mandate, the child welfare and

protection sector is in a unique position to assess the dangerousness of the abuser. In

addition, this sector can also make recommendations to the court systems regarding

decisions related to access to children and appropriate interventions with the abuser

related to risk management, parenting capacity, and accountability.

In the cases involving children, a number of risk factors associated with the perpetrators

were clearly present, including histories of past violence, criminal convictions

accompanied with numerous breaches of court orders, addictions, separation, custody and

access disputes, and ongoing harassment and stalking of mothers and their children. In

two tragic cases where young children were killed, no attempt was made to assess the

potential lethality risk of untreated abusers fighting for access to their children as a way

of continuing to exert control over the mothers of the children. Without the appropriate

assessment and characterization of the perpetrator’s behaviour, the mothers and their

children were exposed to the risk of escalating violence and ultimately the deaths of the

children. The murders of the children were a way for the perpetrator to punish the

mothers. In one case where child welfare was involved, we heard that the abused mother

was reluctant to reveal her fears to the CAS due to her belief that they would remove her

child from her care. In another case, the mother did not see the child welfare worker as a

potential ally in seeking safety and assistance. In a candid revelation to the committee,

Family law lawyers are well placed to recognize domestic violence and the escalating

risks in a couple’s separation. In our review of cases in the past two years, separation and

a prior history of domestic violence are significant risk factors for women and children

8 See also recommendations no. 23 to 26 below regarding child-related issues and domestic violence.

34

facing death at the hands of the intimate partner. Lawyers often see victims and

perpetrators in crisis, and have a unique opportunity to intervene to make appropriate

referrals and develop plans to enhance safety where there is conflict over child custody,

support, and possession of the matrimonial property. This type of representation is among

the most important that a lawyer can provide: it can save lives.

There is no family law case more complicated than a case in which safety issues are

present and the abuser uses the legal system to continue to harm and harass. These cases

are both challenging and time-consuming. Family law lawyers would benefit from the

opportunity to receive specialized training in the dynamics of domestic violence and

assistance in identifying risk indicators that might lead to lethal violence. This specialized

knowledge would guide them in seeking appropriate assessments. Trying to have clients

benefit from community counselling programs and promoting safe access through

supervised visitation programs are essential strategies. We reviewed two cases where

toddlers were killed in an apparent attempt to punish the victim for leaving an abusive

relationship. In retrospect, more information should have been available to the court to

help identify the level of risk that these toddlers and their mothers faced. In one case,

advice was given—as it often is—that the victim should remain in possession of the

home to protect property rights prior to actual separation. However, there was no clear

understanding of the risk factors present. If these factors had been recognized, it might

The criminal justice system is concerned with the safety of the alleged victim in cases of

domestic violence. We have seen that when there is a combination of actual or pending

separation, child custody disputes, and a prior history of domestic violence, it can be a

dangerous time requiring special vigilance by the police. In one of our case reviews, a

perpetrator with a prior history of violence and breaching court orders did not return the

child to a supervised access centre at the specified time. At the time, the police did not

perceive it to be a high-risk situation, and no immediate action was taken. The perpetrator

murdered the child.

www.womanabuseprevention.com

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When responding to domestic violence calls, it is critical for police to be aware of the

indicators of dangerousness. Police training should include an understanding that

domestic violence is a process and not a single event. Accordingly, when high-risk

indicators are present, a case management protocol needs to be put into effect to ensure

there is ongoing monitoring and supervision. Breaches of bail need to be dealt with

swiftly. As discussed in our risk assessment subcommittee section, optimally a case

manager should be responsible for the safety of the victim by receiving ongoing

information about the behaviour of the accused while on bail. Police should also receive

training on understanding family law restraining orders and their enforcement.

The committee has reviewed a number of cases where family or members of small

communities were well aware of threatening or abusive conduct, but failed to act upon it

in an effective way. In one instance, members of the community were said to be

figuratively wagering on which of the partners in the relationship would kill the other

first. The committee considered a number of possible reasons for this reluctance to act,

including: fear of the perpetrator; social or familial consequences in getting involved;

cultural barriers (e.g., being ostracized from their families and community); inability to

recognize the conduct as a serious indicator of risk for escalating violence; and the fact

that some victims minimized the conduct and did not want third parties involved.

Whatever the basis, this culture of silence is a barrier to violence being reported, the

victim getting necessary help, and the creation of a safer environment for all parties.

Unfortunately, in some respects, it harkens back to another time when domestic violence

was considered a private matter.

In three of the cases, the perpetrators were seen by their physicians or another counsellor

for mental health concerns, but there was no evidence or documentation of risk

assessments having been done. Subsequently, these perpetrators went on to commit

homicide. Consideration should be give to including education about the dynamics of

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domestic violence and the potential for lethality and its assessment in the undergraduate

and postgraduate curricula for medical students and students of other healthcare

professions. Similar information could also be incorporated into continuing medical

education and professional development for other healthcare professionals.

In two of the cases reviewed by the committee, the victim’s and perpetrator’s alcoholism

presented a barrier to their ability to access services. The service providers had difficulty

recognizing that domestic violence was occurring. As a result, the professionals the

victims and perpetrators came into contact with missed opportunities for intervention in

both cases. In one case, repeated physical injuries to the eventual homicide victim were

written off as having occurred as a result of alcoholism and not as a result of domestic

violence since the victim did not complain about the perpetrator.

Police service managers, supervisors, and police officers should receive training to

recognize the link between the potential for self harm and harm to others associated with

access to firearms. This is especially true when an officer experiences significant jobrelated

and life stressors. Further, once it is recognized that an officer is in a potentially

vulnerable position, the organization should ensure the officer is treated respectfully and

in a non-discriminatory way to enable him or her to continue to be a productive and

valuable employee. The fear of job loss or recrimination from the reporting or

acknowledgment of personal strife has to be eliminated for it to be disclosed and acted on

appropriately.

37

Supervised control of issue firearms includes but should not be limited to having the

officer complete a sign-out sheet identifying the reason the firearm is being removed

from its secure location, and a record of the supervisor’s approval of its removal. An

example would include when an officer requires his or her firearm for a non-scheduled

task (e.g., off-duty training and firearm practice). It is acknowledged that it would be

impractical to require all police officers, depending on their duty assignments, to lodge

their issue firearms in a supervised control access location, however this should be

considered the exception rather than the rule.

In one case reviewed by the committee, a police officer who was required to lodge his

firearm in his locker at his police division retrieved it, along with ammunition, without

explanation when off-duty. He used it shortly afterwards to kill his wife and himself.

The committee has examined several tragic cases involving perpetrators with a number of

pre-existing risk factors who had been released on bail and who subsequently killed their

spouse or child. In the circumstances of court proceedings, unless there is an appeal or

review and superior court direction, the opportunity to benefit from post-event analysis is

lost. There are no appeals from these cases. The lessons that these cases can offer must

not be lost. It is common practice for physicians and others to re-examine their cases to

learn whether improvements can be made in how the case was treated. While every case

will be determined on the evidence and the circumstances particular to it, these are the

kind of cases that should be used by all involved to ascertain the lessons they may learn

to help avoid future tragedies.

As the concept of risk assessment becomes better understood, it is important for

community professionals to recognize that these assessments are not limited to use by

professionals involved in the justice system. Every sector, including the healthcare sector,

needs to use these tools when clients reveal domestic violence in their lives. Healthcare

providers in hospital and community settings are well placed to gather critical

information after victims or perpetrators present physical injuries or mental distress as

symptoms. The nature and history of domestic violence, as well as precipitating crises

such as separation and custody disputes, need to be thoroughly explored. Without a risk

assessment framework, information gathered might not be seen in the serious light in

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which it should be understood.

In one particular homicide–suicide case, the perpetrator was given a series of tests by a

physician/psychotherapist to take home to complete. It was not until after the homicide–

suicide that police obtained the results as part of the coroner’s investigation. As a matter

of practice, the committee recommends that when such tests and risk assessment tools are

used, they should be administered and completed in the presence of the healthcare

provider.

A woman in need of assistance and protection should only have to make one call to

access the shelter system. Shelters provide key services in response to women and

children seeking safety from abusers. In one of the cases reviewed, the victim who

disclosed indictors of high risk—including death threats, the abuser having been recently

released from jail, and threats to take her child—sought assistance from a shelter and was

advised space was not available. She was directed to contact other shelters. It was also

suggested that she contact other services on her own. She was advised that if she had

concerns for her child’s safety, she should contact the local Children’s Aid Society. It

was reported that she declined out of fear that CAS might remove her child. In another

case, a shelter assessed a victim as being in a low to moderate risk situation without

supporting documentation. It would be helpful to have a standardized province-wide risk

assessment process for shelter intake.

In another complex situation that involved a number of barriers—including geographic

isolation, cultural factors, addictions, and absence of batterer intervention programs—a

woman, who was both a victim and herself a perpetrator of violence, sought and received

her greatest support from the local shelter even though the workers were fearful of her. In

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this case, it was said that members of the community expected one of the partners to

eventually kill the other as a result of their continuous history of significant violence

toward one another. Given the trust the woman held for them, the shelter appeared to

have been in the best position to manage the case and take the lead in a case conference

to implement an effective community response. However, the shelter lacked the proper

resources or other local services to do so. A local case coordination of services and

support process might have made the necessary difference to avoid the anticipated death

of one of the partners in this case.

attempt to gather information and identify situations where the likelihood of further

violence is of concern, it would appear that very little is being done to clearly identify

high-risk cases that require additional monitoring. The police are obliged to record

mean and what qualifies as a high-risk case. Our committee has recommended that

form. This form captures the victim’s detailed responses to specific questions. The

information gathered can then be used at a bail hearing, and can be used to source other

potential lethality.

A number of cases reviewed over the past year were involved in the criminal justice

system. Some of these cases involved accused persons who had been released on bail

with conditions. It would appear that none of these cases were red-flagged for immediate

intervention and management. As the case was never identified as a high-risk case, and

even though there were ongoing breaches of bail and an escalation of dangerous

behaviours, no monitoring or management of the case took place. A proper risk

assessment is necessary to identify a high-risk case. Once identified, it should trigger a

high-risk case management response. The risk assessment process also has a number of

benefits to victims. One benefit is that victims will be informed about the potential

danger they may be in. Another benefit is that victims can then be made aware of a

number of appropriate services available to assist them.

Several reviewed cases involving the criminal justice system were not identified as highrisk

cases and no high-risk monitoring or management ever took place. In some of these

cases, police services had the grounds to arrest an offender for breach of conditions but

40

failed to do so at the first opportunity. Instead, they chose to allow the offender to

voluntarily turn himself in to police. During the resulting delay, the offender

demonstrated lethality.

Where the offender is living outside the jurisdiction where the precipitating offence took

place, the original investigating police service must ensure that the police service in the

jurisdiction where the offender is living is advised of the circumstances of the case,

conditions of bail, and degree of risk. A high-risk case management unit will ensure this

is done expeditiously. In this way, there can be oversight and continuity with respect to

the ongoing monitoring and management of the high-risk case.

The Model Police Response to Domestic Violence is the minimum standard for police in

Ontario. It does not specifically address the management of "high-risk" domestic

violence cases. While there exists a guideline for Police Response to High-Risk

Individuals, this guideline is not specific to domestic violence cases. Although some of

the investigative techniques outlined in this document could be used in domestic violence

cases, it does not address the unique management requirements of a high-risk domestic

violence case.

In one case, the victim was on the phone with 911 when the offender arrived at her place

of residence. The responding police were rapidly dispatched, arriving within minutes of

the call, and arriving at the residence just as the perpetrator entered the residence to kill

the caller and himself. The committee had the opportunity to review the call, which

revealed a very quick development of events. There is no indication that anything could

or should have been done during the call that would have effected a different outcome.

However, based on the case, the committee determined that a template consisting of a

series of questions specifically for domestic violence calls, much like the templates used

in medical emergency calls, would help to fully assess the nature of the emergency and

provide valuable information to the responding police officers. The Domestic Violence

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A template or guideline would assist the call-taker to accomplish this goal. It is also noted

that 911 calls are frequently used as evidence in domestic violence prosecutions, and the

information obtained during the call may be of value in that process as well.

One of the issues that arose in a number of cases that gave the committee cause for

concern involved sureties and their role in the release of perpetrators who later murdered

their partner or their child and take their own lives. Several of the cases reviewed

identified weaknesses in the screening process of sureties who act in support of bail

applications. It was apparent that the sureties in these cases were inappropriate due to

having criminal records, being unable to exercise control over the accused, failing to

contact the police when the accused failed to comply with conditions, and lacking

understanding of the consequences of failing to meet the obligation of being a surety. In

one particularly tragic case, the surety was a party to the breach that led to the homicide.

In fact, after leaving court following the granting of bail, the surety drove the accused

directly to the home of the victim. The accused shot his wife in the presence of their

daughter and then took his own life in the same manner. In another case, the surety was

the father of the perpetrator’s wife. He provided a false name, as he believed he would

not be approved as the father of the victim. The accused was released on bail and later

murdered the surety’s grandson.

The committee observed that in a number of cases where bail releases occurred in highrisk

circumstances, sureties might have made a difference in preserving the lives of the

victims had they acted in compliance with their obligations to report breaches. There

were instances of sureties being aware of non-contact breaches with the victim, but they

did not report the breach or seek to revoke their surety. In one case, a son-in-law and

daughter of the perpetrator who acted as sureties failed to report the perpetrator’s noncontact

breaches or not residing where he was required out of fear of hurting their father

or causing him to be incarcerated. In another instance, the surety—who had a criminal

record and with whom the perpetrator was to reside—drove the perpetrator on his release

directly to the home of the victim. In both cases, the perpetrators killed their partners

within days of the violations. In another case, a person who posed as another person was

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approved as a surety without identification.

As an example, consideration should be given to requiring potential sureties to watch an

educational videotape detailing their obligations and responsibilities before they are

approved as sureties in cases of alleged domestic violence. The video should also include

information about risk factors the surety should be aware of.

It is not uncommon for parties who are separating to seek a restraining order in the family

court. Such orders usually provide that the respondent be restrained from contacting the

applicant, visiting the residence, or harassing the applicant. These orders also deal with

custody and access conditions. Many domestic violence victims are not involved in the

criminal justice system, but may be involved in Family Court about child custody or

seeking protection by application for a restraining order. Concerns have been expressed

that civil orders from the Family Court are not taken as seriously and may not be

enforced by the police. As an example, in one case we reviewed, the accused had been

breaching his conditions on his restraining order for several months. These breaches had

been reported to the police, but no action had been taken. The order in this case had not

been entered into CPIC (Canadian Police Information Centre) prior to the homicide.

In one case we reviewed, an accused person had been convicted of assault and was not

ordered to attend a PAR program. Current provincial policy with regards to the operation

of the Specialized Domestic Violence Courts requires that convicted offenders be

directed into PAR programs as a part of their sentence. These are important socioeducational

programs that can help increase victim safety by: 1) intervening with the

offender; 2) providing education for the offender; 3) monitoring the offender on an

ongoing basis; and 4) ensuring contact with the partner.

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Currently, half of the states in the U.S. have a legislated rebuttable presumption against a

domestic violence perpetrator having custody or joint custody of children, which should

be considered in Ontario.

Although professionals and the general public are beginning to understand the impact of

domestic violence on children, there appears to be an inconsistent application of this

knowledge in the assessment and intervention strategies we reviewed. We understand that

some children who are exposed to domestic violence may suffer serious emotional harm

that may be comparable to children who are abused directly. These children may be

exposed to inappropriate role models in their families, and be impacted in their

development of future trust relationships. The potential harms that result have been

documented in both short-term and long-term consequences.

In the area of domestic homicides, children may witness extreme violence and death.

U.S. and Canadian studies suggest as many as one-quarter of homicides have children

present. Children are also in danger of becoming homicide victims themselves as the

perpetrator may kill children as part of an overall homicide–suicide plan, or kill children

to punish their estranged partner for leaving the adult relationship. We reviewed two such

cases in 2004, where a toddler’s homicide was a direct act of revenge for a woman

seeking to end an abusive relationship. Both of these tragic circumstances reflect the lack

of clarity in law and practice on how to intervene with children exposed to domestic

violence.

One area that needs to be addressed is the role of the Children’s Aid Society (CAS). In

responding to domestic violence calls involving children, current practice by police in

Ontario involves sending a copy of the occurrence report to the CAS for their

investigation. The CAS intervention varies, depending on a number of issues such as

local practice and protocols as well as the nature of the circumstances. A common

circumstance in potentially lethal cases is parental separation. The CAS worker has to

decide whether this is a case that requires their protection and/or counselling mandate, or

whether the case can be managed in the private custody and access sector involving other

resources such as family law specialists, supervised access centres, mediators, and

custody evaluators. The CAS decision also happens in a context of not wanting an abused

spouse to feel re-victimized by the intervention (e.g., You’re an abuse victim but also a

bad parent for letting your child live with this violence). Without assigning blame in the

44

cases we reviewed, it appeared that the CAS workers were well-intentioned in their

contact with the abuse victim, but failed to assess the perpetrator, support safety planning

or risk reduction, or coordinate their efforts with other professionals.

Some confusion exists in the field regarding roles and responsibilities in dealing with

children in the context of domestic violence. The criminal court properly assumes

innocence until the allegations are proven beyond a reasonable doubt. The process of

preliminary hearings and trials may take many months, and in some cases may take years.

However, the victim and children may need an immediate safety plan that either suspends

contact with the perpetrator or requires supervised visits or exchanges between the

parents. The challenge to the court system and community services is how to manage

such a plan and respect the presumption of innocence. The Family Court can make

interim findings on the balance of probabilities if proper evidence is presented. Some

scepticism is usually found within the courts when one parent raises allegations of abuse

against the other parent and tries to limit contact, since the system depends on friendly

and cooperative parents willing to put the past behind them in the best interests of the

children. This approach is counter-intuitive for a domestic violence victim who is seeking

safety and an end to the violence. The CAS may also be sceptical that they are being

drawn into a private family law dispute with allegations being made by separating

parents.

The cases we reviewed illustrate many of the points outlined above. Access was offered

in cases where there should have been none, or where there should at least have been

strictly supervised visits. The criminal court and family court did not coordinate their

services or interventions. It was unclear whether the CAS should intervene or leave

matters to private child custody proceedings. The CAS appeared to focus on the basic

care of the children rather than the danger the perpetrator continued to present. There

were no systematic approaches to risk assessment and risk reduction. Violations of court

orders were ignored or seen as low priority in the face of a disconcerting pattern of

behaviour that could have been readily identified at the time. There seemed to be a lack

of any comprehensive assessment that addressed the risks that the victim and her children

faced in the context of domestic violence. Ultimately, it was unclear who was in charge

of the case and who was accountable.

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An effective response to domestic violence requires not only well-informed individual

interventions, but also coordination of services by different professionals involved with

family members. Previous research on intervention strategies with perpetrators of

domestic violence has reinforced the notion that the "system matters" and successful

outcomes are more likely with the justice system and community services working

different individuals had had an opportunity to put risk factors together as pieces of the

same puzzle, rather than appearing to be isolated and unconnected incidents. At the same

time, in retrospect, interventions by individual professionals lacked the effectiveness that

might have been achieved with genuine collaboration.

Several of the 2004 cases highlighted the need for ready access to critical information,

such as having restraining orders placed in a timely fashion on CPIC (Canadian Police

Information Centre) to help subsequent police interveners recognize a potential red-flag

situation. Several cases we reviewed suggest the importance of coordination of

information and interventions within family and criminal law proceedings. Families in

which domestic violence occurs may find themselves in three different streams of court

proceeding: criminal, child custody, and child protection hearings. There is considerable

confusion about the roles and responsibilities of the latter two systems regarding when

domestic violence is an issue for state intervention (e.g., the CAS on behalf of provincial

child protection legislation) versus an issue for parents to settle privately through

provincial laws for custody and access post-separation. There appears to be no formal

mechanisms in place to foster communication between the family court and criminal

court in coordinating issues around child custody and safety of individual family

members. These cases raise the importance of understanding the special circumstances

surrounding children exposed to domestic violence and the fundamental relationship

between victim and children’s safety.

Publications.

46

In one of the cases, the mother of a missing child had to physically go to the police

station and beg the police to start an investigation. It was reported that the officer that

spoke to the mother responded in a frustrated and confused manner and seemed unsure of

The investigating officer from a large urban police service advised the committee that his

jurisdiction had a large number of domestic violence cases, at least five reports per shift,

and the officers felt frustrated because they did not have adequate personnel to respond

effectively.

In reviewing the cases of the past year, it became apparent that the accessibility and

availability of domestic violence services for people residing in rural and remote northern

communities is gravely lacking in comparison to domestic violence services available in

the more populated southern communities. Resources should be made available to

develop domestic violence services that are culturally specific and appropriate for the

population served. Services should be delivered to the community where domestic

violence services are needed, and/or the people requiring domestic violence services

should be provided with transportation to areas where such services can be accessed.

The committee has made a number of recommendations identifying a need for resources

for training within child welfare and protection agencies. In addition, other agencies in a

position to provide valuable assistance to the courts when these courts are called to render

decisions require resources and training to help them administer appropriate assessment

tools and techniques. Four of the nine cases reviewed by the committee involve parents

who were engaged in custody and access disputes. In two instances children were

murdered, and in one of those cases and in a number of the other cases children also

became surviving victims of domestic violence who suffered the loss of a parent and/or a

sibling.

47

In recognition of the recommendations made in earlier inquests and issues arising from

the case reviews about the need for appropriate risk assessment tools to help identify the

potential lethality of a situation, the DVDRC created a subcommittee to survey existing

and proposed risk assessment instruments. In the last report of the DVDRC, we reported

gathered through a series of focused questions would be useful, not only for assessing the

level of risk and danger that the victim may be exposed to, but it also has potential

evidentiary value for those engaged in the criminal justice system. Further, it could be

useful for those trying to help the victim develop a safety plan. It is intended that the form

be modified to suit the needs of the agency or organization using it. The subcommittee is

As a result of the case reviews this year, the subcommittee observed there is a lack of

coordination and follow-up of domestic violence cases, as well as a lack of continuing

vigilance—particularly in the justice system—pending completion of the case. When

serious injury or death occurs, the unacceptable but common response is that the case fell

through the cracks. Unfortunately, a number of the tragic cases that result in fatalities

occur when the perpetrator is subject to a bail order or the victim has obtained a

restraining order. As a result, the focus of attention of the subcommittee this year has

been on the need for a process to provide some measure of safety to victims: a process

that would help limit the risk.

This chapter describes a basic case management framework, as well as a preliminary

examination of a number of different approaches that have been used by some

communities in an effort to manage high-risk cases. The following does not purport to

recommend any particular approach. Over the next year, we intend to conduct a more

extensive survey of approaches from a number of jurisdictions to determine the best

practices in the area. On the basis of that survey, our committee hopes to develop a more

comprehensive manual on how high-risk cases could be managed.

Once a high-risk case has been identified, it is critical that there be a process to actively

manage the case to minimize risk of future violence. In recent years, advances have been

made to help determine which cases qualify as high-risk cases. Since high-risk cases are

situational, it is imperative that a management plan be implemented immediately to

positively intervene to prevent lethal violence taking place. In many domestic homicide

cases reviewed by our committee, numerous pre-incident indicators were present that

signalled imminent harm to the victim. Unfortunately, these indicators were neither

48

understood nor acted upon to trigger a management response.

Victims play a critical role in the identification of high-risk cases and in the management

of those cases. Many victims experience fear intuitively and have a clear understanding

of what their partner is capable of doing. Some victims may be complacent to the

imminent danger they are in, but may provide an excellent source of information for

others to act upon. Whatever the situation, to effectively manage a high-risk case, it is

necessary to determine what harm may befall the victim. Accordingly, victims should be

interviewed as soon as possible and, in some cases, immediately. Our committee has

interviewing process.

Typically, a victim is first asked about biographical details and then is asked about the

form. The form is then available for use before a decision to release is made by the police

or by the Crown. The document would also be available for bail court. It is recommended

that the entire interview be videotaped, under oath, to preserve the evidence. This is

especially desirable should the victim later decide to recant. There have been a number of

cases where victims had been thoroughly interviewed on videotape, disclosing clear and

imminent danger to their lives, and yet law enforcement and the prosecution never

viewed these videotapes or never used the information from them to develop a

management plan. Tragically, many of these cases resulted in lethal violence that could

have been prevented. It is therefore imperative that any model designed to manage highrisk

cases must focus on the victim and must include information on risk that the victim

has disclosed.

Most communities without formal case management models attempt to manage cases

through the use of bail. Ideally, once a case is identified as high-risk, a thorough and

complete bail brief is prepared to support an effort by the prosecution to seek a detention

order. Keeping an accused person in custody is one way to prevent a domestic homicide.

The reality is that few cases result in detention orders, and many cases result in the

release of the accused into the community. This may occur should the police wish to

exercise their discretion to release a person on conditions by way of an undertaking.

If an accused person is held in custody for a bail hearing, the Crown may consent to the

person’s release with conditions. Should a bail hearing actually take place, a judicial

officer may release a person with conditions. Whatever the case, if an accused person is

released, there should be stringent bail conditions and the need for a surety. The

49

following conditions should be considered:

Our committee is of the view that sureties should play a greater role in the management

of accused persons in the community. When a person is on bail with a surety, the role of a

surety has been likened to that of a keeper of a detention centre. A surety is responsible to

ensure that there is compliance with all bail conditions. Sureties are under an obligation

to call the police in the event of non-compliance or apply to the court to be released as a

surety.

It is important that sureties be reliable and responsible persons. Not only is it important

for sureties to pledge valuable security as part of a bail release, but sureties should also

have a clear understanding of their role to help ensure that alleged victims will be safe

from harm. In this regard, sureties should be required to learn about lethality indicators,

which may precede a lethal act. They should be educated on what they need to do should

they recognize danger signs. They should have available a telephone number that they

can call so immediate action might be taken by the authorities. It is recommended that the

potential surety be obligated to watch an educational videotape dealing directly with

dangerousness in domestic violence cases.

Regardless of whether a formal case management model is in place, it is recommended

that police agencies undertake some basic management techniques to safeguard victims.

All victims of domestic violence should be promptly notified of bail conditions and a

safety plan should be undertaken. In some cases, it is also important to notify the victim’s

50

family, work, and the schools of any children. The victim should be warned to be wary of

individuals acting on behalf of the accused. Ground rules should be established with the

victim so that the victim contacts the police for even what may appear to be insignificant

events such as hang up calls, drive-bys, and disturbances to the outside or inside of the

house. The victim should be asked to maintain a log of any suspicious events.

The police should ensure that all conditions of bails are entered on CPIC (Canadian

Police Information Centre) record system. As well, any Family Court restraining orders

should be entered on CPIC. In appropriate cases, the police should undertake physical

and electronic surveillance. They should have regular contact with the victim. They

should consult with their Threat Assessment Unit or other experts, such as the Behaviour

Sciences Unit of the Ontario Provincial Police. There should be a system whereby one

officer is responsible for the high-risk case. That officer should be notified of any

incidents involving the accused or the victim reported to other officers. This would

ensure that the case manager is aware of any developments and takes appropriate action.

In Huron County, the Ontario Provincial Police has undertaken an innovative service

delivery model in an effort to deal with high-risk cases. There are four platoons

responsible for policing in the county. One officer per platoon has been designated an

Abuse Issues Resource Officer. That officer has received training in criminal

investigation, child interviewing, sexual assault, and domestic violence. Each Abuse

Issues Resource Officer is responsible for assisting in the investigation and monitoring of

cases of domestic violence that occur while their platoon is working. A platoon consists

of twelve officers. Each Abuse Issues Resource Officer ensures that proper investigative

procedures are followed, proper bail conditions are applied for, and that there is general

quality control. The goal is to deliver a more seamless police response to domestic

violence. With respect to high-risk cases, the Abuse Issues Resource Officer would have

carriage of the case. These officers are to be notified of any incidents involving the

accused or victim by way of SIP (Special Interest Person) entries on CPIC, the

Occurrence Report Management System, and by email.

It is recommended that perhaps the most effective way to manage high-risk domestic

violence cases is to have a team approach. Some communities have established dedicated

teams within their police departments who specifically manage high-risk domestic

violence cases. These dedicated teams consult and work with community-based agencies.

Other communities have established a coordinated approach involving a number of

agencies to manage high-risk cases. The subcommittee is in the process of reviewing

responses from police agencies across Ontario concerning any domestic violence highrisk

case management protocol that may exist. Once all responses have been received, a

detailed analysis of best practices will be compiled and reported on. Until this process is

51

complete, it may be useful to outline a number of domestic violence high-risk case

management models that have been implemented in large and small jurisdictions.

INVEST was established in Jacksonville, Florida, to identify and intervene in the most

potentially lethal domestic violence cases. The team is comprised of two police officers

and two social workers. All domestic violence police reports and referrals from other

agencies are reviewed and assessed for potential lethality. Advocates and sheriff’s

officers who work together to provide services to victims and perpetrators follow up

cases identified as high-risk for lethality. INVEST clients receive intense case

DVERT was established in Colorado Springs, Colorado, to ensure the safety of high-risk

lethality victims. DVERT relies on a multi-level, multi-disciplinary case management

approach. The team consists of criminal justice officials, non-profit organizations, victim

advocates, and city and county human service agencies. DVERT involves efforts to

establish communication among criminal justice and social service agencies to establish

advocacy services to meet victim’s needs, and to implement policies aimed toward more

aggressive apprehension and sanctioning of offenders. The DVERT program focuses on

three levels of domestic violence situations:

danger

DVERT uses an intake team, an assessment team, and an ongoing contact team. For more

During the latter part of 2003, the Victim Services Branch and the Family Violence

Resource Unit of the Hamilton Police Service recognized the need to identify and

manage high-risk domestic violence cases. The High Risk Domestic Violence

Operational Team and the Community Advisory Team of the Hamilton Police Service

were developed as a result.

The High Risk Operational Team is comprised of two detectives from the Family

Violence Resource Unit, the coordinator and administrator from the Victim Services

Branch, and a detective from the Bail Pilot Project at the courthouse. The team meets

52

each Tuesday to determine which cases will be considered high risk and how to manage

them with action-oriented plans (e.g., contacting probation to ensure intensive

supervision; discuss surveillance regarding High Risk Wanted Offenders; prepare threat

assessments background information to be forwarded to the O.P.P.; safety planning). The

team reports to the Investigative Services Division inspector. The High Risk Operational

Team has been meeting weekly since the spring of 2004.

The Community Advisory Team was introduced in October 2004 (on a pilot basis).

Members of a number of agencies were invited to attend to represent both victim- and

offender-based programs (e.g., CAS, corrections, VWAP, probation, Canadian Mental

Health, men’s anti-violence, women’s shelter, etc.). The team is still in the development

stage as individual agencies are finalizing their decisions to participate. Participants are

required to sign a Memorandum of Understanding. Once the team members are finalized,

they will participate in the review all high-risk cases and help develop an approach to

dealing with high-risk offenders and victims of domestic violence.

HART was established in December 2002. The team consists of the Domestic Violence

Assistant Crown Attorney, the manager of the Victim Witness Program, and a police

officer who is the Domestic Violence Coordinator. Only cases where criminal charges

have been laid are referred to the team. The team meets by teleconference every second

Tuesday. The Victim Witness Program manager is the coordinator and maintains the list

of cases. Any agency working with the victim may suggest a review. A review may lead

to follow-up and further investigation.

In 1997, PAST was implemented in Ottawa to promote a coordinated criminal justice

system response to partner assault cases. PAST membership consists of the police, the

victim crisis unit, prosecutors, the Victim Witness Program, regional social services,

CAS, and probation. All team members are responsible for referring high-risk cases for

review and providing information about their involvement in each case review. High-risk

cases are reviewed on a weekly basis. Concerns are identified and action is taken,

including follow-up.

The Ottawa Police Service has a specialized domestic violence unit consisting of fifteen

detectives, four sergeants, and one staff sergeant. All domestic violence incidents are

subject to daily assessment by the unit case manager, with immediate priority to high-

risk files. The Partner Assault Unit participates in weekly meetings with PAST.

53

WACT is a policy development and planning body with a mandate to develop a

case management model recommended for high-risk cases. Over 40 agencies in Toronto

have been trained with this kit. In 2003, WACT formed the High Risk Consult Team to

provide expert consultation to front-line practitioners who are struggling with high-risk

and potentially lethal cases. The team is an inter-disciplinary group of practitioners, all of

whom have extensive experience working with abused women and their families.

Any agency staff person in the community can contact WACT for assistance. A thorough

interview is completed, a high-risk assessment is undertaken, and a review takes place of

what interventions have already been attempted. If the case is complex and high risk, the

case is brought forward to a monthly meeting of the consult team. Cases are presented

without identifiers before the team. While safety planning is important, the team also

focuses on the abuser. The team assists front-line practitioners by providing opportunities

to learn about possible interventions through various sectors. The team shares creative

ways of working with abusers and women victims. The team develops its collective

wisdom as cases are discussed and recommendations for interventions and approaches

HARRT was established in 2004 in Huron County. Membership of HARRT consists of

the Crown Attorney, police, the women’s shelter, CAS, mental health, Victim Witness

Program, and probation. HARRT was created in response to the recognition that many

murder/suicide cases result from the accused being chronically depressed, with little

support and having nothing to live for. HARRT is of the view that in some cases, it may

be extremely helpful to bring together persons from the community in a non-adversarial

setting to help the accused and protect the victim. Any member of HARRT may refer a

case for review. Once a high-risk case is identified, any team member can arrange an ad

hoc conference call.

54

In our second year as a committee, we were able to complete nine comprehensive

reviews of domestic violence homicides. When compared to our previous year, we found

many of the same trends. Most remarkable was the fact that eight out of nine cases

appeared predictable and preventable with the benefit of hindsight and our analysis. The

vast majority of cases had seven or more risk markers that are commonly found in the

literature on assessing lethal domestic violence.

We were able to review four cases that involved the complexity of criminal and family

law proceedings. These cases present a challenge for collaborative efforts to keep victims

and their children safe. Two cases involved fathers killing toddlers to punish their wives

for leaving an abusive relationship. These cases call out for enhanced risk assessment,

safety planning, and risk reduction as outlined in many of our recommendations as well

as Appendix A, the recommendations from our last report. These cases also highlight the

dangers facing children in the context of domestic violence by the direct and indirect

impact of this violence.

The work of our committee has attracted many inquiries from other jurisdictions across

Canada and the United States. The chairperson and other members, have been called on

to present at provincial, national, and international conferences on the findings from our

first annual report. Senior government officials in two provinces have expressed interest

in developing a similar committee in their jurisdiction. Outside observers have

commented on the thoroughness of our review process, made possible by working within

the legislative and operational structure of the Office of the Chief Coroner.

Our committee members have a passion to save lives by learning vital lessons from the

horrific tragedies we review. We believe that the results of our reviews are making a

difference. One of the longest-standing domestic violence death review committees was

founded in 1994 in Santa Clara County, California. There is some evidence of a reduction

in homicides, associated with the committee’s work. In their most recent annual report

entitled "Speak up – Save Lives," they state:

55

It is our hope that the work of the committee and action taken in response will have the

December 31, 2004. San Jose, CA: Author, p. 14.

56

Chief Counsel, Office of the Chief Coroner

Coroner’s Counsel in the May/Iles and Hadley Inquests

Hull, Québèc

Former member of the Aboriginal Circle Against Family Violence

Aboriginal Health Consultant

St. Catharines, Ontario

Regional Supervising Coroner, Niagara Region, Office of the Chief Coroner

Barrie, Ontario

Inspector, Barrie Police Service

Established Barrie Police Service’s Domestic Violence/Sexual Assault Unit.

Authored police procedures on domestic violence, criminal harassment, bail and violent

crime, parental and non-parental abductions, and victim assistance.

57

Peel Region, Ontario

Inspector, Peel Regional Police

Past member of the Peel Committee Against Woman Abuse (PCAWA)

Member of the Solicitor General’s Policing Standards Branch working group that

established new standards for police response to domestic violence and criminal

harassment.

Toronto, Ontario

Executive Director, Woman Abuse Council of Toronto

Member of Ontario Government commissioned Joint Committee on Domestic Violence

London, Ontario

Professor, Faculty of Education, University of Western Ontario

Academic Director, Centre for Research on Violence Against Women & Children

Director Emeritus, Centre for Children & Families in the Justice System of the London

Family Court Clinic

Toronto, Ontario

Managing Director, Adobe Consulting Services

Former Director of Programs & Services, Assaulted Women’s Helpline

58

London, Ontario

Associate Professor, Department of Family Medicine, Victoria Family Medical Centre,

University of Western Ontario

Goderich, Ontario

Crown Attorney, Ministry of the Attorney General.

Co-founded the first Domestic Assault Review Team (DART) in Canada.

Implemented the first questionnaire in Ontario to identify risk and potential lethality for

domestic assault victims.

Helped establish the Huron Assessment Risk Reduction Team (HARRT) in Huron

County.

Toronto, Ontario

Manager (former) with the Victim/Witness Assistance Program

Developed Early Intervention Programme for Young Offenders in dating relationships,

the R.S.V.P. (Relationship Skills in Violence Prevention).

Toronto, Ontario

Deputy Chief Coroner – Inquests

59

Toronto, Ontario

Founding member of the Emily Stowe Shelter for Women

Consultant to Durham Region’s Violence Prevention Co-ordinating Council

and other articles and papers related to violence against women and children.

Barrie, Ontario

Assistant Crown Attorney, Ministry of the Attorney General

Former Domestic Violence Coordinator for Simcoe County Crown Attorney’s office

Member Domestic Assault Review Team (DART)

Assistant Crown Attorney since 1991

Mississauga, Ontario

Executive Director, The Speers Society

The Speers Society is committed to the prevention of youth relationship abuse through

Toronto, Ontario

National Judicial Institute representative

From August 2002–December 2003, served as legal counsel to the Honourable Peter

Cory on an inquiry into six murders that occurred in Northern Ireland.

60

Crown Counsel in the Crown Law Office – Criminal since 1989

Aurora, Ontario

Former Executive Director, Yellow Brick House

London, Ontario

Regional Supervising Coroner, Office of the Chief Coroner, Southwestern Region

61

Chief Coroner of Ontario

Deputy Chief Coroner

62

Executive Officer

Administrative Assistant

63

This report is based on the cases the committee reviewed during meetings in 2003, and

includes all 2002 Ontario domestic violence deaths as defined in the committee’s

mandate, except a significant proportion still before the courts. The following

recommendations are based on the specific cases reviewed in the committee’s first year.

The limited or narrow focus of the recommendations in this report are derived from the

specific case reviews, and should not be seen as diminishing or detracting from the

recommendations or reports of previous inquests in this area.

The recommendations made by the committee fall into three major subject areas of

First, there is a need to heighten awareness and provide education about domestic

violence. In every case review we examined, family members, friends, neighbours, and/or

professionals had some knowledge of the escalating circumstances between the

perpetrators and victims. However, these individuals did not appreciate the significance

of the situation, the information available to them, or what to do about it. Accordingly,

many of the recommendations address the continuing need for targeted public awareness

and professional educational programs that teach about the signs of domestic violence

and the risk factors leading to potentially lethal consequences.

Second, there is a need to have appropriate tools available to those who work with

victims and perpetrators of domestic violence to better assess the potential for lethal

violence in their lives, and corresponding access to appropriate services and programs. As

an example, victims may need assistance with safety planning and perpetrators may need

access to counselling programs or the need of restrictions to control their behaviour to

better manage the risk.

Third, adequate resources are required to ensure victim safety and reduce perpetrator risk.

All programming and services require resources to become operational. These include,

but are not limited to:

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exposed to domestic violence.

These areas for intervention are links in a chain—if one or more is weak or absent, the

chain breaks, and opportunities for prevention are lost. In many of the cases reviewed,

one or more of these links were present, but an adverse outcome was attributable to the

absence of another. For instance, a properly performed risk evaluation is of little value if

the police or others do not use it for safety planning, or the admissible information on

which it is based is not brought before the criminal courts when necessary.

As observed in the verdicts of several inquests and in the Report of the Joint Committee

on Domestic Violence, there is a continuing need to heighten awareness and provide

educational programs that focus on the signs of domestic violence, including the risk

factors that may lead to lethal circumstances. This awareness and these programs should

also focus on the necessary individual and community response by:

leaders, as well as the victims and perpetrators themselves);

course of their work, come into contact with victims, perpetrators, or the children of

domestic violence;

as police officers and healthcare professionals).

We can draw conclusions from our reviews as to whether or not homicides with similar

presenting factors could have been predicted or prevented. In 5 of the 11 cases reviewed,

a domestic homicide would likely have been predicted if similar facts were presented to

professionals knowledgeable about domestic violence. In 6 out of 11 cases, a domestic

homicide would not have been anticipated per se. Nonetheless, in these cases, a tragedy

may have been prevented in similar circumstances by intervening with the stressors being

experienced by individuals or family conditions that ultimately became a factor in the

homicide.

It is troubling to the committee that the inquests and other reports on domestic violence

have seen the need to continue to address this issue. We note that the Ontario Women’s

Directorate and outside agencies have sponsored excellent campaigns, however there is a

need for a more widespread, ongoing and consistent strategy of public education efforts.

In eight of eleven cases reviewed by the committee, family, friends, or neighbours

65

observed indicators of domestic violence in either the victim or perpetrator or both.

Notwithstanding their concerns, they neither recognized the significance of those

indicators, nor did they act upon them. In each case, risk factors were identified on

review. In nearly half of the cases, four to more than ten risk factors were present.

The implementation and use of effective public education programs need to be increased

to heighten awareness of the warning signs of symptomatic abusive behaviour and

appropriate courses of action for victims, perpetrators, and others to take in response. All

too often, domestic violence is only recognized as physical abuse. Emotional abuse also

needs to be recognized, such as jealousy, economic abuse, intimidation, threats,

controlling behaviours, and isolation.

Domestic violence public awareness programs should contain features directed to

increasing awareness that the non-reporting of abuse by victims, or threatening

behaviours of perpetrators, can not only impact their own safety, but the safety of others

close to them. Non-reporting can also impact the safety of others who later enter into

relationships with the abuser. It was noted in one case that as many as three prior victims

resided near the perpetrator, however not all had reported the abusive behaviour. In some

instances, it was not until the aftermath of the domestic violence death that other victims

of abuse divulged information.

In one instance, a divorced spouse suffering from paranoid schizophrenia and alcoholism,

with a history of verbal and physical abuse as well as the obsessive monitoring of his

former spouse’s activities, openly voiced suspicions to his family members about his exwife

poisoning his food. Even though divorced, he continually stayed at his estranged

wife’s home. The family, fairly recent émigrés from an eastern European country

expressed considerable shame about the perpetrator’s mental illness, which appears to

have inhibited them and his estranged wife from reaching out to community services that

66

might have assisted. One evening, after voicing his suspicions to his son, he stabbed his

estranged wife to death and hanged himself.

In one case, the committee noted that the perpetrator demonstrated an unnatural and

obsessive involvement with his daughter that should have been apparent and troubling to

his family and friends. He was also known to put the child at risk when he took her out

with him for extended periods of time, after which he would drive his car in a highly

intoxicated condition. At the point of declared separation by his wife, the perpetrator

killed himself and his daughter.

Training must deal with two issues: the first is recognizing domestic violence in all its

forms—emotional, psychological, and physical—and the second is identifying high-risk

situations that require intensive assessment and immediate intervention strategies. In

several case reviews, the committee observed numerous points of intervention at which

steps could have been taken to respond to the escalation of aggressive and threatening

behaviour. Evidence was present that should have signalled to the professionals that

potential fatal outcomes were possible and/or probable, however there was no apparent

appreciation of the significance of the evidence or application of an assessment to

evaluate its significance and the appropriate action to minimize risk to the victim.

In one instance, a family counsellor who was conducting sessions with both spouses

directly observed the perpetrator’s irrational paranoia and volatility during a session. The

counsellor, however, did not discuss a safety plan with the victim beyond advising her to

contact police if she felt in danger.

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The review included a number of cases where the victims and perpetrators came from

other diverse ethnic or cultural backgrounds, including people of the First Nations.

Religious and spiritual leaders can play an important role in assisting their congregations

to access cultural and community services to help them deal effectively with mental

health and domestic violence issues. In several cases, the perpetrators had direct

involvement with religious or spiritual leaders, having been sought out or referred by

others due to concerns about the deterioration of their relationships with their spouse and

their threatening behaviour. In one instance, the perpetrator threatened to kill himself, and

in another, he threatened to shoot a person he believed was involved with his spouse.

Of all the professional groups that we encountered during the case reviews, the role of the

family doctor was pivotal. In many of the cases, the victims and perpetrators were

involved with family physicians to deal with depression from a variety of stressors

having an impact on their relationships. One case review revealed that both the victim

and perpetrator were patients of one family physician for more than 20 years. While

patient confidentiality is paramount and to be respected, questioning of the patient’s

personal circumstances might have elicited information about the spouse, particularly the

perpetrator in this case, which might have created a clearer picture of the risk for violence

in their lives.

Educational programs should address the following:

relationships about the difficulties they are experiencing in their intimate

relationships. Family physicians need to be aware of how common the problem of

domestic violence is. In addition, family physicians should be able to assess the risk

in their patients’ home environments. If physicians feel they lack the skill or expertise

to make such assessments, they should ensure they know of other healthcare

providers or community agencies to which they can refer these patients.

inappropriate use of alcohol, street drugs, or prescription drugs, should alert

professionals to the strong possibility of repeated violence. In such a situation,

healthcare professionals should inform their patients about the risk of the situation,

and urge these individuals to seek help. Depending on their assessment of the risk and

the apparent impulsivity of the abusive partner, family physicians may need to

consider warning the other partner or informing the police of their concerns about the

possibility of worsening violence.

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suicidal and/or homicidal thoughts, and to consider the risk of the patient acting on

such thoughts. The patient’s depression and/or anxiety may reflect the patient’s

experience of domestic violence, or may increase the likelihood of abuse. In addition,

physicians need to be particularly attentive to the possibility of access to firearms or

other weapons, especially when working in rural communities.

within an intimate or family context and the perpetrators of the same abuse, they must

ensure that the needs of the abused women and the perpetrators are addressed

independently, such that their rights to autonomy, confidentiality, honesty, and

quality of care are maintained. Couple or marital therapy is contraindicated unless the

woman’s safety can be ensured and the man has taken responsibility for his abusive

behaviour.

Educational programs should address the following:

grade 12) to promote building skills and strategies for positive interpersonal

relationships.

of abuse and the potential for violent/abusive behaviour. The program needs to

recognize the different roles in which children and adolescents come in contact with

domestic violence. These roles include exposure to violence at home, in the media,

and in dating relationships as victims, perpetrators, and peer groups.

interpersonal relationship choices in prevention and intervention programs.

program development and implementation. By working together as a team, they have

the opportunity to promote awareness, understanding, skills, and knowledge.

This recommendation arises from the nature of the cases we reviewed. In one case, the

perpetrator had confessed his intention to kill his former girlfriend to a peer who did not

know how to handle this disclosure. The girlfriend had been warned about the nature of

the relationship by her mother and a guidance counsellor, but minimized the abuse as

"only" possessiveness and jealousy. The facts of the case speak to the importance of

broader curriculum initiatives that engage potential perpetrators, victims, and peers who

observe abuse and receive disclosures.

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In several cases, perpetrators grew up in families where child abuse and exposure to

domestic violence were present. Although there was little information available about

how these problems were addressed in childhood for each perpetrator, it does raise the

importance of early identification and prevention programs for children in these

circumstances. As well, several of our cases illustrate the dilemma adolescents and young

adults face in dealing with the violence in their parents’ marriage. Without putting

unreasonable expectations or burdens on these adolescents to intervene with adult issues,

their potential learning experiences about domestic violence in school may alert them to

the dangers in their homes. Obviously, as part of these lessons, safety planning that does

not endanger them or other family members has to be addressed.

Although we often think of adults worrying about the welfare of children, it is not

unusual to find children and adolescents bringing home changing social attitudes and

behaviours about smoking, drinking and driving, and polluting the environment.

Domestic violence may be another such topic that leads to potentially life-saving

discussions. In two of our cases, the children themselves became homicide victims. In

several other cases, it appears they might have been targets who were spared only by

fortuitous circumstances. In these homes, domestic violence and safety planning was as

essential as learning about fire, traffic, or water safety.

• •

•

In a particularly tragic case of multiple-homicide, the recently estranged spouse had

prepared an extensive narrative of past emotional and physical abuse against her and their

children, as well as unfounded paranoid threats against two third parties. One of the third

parties was later murdered on the same night as the estranged spouse, and an attempt was

made on the life of the other by the perpetrator. The perpetrator later died at the end of a

police chase when he crashed the vehicle he was driving. The detailed narrative had been

provided to the police, at their request, after the accused had been arrested. However, he

was released after he had a bail hearing. No apparent assessment was made of the

information, nor was it used even after it was known that he was continuing to harass his

70

estranged spouse and violating the terms of release.

Notwithstanding the need for safety planning seen in a number of the cases, the victim

was provided with safety planning information in only one case. In that one instance, the

victim visited a resource centre for abused women in a distant community with the

assistance of her sister. She received information to assist her in dealing with the abuse

and how to go about safety planning.

In one particular instance, after the bail court had dealt with the matter involving the

perpetrator, the victim at the request of the police completed a "dangerousness

assessment in domestic violence" questionnaire. The responses contained sufficient

information about prior abuse and threats to the victim and others to make it a high-risk

case. After his release, the perpetrator continued to harass the victim and repeatedly

breach the terms of his recognizance, most of which was reported to the police service

involved in the original complaint. If a case manager or domestic violence case

coordinator had been assigned, the continuing complaints about the perpetrator’s alleged

breaches may have been dealt with differently and with greater attention, particularly if

assessed by one officer possessing all of the information reported to the police service.

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Many cases the committee reviewed had multiple community agencies and professionals

involved who held important information about the case, but had no formal mechanism to

share that information. Had they known the totality of the information, there might have

been a more effective response to ensuring the safety of the victim? All professions need

to explore ways that permit their practitioners to participate meaningfully in case

conferencing opportunities while respecting privacy and confidentiality constraints.

Access to firearms is an important risk factor. Moreover, restricting access to firearms is

important in terms of effective intervention and risk management. Four of the eleven

cases reviewed involved the use of firearms and situations where family members and

friends were aware it was not in the perpetrator’s interest to possess them due to mental

and/or emotional issues during a time immediately preceding the homicides. It is also

well established that the time of separation can be the most dangerous time, and in all of

the cases involving the use of firearms, the homicides occurred shortly after separation or

in anticipation of it occurring.

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Information is the necessary resource to ensure the effectiveness of the DVDRC. The

more information available to the DVDRC about the circumstances of the victims and

perpetrators, the better the committee will be able to:

In 64% of the cases reviewed by the committee, the perpetrator subsequently took his

own life. Because such cases do not generally give rise to criminal charges, the police

may not investigate the deaths as thoroughly as they would if charges were to occur,

notwithstanding the fact that the police use a major case management investigation model

for the cases. The committee has had the benefit of some very thorough investigations for

its work. However, some cases were not investigated to completion, leaving the

committee uncertain as to the actual facts of the related deaths. The committee is

dependant on a complete set of facts for each investigation to extract the lessons that may

be learned from each case to make recommendations to prevent deaths in similar

circumstances. The committee suggests that an investigative protocol be established

requiring all homicide/suicides be as completely investigated as those leading to criminal

charges. Such an approach will assist in the community’s efforts to better understand the

root causes of domestic violence, the best course, and practices for its prevention.

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that, despite Ralph Hadley being assessed as high-risk, the perpetrator was granted bail"

was with respect to the assessment of the inquest jury and the police officer involved who

predicted "dire consequences" if Ralph Hadley was to be released based on her

assessment of Hadley's behaviour and prior history. In fairness to all the professionals in

the justice system, not all those engaged in the bail proceedings made similar findings

based on the information available to them.