DVDRC Committees

Domestic Violence Death Review Committees (DVDRCs) are multi-disciplinary advisory committees of experts that review of domestic violence related deaths with the underlying objectives of preventing them in the future. The first Canadian DVDRC was established in 2003 in Ontario in response to recommendations made from two major inquests into the deaths of Arlene May/Randy Iles and Gillian and Ralph Hadley.

Several provinces and territories in Canada have established Domestic Violence Death Review Committees (DVDRCs), fatality reviews and/or inquests into deaths related to domestic violence. Other provinces and territories have taken steps to assess need for and/or are the in process of establishing DVDRCs. Internationally, several countries also have Domestic Violence Death Review Committees. Find out more information about implementing a death review committee here.


Family Violence Death Review Committee: Annual Report to the Minister of Human Services
Alberta’s Family Violence Death Review Committee convened its first meeting on February 11, 2014, and established guiding goals to: understand the reasons for family violence deaths; understand where and how agencies and systems intersect and how they can better work together; determine the barriers to supports and services that the victim and perpetrator may have experienced; understand and make recommendations on how family violence can be prevented and reduced. The Committee identified six cases for in-depth review during the first year and assessed all 76 incidents of family violence-related deaths to provide information that establishes a clear picture of family violence in Alberta and to understand the work ahead.

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British Columbia

BC Coroners Service Death Review Panel - A Review of Intimate Partner Violence Deaths 2010-2015
n June 8-9, 2016, the British Columbia Coroners Service death review panel examined 75 fatal intimate partner violence incidents that occurred between 2010 and 2015. Three key areas to reduce intimate partner violence deaths were identified: 1) intimate partner violence awareness and education; 2) collaborative safety planning and case management; and 3) data access, quality and information sharing. The review resulted in three recommendations around these key areas.  The report highlights literature findings and the BC context; legislation and regulations; services, intervention and supports; findings from the case reviews; and recommendations.

Report to the Chief Coroner of British Columbia: Findings and Recommendations of the Domestic Violence Death Review Panel
In 2010, the Domestic Violence Death Review Panel of British Columbia reviewed 11 incidents of domestic homicide, some dating back to 1995. The result of these case reviews were 19 recommendations that highlighted the need for collaboration, standardization, resources and training, coordination, information sharing, and community involvement in order to prevent similar tragedies from occurring in the future.

Honouring Christian Lee – No Private Matter: Protecting Children Living With Domestic Violence
On Sept. 4, 2007, six-year-old Christian Lee and four members of his family died in a murder/suicide. Peter Lee murdered his son Christian, his wife Sunny Park, his parents-in-law from Korea and then killed himself. The Representative for Children and Youth in British Columbia is responsible for reporting on reviews and investigations of deaths and critical injuries of children receiving reviewable services. This 2009 report, which made five recommendations, found that the systems of support for children and families exposed to domestic violence were not adequate to protect Christian and his family.

Honouring Kaitlynne, Max and Cordon – Make Their Voices Heard Now
This Representative’s investigation examined the lives and deaths of Kaitlynne, Max and Cordon, three B.C. children killed by their father, Allan Schoenborn, on April 6, 2008. A key message of this report was that each arm of the system of supports and protections for vulnerable children and adults in B.C. must be attuned to the risks for their clients, especially to children, and be prepared to refer to and accept referrals from other services. The Report makes eight recommendations. systemic change in the way we address domestic violence and mental illness.

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Domestic Violence Death Review Committee: Annual Report Executive Summaries
On June 16, 2010, the province of Manitoba established the Domestic Violence Death Review Committee (DVDRC). The purpose of the Manitoba DVDRC is to review homicides that occurred in the context of domestic violence in order to identify trends, risk factors and systemic concerns to prevent similar tragedies and recommend changes for improvement. Since the creation of Manitoba’s DVDRC, four reviews have been completed.

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New Brunswick

Domestic Homicide in New Brunswick (1999-2008)
Following the announcement in 2009 by the provincial government regarding the establishment of a domestic violence death review committee in New Brunswick, the Muriel McQueen Fergusson Centre for Family Violence Research (MMFC) conducted a study on domestic homicide in the province. The study analyzed 32 cases of domestic homicide that occurred in New Brunswick over a 10-year period (1999-2008). The purpose of the study was to learn from domestic homicide cases in New Brunswick, identify the risk factors associated with domestic homicide, and determine the next steps that can be taken to prevent these tragedies from occurring.

Recommendations from the Domestic Violence Death Review Committee 2012-2013
The Domestic Violence Death Review Committee of New Brunswick reviewed four cases of domestic homicide that occurred between 2010 and 2014.  This report outlines the recommendations that stemmed from the reviews and the responses of government departments and agencies involved with the cases.

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Domestic Violence Death Review Committee
The Ontario Domestic Violence Death Review Committee (DVDRC) was established in 2002 in response to recommendations that arose from two major inquests into the domestic homicides of Arlene May and Gillian Hadley by their former male partners. The purpose of the committee is to assist the Office of the Chief Coroner of Ontario in investigating and reviewing deaths that occur in the context of domestic violence and form recommendations to help prevent similar tragedies in the future. Since its establishment, the Ontario DVDRC has published nine annual reports.

2003 Annual Report

2006 Annual Report

2009 Annual Report

2012 Annual Report

2004 Annual Report

2007 Annual Report

2010 Annual Report

2013-2014 Report

2005 Annual Report

2008 Annual Report

2011 Annual Report

2015 Annual Report

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Sask. Domestic Violence Death Reviews Are Late But Important, Expert Says, CBC News, Oct 27 2015
This article features comments from Jo-Anne Dusel, Provincial Coordinator for PATHS Saskatchewan, on Provincial Justice Minister Gordon Wyant announcement that the province would develop a process to review deaths resulting from domestic violence.

Saskatchewan to Begin Reviewing Domestic Violence Deaths Oct 26, 2015
In late 2015, Provincial Justice Minister Gordon Wyant announced that the province would develop a process to review deaths resulting from domestic violence.

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The National Domestic Violence Fatality Review Initiative
The NDVFRI is a resource center dedicated to domestic violence fatality review housed at Northern Arizona University in Flagstaff, Arizona, under the direction of Dr. Neil Websdale, Professor of Criminology and Criminal Justice. Many states have Domestic Violence Fatality review teams. The National Domestic Violence Fatality Review Initiative contains a clickable map of all fatality review teams in the United States.

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Out of Character? Legal responses to intimate partner homicides by men in Victoria 2005-2014
This discussion paper examines intimate partner homicides perpetrated by men in Australia and the legal responses to these crimes.  Specifically, the paper provides an overview of intimate partner homicides in Australia including those perpetrated by men and women, demographic data, risk and contextual factors, and legal outcomes; an examination of the legal responses to intimate partner homicides including how this violence is understood and discussed by legal professionals, how evidence of prior violence is used in trials, defense arguments and narratives, and sentencing processes; and an outline of conclusions and recommendations based on the research findings.

Domestic Violence Death Review Team: Annual Report (2012-2013)
The Domestic Violence Death Review Team examines homicides that occur within the context of domestic violence, inclusive of suicides and fatal accidents in New South Wales. The review period spanning this report was from July 2009-June 2010. Out of 877 homicides that took place during this time, 238 of these were domestic violence-related, of which 69 children were killed in this context. Data pertaining to these domestic violence homicides are included and discussed within this report. 

Report of the Domestic and Family Violence Death Review Panel (2010)
The Domestic and Family Violence Death Review Panel was formed by the Minister for Community Services and Housing and Minister for Women. This panel’s objectives are to strengthen coronial processes as to increase the Coroner’s ability to comment on domestic and family violence issues and to identify systemic gaps and barriers to help prevent future domestic and family violence related deaths.  This report provides background information on domestic and family violence death review in Queensland, outlines the proposed domestic and family violence death review mechanism model, and lists recommendations for addressing the two key objectives of the Domestic and Family Violence Death Review Panel.

Report of the Domestic Violence Homicide Advisory Panel (2009)
The Domestic Violence Homicide Advisory Panel was established to review domestic violence related homicides. This report outlines recommendations around domestic homicide review; background information on the Domestic Violence Homicide Advisory Panel and other existing death review mechanisms; descriptions of domestic violence homicide reviews in Australia and other jurisdictions; information on data collection and privacy issues; New South Wales crime statistics and research trends; options for review mechanisms in New South Wales; and assessment of these options.

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New Zealand

Family Violence Death Review Committee
The New Zealand Family Violence Death Review Committee’s Inaugural Report to the Health Quality and Safety Commission describes the progress and development of the process of their mortality review. This review process incorporates all agencies involved in the deceased person’s life to review their death. Furthermore, the Family Violence Death Review includes the lives of the family members alongside those who have died and the perpetrator responsible for the death. The ultimate goal of this review committee is to prevent family violence deaths in New Zealand. The Family Violence Death Review Committee in New Zealand has produced four annual reports. As a result of the case reviews, the committee has provided several recommendations aimed at intervention and prevention.

Family Violence Death Review Committee: Submission on the Green Paper for Vulnerable Children
New Zealand’s Family Violence Death Review Committee (FVDRC) reviews and reports on family violence deaths with an aim to reduce the number of these deaths, and to improve programs and plans to reduce family morbidity and mortality. The submission on the Green Paper for Vulnerable Children was compiled by FVDRC to help children who are affected by family violence, as child abuse and intimate partner violence are not always dichotomous. The submission is based on the personal views and professional experience of FVDRC members. The key themes discussed in this submission are: children’s emotional wellbeing and safety needs to be the paramount concern in all agency decisions; a whole-of-family approach needs to be taken when helping vulnerable families/children; training for all professionals working with vulnerable children is necessary; decisions about the risks posed to vulnerable children are best made through robust multi-agency working and decision making processes; information sharing is a critical component of multi-agency working; all practices and processes need to be culturally appropriate; and creating an effective system to address the needs of vulnerable children will require significant financial and human capital investment.

FVDRC Submissions on Reviewing the Family Court: A Public Consultation Paper
The Family Violence Death Review Committee (FVDRC) believes that the current approach to reviewing and reforming the justice system is problematic in its treatment of family violence.  In this report, the FVDRC discusses the need for an integrated and timely approach across all sectors, including justice, which prioritizes the safety and provision of support to victims of domestic violence and child abuse.  The submission is based on the personal views and professional experience of FVDRC members. 

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A Domestic Homicide Review into the Deaths of Julia and William Pemberton: A Report for West Berkshire Safer Communities Partnership (November 2008)
This document is the report of a domestic homicide review set up by West Berkshire Council on behalf of the West Berkshire Safer Communities Partnership.  An independent panel reviewed the homicides of Julia Pemberton and her son, William, perpetrated by Alan Pemberton, Julia’s ex-partner and William’s father.  Alan Pemberton committed suicide after the murders.  The report provides a summary of the events that occurred with the family during the period between September 2002 and November 2003 and the actions and responses of professionals both prior to and after the deaths.  The report lists the panel’s findings, conclusions, and recommendations to improve services for victims of domestic violence and their children.  

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Implementing a Death Review Committee

With the sudden growth in domestic violence death review committees across Canada, the CDHPI has provided resources and information for communities that are hoping and/or planning to implement their own committee or review process. The National Domestic Violence Fatality Review Initiative provides an excellent outline of the steps needed to take in order to establish a domestic violence death review committee, as well as supporting documents. The CDHPI has summarized this outline below:

  • Determine what agency or governing body will form the committee (e.g., legislative mandate vs. grant funding vs. informal reviews)
  • Identify key stakeholders who will be members of the committee
  • Decide who will house the committee and committee documents and who will generate reports
  • Develop confidentiality agreements for committee members and affiliated agencies (view a sample Confidentiality Agreement from the National Domestic Violence Fatality Review Initiative)
  • Define the mandate of the committee
  • Determine protocols for what the committee will review such as the type of case (e.g., murder-suicides, cases involving child victims); number of cases (e.g., several cases to identify trends and themes or one case that involves a very in-depth review); and how the committee will identify cases for review (e.g., coroners reports)
  • Determine how the committee will obtain documents and information related to the domestic homicide case for review (e.g., police reports, agency documentation, interviews with family and friends of the victim and/or perpetrator)
  • Establish a meeting schedule that can accommodate most, if not all, committee members (e.g., monthly meetings that last for a day; quarterly meetings that last for 3 days)
  • Conduct the review.  Important questions to ask:
    • What was the timeline of events leading up to the homicide?
    • What risk factors were present?  (view Appendix B of the Ontario Domestic Violence Death Review Committee Annual Report for a sample Risk Factor Coding Form)
    • What systems and agencies were involved with the couple/family?
    • What was the degree of communication and coordination among these systems and agencies?
    • What were some missed opportunities that could have improved the systemic and/or community response to the couple/family?
  • Summarize the case review into a workable document
  • Determine how and to whom the information will be disseminated

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