Fatality Review Bulletin
National Domestic Violence Fatality Review Initiative
Northern Arizona University
P.O. Box 15005
Flagstaff, AZ 86011-5005
In This Page 1 2004 Conference Announcement! Pages 4 & 5 Evaluating Fatality Reviews
Issue Page 2
Listening for a Change
Media Project & Website Update
NDVFRI Site Visits
More Site Visits & DoD Conference
NDVFRI Director Program Coordinator Administrative Secretary
Neil Websdale, Ph.D. Lynn Spence Debbie Mariage
Staff email@example.com firstname.lastname@example.org email@example.com
Office: 928-523-9205 Office: 928-523-0105 Office: 928-523-0108
Cell: 928-600-4710 Fax: 928-523-0159 Fax: 928-523-0159
The 2004 National Conference on
Domestic Violence Fatality Review
SEPTEMBER 20 - 21, 2004
Delray Beach Marriott
10 North Ocean Blvd.
Delray Beach, Florida
The National Domestic Violence Fatality Review Initiative would like
to invite domestic violence fatality review teams to attend its
annual conference on domestic violence fatality review.
Deadline to register is August 27, 2004.
Registration Form Inside!
The Fatality Review Bulletin is a publication of the National Domestic Violence
Fatality Review Initiative (NDVFRI). NDVFRI provides technical assistance through
annual conferences, teleconferences, newsletters, customized information packets,
fatality review team training, and other types of technical assistance on an as-needed
basis. NDVFRI works closely with other leading domestic violence organizations to
provide support and information for their fatality review work. NDVFRI is sponsored
by The U.S. Department of Justice Office on Violence Against Women, grant number
Volume 2, Issue 3, Summer 2004 www.ndvfri.org
Listening For A Change
By Cynthia Rubenstein, MS, LMHC
reating change within our community is one goal of the Palm Beach County Domes-
tic Violence Fatality Review Team (the Team). As a team, we look for innovative ways to have
an impact on our system instead of relying on recommendations like “increased training” that
become meaningless after awhile. The Team decided that listening to the experiences of survi-
vors could provide additional information in order to make a difference.
A group of 9 women who were completing a support group welcomed the opportunity
to share their stories. All interested Team members were encouraged to attend. The Team
agreed that our function was to listen only. Our role was to bear witness to the experiences
of the support group members, not to engage in dialogue by providing information or asking any
questions. Bearing witness opens a space to share an experience from the speaker‛s point of
view. Greater possibility exists in a dialogue to focus more on expressing, or even arguing, for a
point of view and less on learning from other perspectives. Listening itself becomes a catalyst
for change because the process of hearing other viewpoints causes shifts in awareness that
lead to new ideas.
The actual experience of bearing witness challenged the Team. The poignancy of the
stories made an impact even though we were already aware of the gaps the women identified
such as jurisdictional problems, cultural barriers and court overcrowding. One finding that
surprised the Team was three of the women stating they would have preferred being ordered
to attend a support group at the earliest possible intervention into their case. Would many
victims prefer to be mandated into treatment and if so, how does that fit into our current
It was difficult to hear about failures in our system and not try to fix the problems on
the spot. I wanted to jump in with questions and comments, as did others. Law enforcement
personnel felt strongly that they had a responsibility to correct misinformation about police
procedures. Some of the women still seemed misinformed even after having already received
correct information through interaction with the criminal justice system and the support group.
Remaining silent allowed me to hear things in ways I may have missed if we had engaged in
dialogue. I began wondering if learning based on experience overrides fact based knowledge.
Did the actual experience of using the system, especially while experiencing trauma, form the
basis of the current beliefs of the women instead of what they had been told?
There is a need to provide victims with the knowledge to access and navigate the system.
However, are we sharing information in a way that makes sense to the people we are trying to
reach? Seeking first to listen and understand builds a two-way educational model based on the
exchange of information instead of the more typical model in which information flows in only one
direction. Would our efforts to educate survivors be more effective if we allowed them to first
educate us? How well do we really listen to survivors? I also wondered if the same holds true
for professionals in the field and how our experiences working with domestic violence affect our
practice no matter how well we are trained. Would we be more effective if we listened better
to one another?
Visiting the support group caused lively debate within the Team and we left with more
questions than answers. We are still discussing what to do with what we learned and would like
to get additional input from other survivors. While the process was deemed worthwhile, the
Team thought a question and answer period needed to be included in future sessions. An idea
under consideration is to sponsor a two-part focus group for survivors to share their stories
during the first half followed up with a dialogue between the survivors and the Team. The visit
reinforced the importance of the voice of survivors in the fatality review process. An interest-
ing exercise may be for teams to also bear witness to groups of police officers, judges, advo-
cates, or possibly even batterers. Creating a forum for hearing from all of the stakeholders is
something for fatality review team to consider in creating change.
Cynthia Rubenstein is a member of the NDVFRI Advisory Board and President of Chosen
Path, Inc. - a training and consulting company that specializes in experiential teambuilding.
She has co-chaired the Palm Beach County Domestic Violence Fatality Review Team since
NDVFRI has expanded the website!
• Background information on fatality reviews
• How to get a fatality review team started
• Recently published articles on DV homicides
• Protocols & Team Philosophy
• Sample legislation
• Victim Resources
• Conference Information
Also, NDVFRI Board Members are discussing the pros & cons of operationalizing a list-serve on the website.
DOMESTIC VIOLENCE FATALITIES
In order to further inform the reporting of domestic violence related
fatalities, NDVFRI has commissioned three consultants to produce a series
of media tool-kits. The consultants are interviewing journalists, fatality
review team members, and other professionals to explore the process of
reporting such deaths. In addition they are examining news articles and
some of the research work conducted in this area. Our idea is to provide
technical assistance to journalists and review team members across the
country so that these tragic deaths are reported accurately and comprehen-
sively. The toolkits will appear in forthcoming editions of the newsletter
and be put up on the ndvfri.org website.
If you have any suggestions regarding this project please contact Lynn
Spence at 1-800-531-2693 or firstname.lastname@example.org.
Evaluating Fatality Reviews
By Alex Alvarez, Ph.D.
The problem of domestic violence continues to plague the United States. In any given year, roughly one
thousand women are murdered by intimate partners and many thousands more are violently victimized. One
fairly recent development in the struggle against domestic violence has been the emergence of fatality review
teams. Present now in 29 states around the country, these teams are part of a larger movement that approaches
the problem of violence from multi agency and multidisciplinary perspectives. Increasingly, we understand that
violence prevention is not just a criminal justice issue, but also involves social, psychological, political and cul-
tural issues as well. This type of approach to the study and prevention of violence and injury, holds great prom-
ise for making our society safer. Fatality review fits squarely into the mainstream of this larger movement.
Fatality Review teams share a number of long term and short term goals. In the long run they have been
created with the intent of ultimately preventing domestic violence homicides and domestic violence in general. In
the short term these teams are often intended to facilitate better inter-agency cooperation and influence public
policy. They do so through the in-depth analysis of a variety of domestic violence fatalities. Bringing together
professionals from various agencies including courts, law enforcement, shelters, and other social service orga-
nizations, these teams work to identify important elements in the sequence of events leading up to the fatality.
This information is expected to help criminal justice and social service agencies intervene more effectively. It
is also hoped that teams’ work will foster greater accountability on the part of both the perpetrators of domestic
violence and the multiple agencies and organizations that come into contact with those involved. In addition to
these teams, the National Fatality Review Initiative has been created in order to provide technical assistance to
fatality review teams, help develop and train new teams, and to act as a national clearinghouse of information for
teams around the country.
The rapid spread of fatality review suggests that communities have found them useful. Whatever under-
lies this expansion it is important to consider how we might evaluate the success of teams.
One potential measure concerns the ability of the teams to influence and bring about policy change. In
this regard a strong case can be made that fatality review teams have already proved influential and success-
ful. For example, the recommendations of various teams has helped change the work of law enforcement,
advocates, practitioners, and others in various jurisdictions around the country. In response to the high level of
firearm deaths, the Santa Clara County team in California worked with local law enforcement to develop a new
protocol for obtaining firearms in domestic violence cases that involves not only inquiring of the victim and the
abuser as to the presence of firearms and other deadly weapons, but also checking data bases for registered
weapons and seizing weapons in plain sight or discovered after a lawful search. All law enforcement agencies
in the county have now signed on to the new protocol. The reviews conducted by the Hennepin County Fatality
Review Team in Minnesota found a number of domestic violence cases that had been misclassified as misde-
meanors even though they met the criteria to be considered felonies. In response to this perceived problem, the
team has successfully assisted in revising the process of classification so that felony domestic violence cases
are not misclassified as misdemeanors. In Brevard County Florida, the fatality review team has helped modify
the notification procedure for those individuals seeking an injunction for protection and has made sure that infor-
mation in the form of a pamphlet is available at the clerk of courts office where injunctions are obtained. In New
Hampshire, fatality review has helped change court protocol so that notifications are sent out to both the plaintiff
and the defendant when domestic violence protection orders are set to expire. The plaintiff is informed of the
renewal procedures, while the defendant receives information as to the provision for a hearing on a request for
renewal. Because the reviews conducted by the Miami/Dade County Florida team revealed that in most cases
families and friends were aware of the history of violence in the relationship, the team worked to develop the
domestic violence awareness campaign of “Silence isn’t Golden Anymore.” This team also helped law enforce-
ment develop initiatives for assessing the potential for lethality in domestic violence offenses. Many teams have
also developed educational materials and programming for various groups in order to sensitize them to the
needs and dangers of domestic violence cases.
These are but a few examples that illustrate the impact that fatality review teams are having in their com-
munities and states. Clearly, if policy change and/or implementation and raising awareness are the standards
by which fatality review is judged, then the teams are having an impact. But is this enough? Is it possible to link
the work of these teams and the policy changes they have effected to possible reductions in domestic violence
homicides? The short answer is no.
How can we demonstrate that fatality review teams reduce the number of domestic violence related
deaths? Since the early 1990’s when adult domestic violence fatality review teams first began operation, inti-
mate partner homicides have decreased, especially for African Americans. In 1990, 441 African American males
and 490 African American females were intimate homicide victims. By the year 2000 that number had decreased
to 192 for males and 333 for females. This represents a 56% decrease for African American males and a 32%
decrease for African American females. For white males during the same period the number changed from 393
victims in 1990 to 229 victims in 2000 a decrease of around 42%. This pattern changes, however, for white
females. In 1990, 952 white women were murdered by intimates compared to 851 in 2000 which represents an
11% decrease. It is tempting to attribute the decreases that have occurred to the impact that teams are having,
and even though these reductions are important and significant we cannot say that they are caused by the work
of the fatality review teams.
First, we should recognize that, not only do these decreases predate fatality review, but they are occur-
ring nationwide, even in states without fatality review teams. Second, when the figures are disaggregated, we
find that most of the decrease has been for male victims of domestic homicides, while the overall rate for white
female victims has largely remained static. In fact, since 1998, the number of white women killed by intimates
has actually increased. Third, it is also important to note that during the same time period, homicides in general
experienced a sustained and significant decrease even though non-domestic violence related homicides lie
beyond the mandate of the fatality review teams. Clearly, the decrease in homicides, even domestic homicides,
cannot be attributed solely, nor even primarily, to the effects of domestic homicide fatality review. Any explana-
tion of the decrease in intimate homicides, as well as other forms of homicide, must take into account the multi-
plicity of factors that have been shown to influence the homicide rate.
By making this point, I am not suggesting that fatality review teams are not affecting domestic violence
fatality rates, especially at the local level in communities with active teams. Rather, I am pointing out that as-
sertions suggesting fatality review is responsible for decreases in domestic violence fatalities are premature and
misleading. An important next step in this movement is to conduct empirical analysis at the local, state, and na-
tional level in order to explore whether or not decreases in intimate homicide rates can be attributed to the work
of fatality reviews teams. Given the limitations of statistical research and the shortcomings of intimate partner
homicide data it is unlikely that any conclusive proof for the direct linkage between the work of fatality review
teams and intimate partner homicides will be forthcoming.
Dr. Alex Alvarez is a Professor in the Department of Criminal Justice at Northern Arizona University. His
main areas of study have been in the areas of collective and interpersonal violence. Dr. Alvarez has published
widely on justifiable and criminal homicide, and genocide and has been invited to present his research in
various countries such as Austria, Bosnia, Canada, Germany, and Sweden.
NDVFRI Site Visits
SAN DIEGO, CALIFORNIA
January 29, 2004
Interagency Council on Child Abuse and Neglect (ICAN) Annual Conference
Presentation by Neil Websdale: “The relationship between child abuse and neglect deaths and
adult domestic violence related deaths.”
February 1, 2004
Anne Arundel Courthouse - Statewide Fatality Review Training
Presentation by Neil Websdale: “Reviewing domestic violence related homicides and setting up
death review teams.”
February 2, 2004
United States Department of Defense
Presentation by Neil Websdale: “Overview of developments in the field of domestic violence fatality
review.” Attendees included representatives from all four branches of the Department of Defense.
February 3, 2004
Battered Women’s Justice Project (BWJP) & The Office on Violence Against Women
Orientation Training for new Grants to Encourage Arrest Policies (GTEAP) Grantees
Training by Neil Websdale: “Domestic homicides, technical assistance provisions of the NDVFRI,
and risk assessment strategies.”
SAN FRANCISCO, CALIFORNIA
February 5, 2004
Neil Websdale met with Chic Dabby, Director of the Asian & Pacific Islander Institute on Domestic
Violence and Debbie Lee of the Family Violence Prevention Fund. Topic of discussion included
Domestic Homicide in Asian Communities, Contract Killings and the Role of Prevention &
March 3, 2004
Domestic Violence Fatality Review Conference - Sponsored by the Judiciary, State of Hawaii
Funded by the US Department of Justice, STOP Violence Against Women Formula Grant Program
and the Judiciary, State of Hawaii. The Conference was opened by The Chief Justice of Hawaii
Presentations by Neil Websdale included the following:
“Challenges for the State of Hawaii: Developing local teams and resource building”
“National trends and initiatives in fatality review” with Kelly Starr of the Washington Coalition Against
“Scoping out reviewable cases for fatality review.”
Following the conference, Neil met with 30 community Agency personnel to discuss a plan of action
for operationalizing the statewide plan.
March 16 & 17, 2004
Neil Websdale met with the Governor’s Division for Women, the Governor’s Office of Children, Youth
& Families and the Arizona Coalition Against Domestic Violence. The focus of this meeting was to
discuss the expansion of fatality reviews throughout the state of Arizona.
April 30, 2004
Domestic Violence Fatality Review Team Conference
NDVFRI presenters included: Neil Websdale, Cynthia Rubenstein President of Chosenpath Inc.,
Boca Raton, FL, Matt Dale, Director of the Office of Victim Services and Restorative Justice, Helena,
MT, Major Craig Broughton, Commander of the Support Services Division of the Volusia County
Sheriiff’s Office, Deland, FL and Barbara Hart, JD, Pennsylvania Coalition Against Domestic Violence,
Legal Director and Battered Women’s Justice Project, Associate Director, Harrisburg, PA.
The Spring 2004 issue of Unified Response, The Child Fatality Review Team Newsletter will feature
an article by Neil Websdale titled The National Domestic Violence Fatality Review Initiative.
U.S. DEPARTMENT OF DEFENSE
Fatality Review Conference
July 13 - 14, 2004
Crystal City, Virginia
The Department of Defense will host a Fatality Review Conference July 13-14, 2004 at
the Doubletree Hotel in Crystal City, Virginia, pursuant to its implementation of Section 576 of
Public Law 108-136, the National Defense Authorization Act for Fiscal Year 2004, which calls
upon the Department to conduct impartial multidisciplinary reviews of fatalities resulting from
domestic violence and child abuse, and similar recommendations of the Defense Task Force on
The conference is a product of the collaborative partnership that exists between
Department of Defense and the Department of Justice Office on Violence Against Women. The
conference is being organized by the National Domestic Violence Fatality Review Initiative.
Topics to be addressed include establishing a fatality review team, defining the scope of
cases to review, the role of advocacy and justice professionals in fatality review work, linking
child and adult death reviews, cultural implications of fatality review, promising practices as
well as a mock review exercise. This conference is by invitation only and is limited to 100
Thomas A. Andrew, MD
Chief Medical Examiner
Concord, New Hampshire
Gretta Gordy, Managing Attorney
Pennsylvania Coalition Against Domestic Violence
Major Craig Broughton Margaret Hobart Cynthia Rubenstein, MS, LMHC
Commander, Support Services Division Washington State Coalition Against Chosenpath, Inc.
Volusia County Sheriff’s Office Domestic Violence Boca Raton, FL
Deland, FL Seattle, WA
Michael A. Town
Susan B. Carbon LTC James N. Jackson Circuit Court Judge
Supervisory Judge Defense Taskforce on Domestic Violence State of Hawai’i
Grafton County Family Division Arlington, VA Honolulu, HI
Byron Johnson Nancy Turner
Sumayya Coleman Baylor University International Association of Chiefs of Police
Urban Justice Center Waco, TX Alexandria, VA
New York, NY
Debbie Lee Robin Hassler Thompson
Firoza Chic Dabby, Executive Director Family Violence Prevention Fund Robin H. Thompson & Associates
Asian & Pacific Islander Institute on San Francisco, CA Tallahassee, FL
San Francisco, CA Honorable Pete Macdonald Neil Websdale, Professor
District Judge Department of Criminal Justice
Mike Durfee, MD Hopkinsville, KY Northern Arizona University
ICAN National Center on Child Fatality Review Flagstaff, AZ
La Canada, CA Linda Major, Prosecutor
Marion County Prosecutor’s Office
Mary Ann Dutton, Professor Indianapolis, IN
Department of Psychiatry
Georgetown University Rhonda Martinson, Staff Attorney
Washington, DC Battered Women’s Justice Project
Kathleen Ferraro, Ph.D.
Department of Sociology
Northern Arizona University
National Domestic Violence Fatality Review Initiative
Northern Arizona University
Department of Criminal Justice
P.O. Box 15005
Flagstaff, AZ 86011-5005
Our mission is to provide technical assistance for the reviewing of domestic
violence related deaths with the underlying objectives of preventing them in the future,
preserving the safety of battered women, and holding accountable both the perpetrators
of domestic violence and the multiple agencies and organizations that come into contact
with the parties.