What do Domestic Violence Death Review Committees do?

What do Domestic Violence Death Review Committees do?

Domestic Violence Death Review Committees (DVDRCs) exist in a number of locations around the world, including Ontario. They are multi-disciplinary committees of experts who review domestic violence related deaths and provide recommendations for change and advice, largely to government and government entities, with the goal of preventing similar deaths in the future.

The recommendations of DVDRCs are not legally binding and do not address the possible criminal culpability of the individual responsible for causing the death. Rather, they are focused on identifying systemic problems that may be connected to domestic homicides and proposing change.

Most DVDRCs look at three overarching and overlapping themes in their reports:

  • Awareness and education
  • Assessment and intervention
  • Resources

At this time, DVDRCs operate in the following countries other than Canada:

Australia: As the result of a 2009 recommendation from the National Council to Reduce Violence Against Women and their Children, domestic homicide review teams have been established in 4 states.

New Zealand: The 2008 recommendations of the Taskforce for Action on Violence within Families led to the establishment of the Family Violence Death Review Committee, which operates under health legislation.

Great Britain: In 2011, it became law that a multi-agency local review be conducted after every domestic homicide. Both professionals and family members can participate in the review.

United States: The first domestic violence death review was conducted in California in 1990. Since then more than 80 DVDRCs have been established across the country, some operating at the state level and others falling under county or city jurisdiction. A coordinating body – the National Domestic Violence Fatality Review Initiative – provides links to all U.S. DVDRC reports

In Canada, six provinces have domestic violence death review committees:

Alberta’s Family Violence Death Review Committee was established 2 years ago in 2014. It falls under the jurisdiction of the Protection against Family Violence Act and reports to the Minister of Human Services. Since its establishment, it has reviewed 76 domestic homicides that took place between 2008 and 2014.

In British Columbia, a Domestic Violence Death Review Panel conducted a one-time review of 11 domestic violence homicides drawn from coroner files from 1995- 2010.

Manitoba created a DVDRC in 2010, which has conducted 4 reviews since then.

New Brunswick’s DVDRC was established in 2009 and, between 2010 and 2014, it reviewed 4 domestic homicides.

In 2015, Saskatchewan announced its intention to review domestic homicides but has not yet created a formal process to do so.

Ontario’s DVDRC was the first in Canada when it was established in 2002 in response to recommendations from two super-inquests into the domestic homicides of two women by their estranged partners. Of course, these were not the only two women murdered in those years; however, they were cases that presented a number of systemic issues that the Coroner felt could best be addressed through inquests.

History of the Ontario DVDRC

In 1996, Arlene May was murdered by her former boyfriend Randy Iles, who also killed himself. Iles had a long history of domestic difficulties, including abuse directed at former partners. At the time he killed Arlene May, he was facing a number of charges related to her and was on bail conditions in more than one jurisdiction that prohibited him from having any contact with her. He had also been ordered to hand over his firearms acquisition certificate, but this was never enforced.

After the murder/suicide, an inquest – the first of its scope and magnitude in Canada – was held. Both METRAC and OAITH obtained intervenor status to the inquest examined and cross-examined witnesses and made submissions. After 51 days of hearing evidence and 10 days of deliberation, the inquest jury made 213 recommendations for systemic change.

In 2000, Gillian Hadley was murdered in the family’s home by her former husband Ralph Hadley, who also killed himself.  The case attracted a high level of public interest because neighbours became involved when Gillian, naked and holding her baby, tried to escape from the house. While neighbours were able to take the baby from her, she was pulled back into the house by Hadley, who then killed both of them.

The Coroner called an inquest, at which OAITH once again had standing. This time, a fathers’ rights organization also obtained standing. After 39 days of evidence, the inquest jury made 58 recommendations, including the recommendation that the Office of the Chief Coroner establish a Domestic Violence Death Review Committee “comprised of specialists and experts to assist the Coroner’s office in the investigation of suspicious deaths which occur within an intimate relationship.”


Ontario’s DVDRC’s purpose is “to assist the Office of the Chief Coroner in the investigation and review of deaths of persons that occur as a result of domestic violence, and to make recommendations to help prevent such deaths in similar circumstances.”

Domestic violence deaths are defined as “All homicides that involve the death of a person, and/or his children) committed by the person’s partner or ex-partner from an intimate relationship.”

Other jurisdictions use somewhat different definitions, with dating relationships proving to be a challenge for DVDRCs. Some, like Ontario, see them as partners and so include homicides in dating relationships while others do not.


Most committees review deaths of any family member or third party (children, other relatives, new partner of the primary victim, etc.) that is caused by the partner of the primary victim.

Some committees examine all family violence deaths (for example, including sibling-sibling homicide), but most, including Ontario, restrict the definition to partner homicides.

Some American committees have embraced a very broad definition of domestic violence deaths to include suicide by women who have been victims of domestic violence as well as deaths of women who are street-involved as a result of fleeing domestic violence. At this time, Ontario’s DVDRC does not review such deaths.

In Ontario, the committee only reviews deaths that are not before the courts. In other words, if the perpetrator kills himself, then the death can be reviewed. However, if he does not and then faces criminal charges, the committee cannot review the case until the criminal proceedings, including any appeals, are completed. As a result, often cases are reviewed many years after the homicide occurred.

While this time lag can be frustrating for those wanting to see change happen quickly, there are advantages of not proceeding until the criminal case is complete. It allows the committee to access all records and documentation, including family as well as criminal court proceedings, and to speak to all witnesses to any aspect of the situation, including family members and others.

Ontario’s objectives

The objectives of Ontario’s DVDRC include:

  • Providing and coordinating a confidential multi-disciplinary review of domestic violence deaths
  • Offering an expert opinion to the Chief Coroner
  • Creating and maintaining a comprehensive database about victims and perpetrators of domestic violence fatalities
  • Helping identify the presence or absence of systemic issues
  • Helping identify trends, risk factors and patterns from the cases reviewed to make recommendations for effective intervention and prevention strategies
  • Conducting and promoting effective research
  • Stimulating educational activities
  • Reporting annually to the Chief Coroner with recommendations for change

Ontario’s committee includes representation from the healthcare, criminal and family justice systems and advocacy/social services. Present members of the committee are:

  • William Lucas, Deputy Chief Coroner
  • Karen Bridgman-Acker, Pediatric Death Review Committee
  • Marcie Campbell, PAR Program
  • Gail Churchill, Investigating Coroner
  • Kimberley Clarke, Ontario Network of Victim Services Providers
  • Myrna Dawson, Professor, Department of Sociology and Anthropology, University of Guelph
  • Monica  Denreyer, Ontario Provincial Police
  • Barb Forbes, Ministry of Community Safety and Correctional Services
  • Mark Gauthier, Ontario Provincial Police
  • Jim Glena, Thunder Bay Police Services
  • Mary Ellen Hurman, Crown Attorney
  • Peter Jaffe, Professor, Centre for Research on Violence Against Women and Children, Western University
  • Kathy Kerr, Office of the Chief Coroner
  • Leslie Raymond, Ontario Provincial Police
  • Deborah Sinclair, Social Worker
  • Lynn Stewart, Correctional Service Canada

Since its inception, the committee has reviewed 199 cases involving 290 deaths.


DVDRCs provide a number of benefits, which are enhanced when they operate within a political climate that is committed to addressing systemic issues related to violence against women. Because recommendations from Ontario’s committee do not carry the weight of law, it is only when those responsible for change are prepared to make those changes that the committee’s work results in positive outcomes.

Over the 10+ years that Ontario’s DVDRC has been in existence, a number of changes have come about as a result of the committee’s recommendations. In particular:

  • The government has supported educational initiatives aimed at the police, health care sector, criminal and family law sector and education sector, among others
  • Public education programs such as Neighbours, Friends and Families have been created and/or enhanced
  • Increased community collaborations have been encouraged through community domestic violence coordinating committees
  • Risk assessment and safety planning tools have been developed and training in the appropriate use of them has been instituted
  • Legislation to address domestic violence and harassment in the workplace has been introduced and passed
  • Much information about domestic violence/homicide has been gathered and disseminated to increase the knowledge levels of those working in this area

The committee’s work has also identified key lethality high-risk identifiers that appear in domestic homicide after domestic homicide. The DVDRC has found that 7 or more known risk factors were present80% of the domestic homicides it reviews. The 10 most common risk factors the committee has identified are:

  • Prior history of domestic violence (present in 72% of homicides)
  • Recent or pending separation (69%)
  • Depression (perpetrator) (54%)
  • Obsessive behaviour (perpetrator) (53%)
  • Escalation of violence (49%)
  • Prior threat/attempts to commit suicide (perpetrator) (44%)
  • Prior threats to kill victim (44%)
  • Prior attempts to isolate victim (42%)
  • Unemployment (perpetrator) (41%)
  • Intuitive sense of fear (victim) (38%)

For more information about Ontario’s Domestic Violence Death Review Committee or to review the committee’s reports see the Office of the Chief Coroner, Ministry of Community Safety and Correctional Services.