Ministry of Community Safety and Correctional Services :: 2011 Report

Chief Coroner

Publications & Reports

Domestic Violence Death Review Committee
2011 Annual Report

Message from the Chair
Committee Membership
Executive Summary
Chapter One: Introduction and Overview
Chapter Two: Statistical Overview: A fresh new look
Chapter Three: Case Reviews and Recommendations - 2011
Chapter Four: Learning from DVDRC Reviews
Appendix A: Domestic Violence Death Review Committee Terms of Reference
Appendix B: Ontario Domestic Violence Death Review Committee Risk Factor Coding Form
Appendix C: Summary of Recommendations – 2011 Case Reviews

Message from the Chair

2011 was an extremely busy year for the Domestic Violence Death Review Committee (DVDRC) as it undertook reviews of 33 cases resulting in 41 deaths involving domestic violence homicides or homicide-suicides in Ontario. From the cases reviewed in 2011, a total of 31 recommendations towards the prevention of future domestic violence related deaths, were made. Much like recommendations made from coroner’s inquests, these recommendations were distributed to organizations and agencies that were in a position to effect implementation and these organizations were requested to indicate the status of implementation of recommendations within one year’s time.

A brief summary of the circumstances of each case that was reviewed in 2011 is provided in Chapter Three. Recommendations that were generated from these reviews are included and a compilation of all recommendations made in 2011 is included in Appendix C.

Over the past year, a retrospective evaluation of data collected and presented on domestic violence homicides in the province has been undertaken. As a result, data presented in previous annual reports of the DVDRC has been updated and revised to reflect standardization and refinement of data collection tools and methods. Chapter Two provides an overview of statistical information pertaining to all homicides with domestic violence involvement (2002-2009), all cases reviewed by the DVDRC (2003-2011) and specific data relating to the reviews conducted in 2011.

Chapter Four of this annual report touches on two specific areas where significant learning has been achieved through DVDRC reviews conducted in 2011. In particular, this includes a discussion of specific issues and concerns relating to domestic violence within Aboriginal or First Nation communities and secondly, on female perpetrators of domestic violence.

Looking forward into 2012, the DVDRC will continue to refine its data collection methods and as additional cases are reviewed, further analysis and discussion of trends and patterns will take place.

William J. Lucas, MD CCFP
Regional Supervising Coroner
Chair, Domestic Violence Death Review Committee

Committee Membership

William Lucas, MD, CCFP.
Committee Chair
Regional Supervising Coroner

Karen Bridgman-Acker, MSW, RSW
Child Welfare Specialist
Paediatric Death Review Committee

Gail Churchill, M.D.
investigating Coroner

Kimberley Clark
Victim Services of Waterloo Region

Myrna Dawson, Ph.D.
Associate Professor,
Department of Sociology & Anthropology
University of Guelph

Debra Heaton
Monica Denreyer
Detective Sergeants, Ontario Provincial Police
Threat Assessment Unit

Peter Jaffe, Ph.D., C.Psych
Professor, Faculty of Education, Academic Director,
Centre for Research on Violence Against Women & Children, University of Western Ontario

Leslie Raymond
Detective Sergeant, Ontario Provincial Police,
Abuse Issues Coordinator, Central Region

Joanne Rudnick
Staff Sergeant, Toronto Police Service

Deborah Sinclair, M.S.W.
Social Worker

Lynn Stewart, Ph.D., C.Psych.
National Manager, Family Violence Prevention
Programs, Correctional Service Canada

Kathy Kerr, M.A.
Executive Lead, Committee Management
Office of the Chief Coroner

Mark Gauthier
Detective Sergeant, Ontario Provincial Police

Marcie Campbell, M.Ed
Research Assistant, Office of the Chief Coroner

Executive Summary

Cases reviewed from 2003-2011:

Since its inception in 2003, the DVDRC has reviewed 144 cases, involving 219 deaths.
53% of the cases reviewed were homicides.
47% of the cases reviewed were homicide-suicides.
74% of all cases reviewed between 2003-2011 involved a couple where there was a history of domestic violence
72% of the cases involved a couple with an actual or pending separation
The other top risk factors were: obsessive behaviour by the perpetrator, a perpetrator that was depressed, an escalation of violence, prior threats or attempts to commit suicide, prior threats to kill the victim, a victim that had an intuitive sense of fear towards the perpetrator and a perpetrator that was unemployed.
In 76% of the cases reviewed, 7 or more risk factors were identified.

Cases Reviewed in 2011

There were 33 cases reviewed by the DVDRC in 2011. This included 27 homicide cases and 6 homicide-suicide cases, resulting in 41 deaths (36 victims and 5 perpetrators)*.
31 recommendations were generated through these reviews.
Of the 36 victims in the cases reviewed, 32 (89%) were female and 4 (11%) were male.
29 (88%) of the 33 cases involved male perpetrators and 4 (12%) involved female perpetrators.
The victims ranged in age from 1 year to 83 years.
The average age for victims was 42.5 years.
The perpetrators ranged in age from 17 to 85 years.
The average age for perpetrators was 45.7 years.
The average number of risk factors identified in the cases reviewed was 9.4.
The number of risk factors ranged from 0 to 21.
70% of the cases had 7 or more risk factors.

* As one perpetrator committed suicide in another province, the homicides he committed are included in Ontario statistics, but his own suicide is not.

Chapter One: Introduction and Overview

History

The Domestic Violence Death Review Committee (DVDRC) is a multi-disciplinary advisory committee of experts that was established in 2003 in response to recommendations made from two major inquests into the deaths of Arlene May / Randy Iles and Gillian and Ralph Hadley.

Mandate

The purpose of the Domestic Violence Death Review Committee 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.

The DVDRC is committed to reviewing all relevant cases dating back to 2002.

The Terms of Reference for the DVDRC are included in Appendix A.

Membership

The DVDRC consists of representatives with expertise in domestic violence from law enforcement, criminal justice, the healthcare sector, social services and other public safety agencies and organizations.

Several members of the present committee have been involved since the DVDRC’s inception in 2003. Membership has evolved over the years to address changing and emerging issues that have been identified. In some cases, external expertise on specific issues may be sought if necessary.

Some members (depending on the organization they are representing), are provided with modest compensation for travel expenses, meeting attendance and report preparation.

Definition of Domestic Violence

Within the context of the DVDRC, domestic violence deaths are defined as “all homicides that involve the death of a person, and/or his child(ren) committed by the person’s partner or ex-partner from an intimate relationship.”

For the purposes of statistical comparisons, it is important to note that the definition and criteria of domestic violence deaths utilized by other organizations and agencies, including Statistics Canada, may be different than those used by the DVDRC.

Method for Reviewing Cases

Reviews are conducted by the DVDRC only after all other investigations and proceedings – including inquests, criminal trials and appeals – have been completed. As such, DVDRC reviews often take place several years after the actual incident.

When a domestic violence homicide or homicide-suicide takes place in the province, the relevant Regional Supervising Coroner notifies the Executive Lead of the DVDRC and the basic case information is recorded in a database. The Executive Lead, together with a police liaison officer assigned to the DVDRC, periodically verify the status of judicial and other proceedings to determine if the review can commence. Since cases involving homicide-suicides generally do not result in criminal and/or other proceedings, efforts are made to process and review these cases expeditiously.

Once it has been determined that a case is ready for review (i.e. all other proceedings and investigations have been completed), the case file is assigned to a reviewer (or reviewers). The case file may consist of records from the police, Children’s Aid Society (CAS), healthcare professionals, counselling professionals, courts, probation and parole, etc.

Each reviewer conducts a thorough and detailed examination and analysis of facts within individual cases and presents their findings to the DVDRC as a whole. Information considered within this examination includes the history, circumstances and conduct of the abusers/perpetrators, the victims and their respective families. Community and systemic responses are examined to determine primary risk factors, to identify possible points of intervention and develop recommendations that could assist with the prevention of similar deaths in the future. In general, the DVDRC strives to develop a comprehensive understanding of why domestic homicides occur and how they might be prevented.

Recommendations

One of the primary goals of the DVDRC is to make recommendations aimed at preventing deaths in similar circumstances and reducing domestic violence in general. Recommendations are distributed to relevant organizations and agencies through the Chair of the DVDRC.

Similar to recommendations generated through coroner’s inquests, the recommendations developed by the DVDRC are not legally binding and there is no obligation for agencies and organizations to implement or respond to them. Organizations and agencies are asked to respond back to the Executive Lead, DVDRC on the status of implementation of recommendations within one year of distribution.

Review and Report Limitations

Information collected and examined by the DVDRC, as well as the final report produced by the committee, are done for the sole purpose of a coroner’s investigation pursuant to section 15(4) of the Coroners Act, R.S.O. 1990 Chapter c.37, as amended. For this reason, there may be limitations on the types of records accessed for the DVDRC review, particularly as they relate to individuals that are still alive (e.g. perpetrators) and therefore protected under other privacy legislation.

All information obtained as a result of coroners’ investigations and provided to the DVDRC is subject to confidentiality and privacy limitations imposed by the Coroners Act of Ontario and the Freedom of Information and Protection of Privacy Act. Unless and until an inquest is called with respect to a specific death or deaths, the confidentiality and privacy interests of the decedents, as well as those involved in the circumstances of the death, will prevail. Accordingly, individual reports, as well as the minutes of review meetings and any other documents or reports produced by the DVDRC, remain private and protected and will not be released publicly. Review meetings are not open to the public.

Each member of the Committee has entered into, and is bound by, a confidentiality agreement that recognizes these interests and limitations.

Reviews are limited to the information and records collected for the purposes of furthering the coroner’s investigation. It is not the intent or mandate of the DVDRC to re-open or re-investigate cases, question investigative techniques or comment on decisions made by judicial bodies.

Annual Report

The terms of reference for the DVDRC direct that the Committee, through the Chairperson, reports annually to the Chief Coroner regarding the trends, risk factors, and patterns identified through the reviews, and makes appropriate recommendations to prevent deaths in similar circumstances.

Disclaimer

The following disclaimer applies to individual case reviews and to this report as a whole:

This document was produced by the DVDRC for the sole purpose of a coroner’s investigation pursuant to section 15 (4) of the Coroners Act, 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.

Chapter Two: Statistical Overview: A fresh new look

Collection of Data

Since its inception in 2003, a variety of data have been collected from homicide cases involving domestic violence that have been investigated by the Office of the Chief Coroner. As the Committee has evolved, so too have the processes for reviewing, collecting and analyzing information that has been gathered. The DVDRC strives to provide information and analyses that are accurate, valid and useful to relevant stakeholders.

Types of Data

It is important to recognize that there are two separate and distinct sets of data relating to domestic violence homicides in Ontario:

Data relating to the actual number of homicide cases where domestic violence has been identified as an involvement factor.

In Ontario, a Coroner’s Investigation Statement (Form 3) is prepared for all cases investigated by a coroner. The Form 3 includes basic personal information (e.g. date of death, age, address, etc.) pertaining to the deceased, as well as a narrative that describes the circumstances surrounding the death. Investigating coroners are encouraged to identify death factors (e.g. trauma – cuts/stabs, shooting – shotgun, asphyxia-hanging, etc.) and involvement factors (e.g. abuse – domestic violence, alcohol involvement, Children’s Aid involvement, etc.). The Form 3 also identifies the “manner of death” or “by what means” the death occurred. In Ontario, manner of death must be identified as one of the following: natural, accident, suicide, homicide or undetermined. Information from the Form 3s for all coroners investigations are maintained within the Coroners Information System (CIS) maintained by the Office of the Chief Coroner.

Statistics generated for the purposes of this Annual Report reflect cases occurring from 2002-2009 where “homicide” has been identified as the manner of death and “abuse – domestic violence” has been identified and coded as an involvement. Some cases where the manner of death is “undetermined” and there is involvement of domestic violence, are included in the data set.

2009 is the last available year that has been officially “closed” within the CIS. “Closed” cases have undergone quality assurance reviews to ensure accuracy and completeness.

It is important to note that some homicide cases identified with the “abuse – domestic violence” involvement code occurring between 2002-2009 are still pending review by the DVDRC. In many cases, DVDRC reviews have not commenced because legal or other proceedings are still underway or pending.

Data relating to the findings of cases that have undergone review by the DVDRC.

The second set of data relates to cases that have undergone review by the DVDRC. These data would include information pertaining to risk factors, type and length of relationship and number/gender of victims and perpetrators. This data is collected in the thorough review conducted by the DVDRC.

The following statistics reflect the findings of analyses of the two different data sources.

Statistical Overview: Homicides with Domestic Violence Involvement (2002-2009)

The following statistics relate to homicides (or in some cases undetermined deaths) in Ontario occurring between 2002-2009 where “abuse – domestic violence” has been identified as an involvement code. Some of these cases may have already undergone review by the DVDRC while others are pending review upon completion of other proceedings (e.g. criminal trials or inquests).

Chart One: Homicides with Domestic Violence Involvement (2002-2009)


Domestic Violence Deaths in Ontario 2002-2009

	2002	2003	2004	2005	2006	2007	2008	2009	Totals
Number of cases	30	22	22	29	33	27	20	20	203
Homicides	19	18	13	21	26	17	15	15	144
									71%
Homicide-Suicides	11	4	9	8	7	10	5	5	59
									29%
Total number of Deaths	46	26	32	37	52	44	29	29	295

Total number of Homicide Victims	35	22	23	29	45	34	24	25	237
									80%
Female (adult)	26	19	21	29	28	27	20	20	190
									80%
Female (child)	4	1	1	0	8	1	0	3	18
									8%
Male (adult)	4	1	1	0	3	4	4	2	19
									8%
Male (child)	1	1	0	0	6	2	0	0	10
									4%
Average age of Homicide Victim	37.8	34.9	40	38.2	28	34.7	43.3	37.2	36

Total number Perpetrator deaths (suicide or other)	11	4	9	8	7	10	5	4	58
									20%
Female (adult)	0	0	1	0	0	1	0	0	2
									3%
Male (adult)	11	4	8	8	7	9	5	4	56
									97%
Average age of Perpetrator	42.5	45.5	42.2	45	51.1	45.2	43.8	60	45.8

Summary of Chart One: Homicides with Domestic Violence Involvement (2002-2009)

There were 203 domestic homicide and domestic homicide-suicide cases that occurred in Ontario between 2002-2009.
71% of the cases were homicides and 29% of the cases were homicide-suicides.
The 203 cases resulted in 295 deaths.
80% of these deaths were homicide victims and 20% were perpetrators who committed suicide or were otherwise killed (e.g. shot by police).
80% of the homicide victims were adult females.
12% of the homicide victims were children.
8% of the homicide victims were adult males.
97% of the perpetrator deaths were adult males.
The average age for homicide victims was 36 years.
The average age for perpetrators who died was 45.8 years.

Death Factors

Death Factors are utilized within the Coroner’s Information System (CIS) to assist with data retrieval/extraction and analysis. Death factors describe the underlying mechanism or force responsible for non-natural deaths (e.g. Trauma – motor vehicle collision); or the anatomical area or system involved for natural deaths (e.g. Cardiovascular system, Central Nervous system). Coroners are encouraged to identify the death factor most appropriate to the circumstances of the situation, and which lead to the fatal injuries sustained by the victim.

Chart Two illustrates the top death factors cited in all domestic violence deaths (homicides and perpetrator deaths) identified in the Coroners Information System from 2002-2009.

Chart Two: Top Death Factors in Domestic Violence Deaths (2002-2009)

Death Factor *	2002	2003	2004	2005	2006	2007	2008	2009	Total	% of Total Deaths
Trauma - cuts, stabs	15	8	11	9	21	14	8	11	97	33%	42%
Trauma - beating, assault	5	4	4	5	6	2	0	0	26	9%	42%
Shooting - handgun	8	5	2	4	1	9	1	3	33	11%	27%
Shooting - rifle	2	0	3	5	5	3	3	2	23	8%
Shooting - shotgun	7	1	2	2	2	2	1	2	19	7%
Shooting - weapon (not spec.)	0	0	1	0	0	0	1	0	2	1%
Asphyxia - airway obstruction	0	1	1	0	0	1	0	1	4	1%	13%
Asphyxia - strangulation	0	3	4	5	6	4	4	0	26	9%
Asphyxia - neck compression	0	0	0	1	2	0	2	3	8	3%
Other	9	4	4	6	9	9	9	7	57	19%	19%
Total	46	26	32	37	52	44	29	29	295

* Death factors as coded within the Coroners Information System (CIS) - the database of all cases investigated by the Office of the Chief Coroner for the Province of Ontario.

Summary of Chart Two: Top Death Factors in Domestic Violence Deaths (2002-2009)

42% of the deaths involved a death factor of Trauma (cuts/stabs and beating/assault combined)
26% of the deaths involved a death factor of Shooting (handgun, rifle, shotgun or gun not specified, combined)
13% of the deaths involved a death factor of Asphyxia (airway obstruction, strangulation and neck compression combined)
19% of the deaths involved other death factors including: Trauma by motor vehicle, train/vehicle or blunt force; Asphyxia from hanging, anoxic environment and carbon monoxide; Drug toxicity; Jump/fall; Fire with smoke inhalation or thermal injury; Burns – thermal; Drowning; and deaths where the factor was Unascertained.

Statistical Overview: Cases reviewed by the DVDRC (2003-2011)

Since its inception in 2003, the DVDRC has reviewed 144 cases that involved a total of 219 deaths. This includes 76 homicide and 68 homicide-suicide cases, some of which may have involved multiple victims.

The high number of cases reviewed in 2011 reflects a concerted effort on behalf of the DVDRC to commence reviews of pending cases where other proceedings (e.g. criminal trials, etc.) were completed and all murder-suicides where no additional proceedings were expected to take place.

The following statistics relate to all cases reviewed by the DVDRC from 2003-2011 inclusive.

Chart Three: Number of Cases Reviewed by the DVDRC (2003-2011)


			Type of Case
Year	# of cases reviewed	# of deaths involved	Homicides	Homicide -Suicides
2003	11	24	3	8
2004	9	11	5	4
2005	14	19	5	9
2006	13	21	4	9
2007	15	25	7	8
2008	15	17	13	2
2009	16	25	6	10
2010	18	36	6	12
2011	33	41	27	6
Total	144	219	76	68
			53%	47%

Summary of Chart Three: Number of Cases Reviewed by the DVDRC (2003-2011)

Since its inception in 2003, the DVDRC has reviewed 144 cases, involving 219 deaths.
53% of the cases reviewed were homicides.
47% of the cases reviewed were homicide-suicides.
The high number of cases reviewed in 2011 reflects a concerted effort on behalf of the DVDRC to commence reviews of pending cases where other proceedings (e.g. criminal trials, etc.) were completed and all murder-suicides where no additional proceedings were expected to take place.

Analysis of Risk Factors: Common risk factors

Based on extensive research, the DVDRC has created a list of 39 risk factors that indicate the potential of lethality within the relationship examined. The recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence through appropriate interventions by criminal justice system partners, including high risk case identification and management.

Risk factors include such things as: history of violence outside of the family, history of domestic violence, prior threats to kill the victim, prior threats or attempts to commit suicide, escalation of violence, actual or pending separation, age disparity in couple, etc. A complete list of all risk factors analyzed, as well as the definition of each, is included in Appendix B.

When reviewing a case, the DVDRC identifies which of the 39 risk factors were present in the relationship between the victim and the perpetrator.

Chart Four: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2011) demonstrates the top risk factors that have emerged from all cases reviewed by the DVDRC from 2003-2011. The most common risk factors are: history of domestic violence, actual or pending separation, obsessive behaviour, depressed perpetrator, prior threats or attempts to commit suicide, escalation of violence, prior threats to kill the victim, prior attempts to isolate the victim, victims who had an intuitive sense of fear and a perpetrator who was unemployed.

Chart Four: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2011)

Chart Four: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2011)

Summary of Chart Four: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2011)

When reviewing a case, the DVDRC identifies which of the 39 established risk factors were present in the relationship between the perpetrator and the victim.
74% of all cases reviewed between 2003-2011 involved a couple where there was a history of domestic violence
72% of the cases involved a couple with an actual or pending separation
The other top risk factors were: obsessive behaviour by the perpetrator, a perpetrator that was depressed, an escalation of violence, prior threats or attempts to commit suicide, prior threats to kill the victim, a victim that had an intuitive sense of fear towards the perpetrator and a perpetrator that was unemployed.

Analysis of Risk Factors: Number of risk factors per case

The recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence through appropriate interventions by criminal justice system partners, including high risk case identification and management.

Chart Five: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2011), clearly demonstrates that in the vast majority of cases (i.e. 76%), 7 or more risk factors were identified. For cases with 4 or more risk factors identified, this increases to 89%. The significance of this finding is that many domestic homicides may have been predicted and prevented with earlier recognition and action towards identified risk factors for future lethality.

Chart Five: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2011)

Chart Five: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2011)

Summary of Chart Five: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2011)

In 76% of the cases reviewed, 7 or more risk factors were identified.
In 13% of the cases reviewed, 4 to 6 risk factors were identified.
The combined proportion of cases with 4 or more risk factors was 89%.
In 10% of the cases reviewed, 1 to 3 risk factors were identified.
In 1% of the cases reviewed, no risk factors were identified.
The recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence.

Statistical Overview: Cases reviewed by the DVDRC in 2011

The following chart is a summary of all cases reviewed in 2011.

Chart Six: Summary of DVDRC cases reviewed in 2011


DVDRC case #	year of death	HOM	HOM-SUI	# of victims	age of victims	age of perp	gender victim		gender perpetrator		# of risk factors
			HOM-SUI				F	M	F	M
1	2010		x	1	64	71	x			x	3
2	2003	x		1	51	55	x			x	12
3	2005	x		1	21	26	x			x	11
4	2005	x		1	48	55	x			x	8
5	2002	x		1	32	36	x			x	8
6	2007	x		2	33	35	x			x	7
					34		x
7	2006	x		1	58	64	x			x	8
8	2005	x		1	25	21	x			x	8
9	2005	x		1	33	36	x			x	10
10	2005	x		1	41	46	x			x	6
11	2005	x		1	23	20	x			x	20
12	2005	x		1	60	61	x			x	0
13	2005	x		1	44	45	x			x	9
14	2008	x		1	52	46		x	x		14
15	2007	x		1	42	61		x	x		8
16	2008	x		1	48	37		x	x		18
17	2007	x		1	44	47	x			x	3
18	2008		x	2	46	41	x			x	4
					69		x
19	2006	x		1	29	35	x			x	8
20	2009		x	1	61	79	x			x	2
21	2004	x		1	40	51	x			x	15
22	2006	x		1	56	55	x			x	12
23	2007	x		1	40	41	x			x	10
24	2007	x		1	26	43		x	x		19
25	2007	x		1	16	17	x			x	4
26	2006		x	1	83	85	x			x	1
27	2008	x		1	51	58	x			x	9
28	2009	x		1	71	50	x			x	21
29	2009	x		1	37	31	x			x	14
30	2009		x	1	55	63	x			x	6
31	2009		x	2	25	27	x			x	13
					1		x
32	2008	x		1	44	41	x			x	1
33	2005	x		1	28	30	x			x	19

Total or Average		27	6	36	42.5	45.7	32	4	4	29	9.4

Summary of Chart Six: Summary of Cases Reviewed in 2011

There were 27 homicide cases and 6 homicide-suicide cases, resulting in 41 deaths (36 victims and 5 perpetrators*), that were reviewed in 2011.
The deaths reviewed in 2011 occurred as far back as 2002 and as recently as 2010.
Of the 36 victims in the cases reviewed in 2011, 32 (89%) were female and 4 (11%) were male.
29 (88%) of the 33 cases reviewed involved perpetrators that were male.
4 (12%) of the cases involved female perpetrators.
The victims ranged in age from 1 year to 83 years.
The average age for victims was 42.5 years.
The perpetrators ranged in age from 17 to 85 years.
The average age for perpetrators was 45.7 years.
The average number of risk factors identified in the cases reviewed was 9.4.
The number of risk factors ranged from 0 to 21.

*As one perpetrator committed suicide in another province, the homicides he committed are included in Ontario statistics, but his own suicide is not.

Analysis of Risk Factors: Number of risk factors per case

The data in Chart Seven: Number of Risk Factors Identified in Cases Reviewed (2011), is consistent with the findings of cases reviewed (2003-2011) which clearly demonstrates that the vast majority of cases resulting in domestic homicide or homicide-suicide, had a significant number of risk factors (i.e. 7 or more) and therefore were potentially predictable and preventable. It is important to again stress that the recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence.

Chart Seven: Number of Risk Factors Identified in Cases Reviewed (2011)

Chart Seven: Number of Risk Factors Identified in Cases Reviewed (2011)

Summary of Chart Seven: Number of Risk Factors Identified in Cases Reviewed (2011)

70% of the cases reviewed in 2011 had 7 or more risk factors
9% of the cases reviewed had 4 to 6 risk factors
18% of the cases reviewed had 1 to 3 risk factors
3% (which represents one case), had no risk factors identified•

Analysis of Death Factors

In Ontario, a Coroner’s Investigation Statement (Form 3) is prepared for all cases investigated by a coroner. Investigating coroners are encouraged to identify death factors such as trauma – cuts/stabs, shooting – shotgun, asphyxia-hanging, etc. in order to better understand the various elements or factors contributing to the death. Death factors are identified on the Form 3 and subsequently retained within in the Coroners Information System through standardized coding that is completed for each investigation.

Chart Eight: Death Factors for Cases Reviewed in 2011 shows that the majority of cases reviewed in 2011 involved some type of trauma including cuts, stabs, beatings, assaults and falls or jumps. The five deaths from shooting – shotgun (three victims and two perpetrators) resulted from one homicide and two homicide-suicide cases.

Chart Eight: Death Factors for Cases Reviewed in 2011

Death Factor *	Victim	Perpetrator
Trauma - cuts, stabs	16	1
Trauma - beating, assault	6
Trauma - fall/jump	1
Shooting - shotgun	3	2
Asphyxia - strangulation	6
Asphyxia - neck compression
Asphyxia - smothering	2
Drowning	1
Smoke Inhalation		1
Unascertained	1
Other**		1
Total # of deaths	36	5

* Death factors as coded within the Coroners Information System (CIS) - the database of all cases investigated by the Office of the Chief Coroner for the Province of Ontario.
** One perpetrator died from pneumonia after stabbing himself.

Discussion and Significant Findings:

In 2011, the DVDRC reviewed more cases than ever before. The high number of reviews is a result of a refined review process and a concerted effort to clear all cases where other proceedings (like criminal trials) were completed. The cases reviewed in 2011 included homicides and/or homicide-suicides that occurred as far back as 2002 and as recently as 2010.

The average number of risk factors identified from reviews conducted in 2011 was significant at 9.2 risk factors per case. This included one case where there were no risk factors and thus almost no predictability for future lethality. In another case, 21 risk factors were identified which implies that there was likely significant opportunity to predict (and prevent) future lethality.

Interestingly, in 2011, four of the cases involved perpetrators who were female. Five of the cases (two of which involved female perpetrators) involved victims and/or perpetrators who were identified as First Nation background. The implications of these findings are discussed further in

Chapter Four: Learning from DVDRC Reviews.

Chapter Three: Case Reviews and Recommendations - 2011

The following is a summary, together with recommendations made towards the prevention of future similar deaths, from the 33 cases reviewed by the DVDRC in 2011. In some cases, no recommendations were made as the Committee either saw no opportunity to recommend anything or the issues identified had already been the subject of recommendations made from previous case reviews.

Case DVDRC- 2011- 01
OCC file numbers: 2010-2686 and 2687

This case involved a 64-year-old female victim and the 71-year-old perpetrator who was her husband. The couple had been married for 46 years and had five adult children.

On March 7, 2010, neighbours heard screaming coming from the residence where the couple lived. Later that morning, the body of the perpetrator was found lying in a pool of blood in the driveway. He had sustained self-inflicted stab wounds to the neck, chest and abdomen. The victim was located inside the house with fatal incised wounds to her neck.

The victim and perpetrator seemed to live independent lives and were not demonstrative of any affection with each other. Their children described them as unhappy, with verbal abuse occurring frequently between them. There were no previous reports of any physical violence.

Three risk factors were identified.

No new recommendations.

Case DVDRC-2011-02
OCC file number: 2003-16227

The victim and perpetrator were involved in a common-law relationship. One week before her death, the 51-year-old victim went for a hike with the perpetrator and told him that she wanted to separate and split their assets. The argument continued back at the house and the perpetrator held a knife to the victim’s throat.

On November 23, 2003, the victim and perpetrator went for a walk at a conservation area. During the walk, the victim allegedly fell over a cliff while investigating a noise. The perpetrator claimed he ran to assist the victim after he heard her scream, then ran to a nearby house to call for help. The death was not initially seen as suspicious and was ruled accidental.

New information came to light when family and friends told police that the perpetrator had been having an affair. The perpetrator was also reportedly very controlling and abusive towards the victim. He had verbally and physically abused her, isolated her from friends and family, and treated her like a slave. Further police investigation lead to the conclusion that her death was a homicide.

Twelve risk factors were identified.

Common themes: public education (Neighbours, Friends and Families), training for family law lawyers

Recommendations:

The Law Society of Upper Canada should adopt a policy of ensuring that lawyers who do deal with family clients are aware of the risk and safety issues in domestic violence cases.
Domestic violence and risk assessment should be part of the mandatory Ethics & Professional Responsibility course to be required by law schools for all students starting with the class of 2015.
Domestic violence should be part of the now mandatory CLE requirement for practicing lawyers, at least for those who practice family law.

Committee Comments: This case represents one of many that have been reviewed where abuse victims have sought advice from family law lawyers shortly before being killed by their partner, usually as part of the separation process. It is critical that education programs are available at the pre-service (law schools) and continuing education or specialization programs for family lawyers.

Case DVDRC-2011-03
OCC file number: 2005-10389

This case involved a 21-year-old female victim and her 26-year-old boyfriend who was the perpetrator. The couple had an on-again/off-again relationship for two years. There were accounts from both family and friends that both had tried to end the relationship on several occasions. The perpetrator was involved with several women at one time.

In July 2005, the perpetrator went to the victim’s bedroom and for unknown reasons, began to beat her with his fists. He stomped on her stomach and hit her in the face multiple times with a wine bottle.

Following the beating, the perpetrator took an unknown amount of cash from the victim’s residence and proceeded to toss the money in the air as he ranted and raved while walking naked along the road. Residents in the neighbourhood called police and the perpetrator was arrested.

The victim subsequently succumbed to the injuries inflicted by the perpetrator.

The perpetrator had several previous relationships that were troubled. He had a history of being violent with family members. There were several accounts of the perpetrator previously assaulting the victim. In 2004, the victim miscarried after an altercation with the perpetrator.

Eleven risk factors were identified.

Common themes: training in the detection of DV by hospital emergency staff (relating to the miscarriage in 2004); Neighbours, Friends and Family and the use of social media for disseminating information

No new recommendations.

Case DVDRC-2011-04
OCC file number: 2005-11624

The victim and perpetrator met in 1995 while in Vietnam and the perpetrator sponsored the victim to come to Canada in 1997 where the couple were subsequently married in an “arranged” marriage.

In August 2005, the 48-year-old female victim and 55-year-old male perpetrator had an argument because the victim wanted a divorce and the perpetrator did not.

The perpetrator left for work on the night shift and returned home the next morning. The couple began arguing and their 5-year-old son witnessed his father grab his mother and take her down to the basement. He saw his father sit on his mother and then his mother became quiet.

The perpetrator then contacted his own mother and asked her to come to the residence immediately. He told her that he and his wife had an argument and that his wife was in the basement. The perpetrator’s mother observed the victim (her daughter-in-law), lying on the basement floor, naked from the waist down, but she did not call for medical assistance. The perpetrator’s brother arrived later and found the victim lying on the floor and cold to the touch. He called 911 and advised them that the victim needed medical assistance and that his brother had taken an overdose of sleeping pills. Ambulance personnel attended and found the victim to be deceased.

Eight risk factors were identified.

Common themes: need for outreach in mental health and domestic violence awareness/ prevention programs, particularly in culturally diverse communities.

No new recommendations.

Case DVDRC-2011-05
OCC file number: 2002-14112

The 36-year-old male perpetrator and 32-year-old female victim lived in distant cities and started a long distance relationship. The perpetrator had a job, but not in the chosen profession to which he aspired. The perpetrator subsequently relocated and moved in with the victim.

The victim had an estranged husband who was still living in China. The husband moved to the city where the victim was living with the perpetrator. The victim and her husband decided to try and save their marriage, so the couple moved into another apartment while the perpetrator was out of town.

When the perpetrator returned home, he found a note from the victim indicating that she and her husband were reconciling and had moved out. As the apartment was in the victim’s name, the perpetrator was told that he had to move out.

On November 7, 2002, the victim was upset and contacted the perpetrator to tell him that she had been diagnosed with cancer.

The perpetrator and victim met up in a parking lot outside of her residence later that day. The perpetrator was upset about the victim returning to her husband, her medical ailments, his inability to work in his chosen profession, being forced to find new accommodations and not having any support network or close friends. The perpetrator stabbed the victim repeatedly while she sat in her car outside of her residence. He then phoned police to say that he had killed his girlfriend.

Eight risk factors were identified.

Common themes: safe separation, support services (the perpetrator was failing in his chosen profession)

No new recommendations.

Case DVDRC-2011-06
OCC file numbers: 2007-1349 and 1350

Victim 1 was the 33-year-old wife of the 38-year-old perpetrator. The couple was separated, but shared custody of their two children (ages 3 and 4 years) and maintained two residences that were also shared. The couple had been married for nine years.

Victim 1 was involved in a new relationship, and Victim 2 was the 34-year-old separated wife of Victim 1’s new partner.

Victim 2 was not in any way involved in the relationship between the perpetrator and Victim 1.

Two weeks prior to the homicides, Victim 1 told the perpetrator (her husband) that she would not be reconciling with him. The perpetrator was aware that Victim 1 had recently gone on vacation with her new partner (the separated husband of Victim 2) and that the couple had spent time in the matrimonial home that the perpetrator and Victim 1 still shared on an alternating weekly basis.

On February 8, 2007, the perpetrator discovered the home address of Victim 2. From their investigation, police believe the perpetrator attended the residence of Victim 2 on February 8 and February 10, 2007, but left when he determined that she was not home.

On February 11, 2007, the perpetrator and Victim 1 spent the day with their children and went to church, brunch and dinner together.

On the evening of February 11, 2007, the perpetrator attended the residence of Victim 2, gained entry into her home and strangled her. He then transported her body to the matrimonial residence he shared with Victim 1. The perpetrator then attacked and cut the throat of Victim 1 in her bedroom. A crumpled photograph of Victim 1 with her new partner was found near her body.

The couple’s two children were asleep in the residence at the time, but were not harmed.

The perpetrator attempted to stage the scene to make it appear as though Victim 2 had killed Victim 1 and then hanged herself in the garage.

There was evidence that the perpetrator had a history of following Victim 1 by using a GPS tracking device. Police reports indicated that there was a history of non-consensual sex between the perpetrator and Victim 1.

Seven risk factors were identified.

Common themes: safe separation

No new recommendations.

Case DVDRC-2011-07
OCC file number: 2006-7233

On June 15, 2006, the 58-year-old female victim was found dead in bed in her residence. The cause of death was stab wounds to the neck and chest associated with blunt force injury to the head. The perpetrator was the victim’s 64-year-old husband who sustained self-inflicted, non-lethal injuries. The perpetrator’s head was resting on a religious statue and another statue was found near the victim. The perpetrator was charged with first degree murder and was found not criminally responsible.

The couple had been separated for many years, but the perpetrator was temporarily residing with the victim since his recent discharge from a hospital psychiatric ward following an admission for a serious suicide attempt.

A few days prior to the incident, the couple’s son said that his father told him that he was “not right and something was going to happen.” The daughter-in-law suggested that the perpetrator go back to the hospital as he needed help. She also indicated that she was afraid to have the perpetrator in her house. The victim indicated that she was afraid to be alone with the perpetrator.

The victim advised the perpetrator that he could not live with her any longer. She told the perpetrator that he would be going into a mental institution; the perpetrator was not happy about the future of residing in an institution.

Eight risk factors were identified.

Common themes: mental health and domestic violence

Recommendations

Psychiatrists and other mental health workers are reminded that documentation about suicidal and homicidal ideation are important components of assessing a patient for either involuntary admission or suitability for release from hospital.
Committee Comments: Suicidal ideation is frequently documented. Homicidal ideation however, is rarely documented. It is not clear whether this is merely an oversight in documentation or reflects the fact that mental health professionals are not considering homicidal risk.
When assessing patients either for involuntary admission or release from hospital, a variety of sources of information should routinely be sought, including family members.
Committee Comments: Recognizing issues of patient confidentiality, it is apparent that mental health workers rely heavily, if not exclusively, on the history and/or thoughts of the patient only. Other sources of information, including family, may provide valuable insight or corroboration that will assist the mental health assessment. In this case, the family had grave concerns about the release of the patient/perpetrator. The family had considerable fear of the patient/perpetrator and concerns about his release, yet he was released into their care because of lack of resources to accept him elsewhere.

Case DVDRC-2011-08
OCC file number: 2006-7233

The 20-year-old male perpetrator and the 25-year-old female victim had been dating for approximately one year, but their relationship reportedly ended just prior to the homicide.

On February 14, 2005, the perpetrator had visited with his sister at her apartment, along with his sister’s boyfriend, his mother and the perpetrator’s female friend. The group apparently drank together throughout the afternoon and evening. The perpetrator phoned the victim and asked her to come over.

The perpetrator’s sister reported that her brother and the victim got into a verbal argument. The sister and her boyfriend left the perpetrator and victim alone.

In the early hours of February 15, 2005, the victim placed a phone call to a male friend. He did not answer his phone so the victim left a message that indicated that she was having an argument with a male.

Some time after the victim’s attempted phone call, the perpetrator entered his sister’s apartment and told her that the victim was not moving and that she needed an ambulance. He uttered to her that there had been an argument, that the victim had tried to stab him and that he had stabbed her in return.

There was no history of physical violence between the victim and perpetrator. The perpetrator had a criminal record for mischief, fail to comply and assault with a weapon.

Eight risk factors were identified.

No new recommendations.

Case DVDRC-2011-09
OCC file number: 2005-14305

The couple had been married for 10 years and had recently been divorced in Korea. The 33-year-old female victim had custody of the children, ages 6 and 8. The victim and her 36-year-old ex-husband (the perpetrator), were living together on a temporary basis, in an apartment they shared with their children.

The victim worked in a restaurant and her colleagues were aware of the problems she was having at home. When she did not show up for work, a co-worker went to check on her. The co-worker was met by the victim’s ex-husband, who stated that the victim would not be going to work that day.

The co-worker was suspicious and told her employer about her concerns. The employer sent another staff member to the victim’s residence to check on her well-being. The perpetrator answered the door, and indicated that the victim had taken the children to school and was not at home.

The staff member returned to the restaurant and told the employer what had transpired. The employer knew about the woman’s marital discord and was aware that the victim was involved in a fight with her ex-husband the night before. The employer was concerned, so he attended the building where the victim lived and when he noticed that the victim’s car was still in the parking lot, he contacted police.

When police arrived, the perpetrator allowed them into the residence where they found the victim’s covered body on the floor. The couple’s two young children were in the home and were not harmed.

The perpetrator admitted to police that he and the victim had been fighting for several weeks over financial matters. The perpetrator admitted to strangling the victim.

The perpetrator had a history of mental health issues and the victim had indicated to friends that her ex-husband sometimes “went crazy.” The perpetrator was apparently very depressed, was suffering from insomnia and had attempted suicide by ingesting pills while living in Korea.

The victim had sought assistance from an advisor at an immigration settlement consulting firm. The day before her death, the victim had confided to her advisor at the immigration consulting firm (through a telephone conversation and online messaging), that her ex-husband abused her, that she was afraid of him and that he had threatened to take their children back to Korea if she did not reconcile with him. She indicated that her ex-husband had taken possession of the children’s passports. The advisor contacted his lawyer for advice and it was suggested that the victim take her children to a shelter for safety. The victim physically attended the advisor’s office later that same day and asked him to call police. The advisor said he did not want the police coming to his office and advised her to go home and call from her home. The victim stated that she could not do this as her ex-husband was there with the children and that he would not let her leave the apartment if she returned home again. Despite these fears, the victim returned home because of the children.

On the same day, the victim also reached out to a friend who suggested that she seek legal assistance for the custody issues. The friend did not know about the abuse, although she had allowed the victim to sleep at her residence a number of times in the previous two weeks so the victim could avoid her ex-husband’s demands for sex.

Ten risk factors were identified.

Common themes: immigration issues and language barriers (including Neighbours, Friends and Families for immigrant communities), unemployment and mental health, workplace education on intimate partner violence, the needs of children who witness (or possibly witness) homicides.

No new recommendations.

Case DVDRC-2011-10
OCC file number: 2005-9549

The 41-year-old female victim returned from a visit to her native country in July 2005 where she had traveled with her two daughters (ages 9 and 15) to visit her grandmother, and reportedly, a male cousin with whom it was alleged she was having an affair. While she was away, her 46-year-old husband (the perpetrator) opened a letter addressed to her from the male cousin that indicated a strong emotional attachment between the victim and her cousin.

The couple had been married for sixteen years in an arranged marriage. On the day of the killing, the victim and perpetrator argued. The victim had reportedly indicated her intention to divorce the perpetrator and return to her native country. They went upstairs to their bedroom to pray at about 9:00 p.m. and then lay down on the bed. The youngest daughter was on the bed between her parents. They continued to argue in front of their youngest daughter until the perpetrator left the bedroom and got a hammer from the kitchen. He returned to the bedroom and began to repeatedly strike the victim in the head with the hammer; the youngest daughter, who was witnessing the beating, began to scream. The screams brought the older daughter upstairs to see what was going on. When she got to the bedroom, she tried to intervene to stop the beating of her mother. The father stopped the assault and he and his daughters returned downstairs.

Just before midnight, the perpetrator phoned a friend who came to the house. The children were crying when he arrived, and although the friend never saw the victim, the perpetrator indicated that he had beaten her and that he had checked on her and she was still alive and breathing.

During this time, the youngest daughter also phoned some other family friends, crying and telling them that her mother was sick and needed help. When they arrived at the house, the perpetrator reported that he had hit his wife. The perpetrator refused to allow the friends to see his wife. At that point, they advised him to call the police and he did so, telling the police that he had pushed his wife and she had fallen.

When police arrived, the perpetrator met them at the front door and reported that he could not control his temper and had assaulted his wife. He then directed them to the second-floor bedroom where they found the victim alive, but unresponsive with signs of massive trauma to the head and face. The victim had injuries to both hands that were felt to be consistent with defensive wounds. She was transported to hospital, but was subsequently pronounced dead.

Six risk factors were identified.

Common theme: safe separation

No new recommendations.

Case DVDRC-2011-11
OCC file number: 2005-13598

On September 10, 2005, the 20-year-old male perpetrator and 23-year-old female victim had a verbal argument over the perpetrator’s use of drugs. He slit his wrists and was transported to the local hospital. The injuries were deemed minor and he was treated and released with a follow-up appointment with a mental health counsellor. The perpetrator did attend this appointment.

Following this incident, the victim moved in with her aunt and uncle because she said she felt safer at that location. The following day, the perpetrator also moved in. The victim reported to an acquaintance on September 18, 2005 that she was staying with the accused out of a sense of guilt and that she planned on leaving him.

On September 23, 2005, the victim and the perpetrator had a verbal argument.

On September 24, 2005 the victim told her boss about the argument the previous night. Another co-worker noticed that the victim didn’t look well and appeared that she was about to cry. The victim did not disclose what was wrong.

At 4:00 p.m. that day, the victim and the perpetrator went to her apartment to clean it up and subsequently returned to the aunt’s house at about 6:30 p.m., where they immediately went downstairs to their living area.

The next morning, the uncle was awoken by the victim calling his name. He ran to the kitchen where he found the perpetrator leaning over the victim with a knife in his hand. The uncle wrestled with the perpetrator in an effort to secure the knife and the victim managed to get to a phone and dial 911. The accused grabbed another knife and stabbed himself in the chest and slashed his forearm. The victim had been stabbed in the neck, chest and abdomen. The victim succumbed to her injuries.

The perpetrator had alcohol problems since his early teens. Due to his unmanageable behaviour, he was placed in the care of the Children’s Aid Society (CAS) when he was 12 years old and voluntarily left their care at the age of 17. He had several convictions as a youth, including assault, forgery, theft, dangerous operation of a motor vehicle and failure to comply with release conditions.

Twenty risk factors were identified.

Common themes: Neighbours, Friends and Family; workplace safety

No new recommendations.

Case DVDRC-2011-12
OCC file number: 2005-9902

On July 22, 2005, the 60-year-old female victim died of drowning and acute Fentanyl intoxication. Her 61-year-old husband admitted to holding his wife’s head under the bathtub water after an attempt to assist her suicide with carbon monoxide failed. She had apparently cut her wrists just prior to the immersion in the tub.

The couple had planned a suicide pact over the past few years.

The perpetrator stated that following his wife's death, he arranged their financial matters and then attempted to end his own life by hanging and cutting his throat. He was unsuccessful in both attempts.

The couple apparently had a good marriage and there was no history of domestic violence or criminal activity.

In 1999, the victim developed severe back and leg pain that became chronic, resulting in her becoming quite depressed. This was identified by the couple as the trigger that changed their lives. The perpetrator chronicled the medical history of his wife from 1999 until January 2005. There were many referrals to specialists with subsequent investigations, treatments and offers of treatments. There was a sense of cynicism and negativism regarding the health care system, even as it related to the victim’s other medical conditions.

No risk factors were identified.

No common themes.

No new recommendations.

Case DVDRC-2011-13
OCC file number: 2005-05

On New Year’s Eve, the 44-year-old female victim told her husband, the 45-year-old perpetrator, that she would not be home from work until late. The couple’s daughter left a note for her mother that said, “Happy New Year. I hope this year will finish off loose ends…and the family will get back together again without (Perpetrator).”

The perpetrator saw the note written by his daughter. He went upstairs and consumed a bottle of wine and a bottle of champagne.

The victim came home between 7:00 and 9:00 p.m. The perpetrator apparently overhead the victim talking on the phone with the man he believed she was having an affair with.

The perpetrator told the victim that he did not want her to go out. When the perpetrator realized that the victim still intended to go out for the night, he retrieved his fishing knife from his bedroom and stabbed the victim repeatedly. The perpetrator then drove to a deserted field where he was planning to stab himself. He became frightened and decided to turn himself into police.

Approximately two months before the homicide, the victim told the perpetrator that she wanted a divorce. The perpetrator agreed to a separation where they would co-exist in the same home and he moved into the basement of the house. During this time, the perpetrator tried to reconcile with the victim and sought help from his church. Separation papers were served just prior to the homicide.

Nine risk factors were identified.

Common themes: education for clergy, workplace intervention, education for family law lawyers, alcohol abuse and domestic violence, safe separation.

No new recommendations.

Case DVDRC-2011-14
OCC file number: 2008-7828

The female perpetrator and male victim, both alcoholics, began drinking early the morning of June 28, 2008. When they ran out of alcohol, they asked a friend to take them to the nearby town to get more. After obtaining more alcohol, they were joined by the victim’s sister and the three drank and played cards into the evening. The victim then went to bed and his sister returned home.

The perpetrator went to the bedroom and lay beside the victim and began to make sexual advances towards him. An argument ensued and the perpetrator went to the kitchen, retrieved a knife, returned to the bedroom and stabbed the victim once in the chest. The victim laid back and stopped breathing. The perpetrator called 9-1-1 and reported that someone had entered her home while she and the victim were sleeping and stabbed him.

The victim was a 52-year-old male who was a member of a First Nation community. He was unemployed and receiving social assistance for most of his life. The victim was never married and did not have any children. He was a severe alcoholic and a diabetic. He had prior contacts with the police for minor drinking offences, but did not have a criminal record and was not considered dangerous.

The perpetrator was a 46-year-old female who was also a member of the same First Nation community. She was unemployed, but was registered to have a small business out of her home. She was receiving social assistance. She had two adult children from a previous relationship. Her mother suffered from Alzheimer’s disease and the perpetrator was caring for her in the home; this proved to be an extreme stressor for the perpetrator.

The perpetrator was an alcoholic, had epilepsy, and was also suffering from Multiple Personality Disorder. She had repeated suicide attempts and was under the care of a psychiatrist.

The perpetrator had an extensive criminal record dating back to 1980. She had 38 convictions including theft, break and enter, breach probation, numerous assaults as well as a conviction for aggravated assault.

The perpetrator had also been previously charged with Aggravated Assault for stabbing another male in the stomach. The case was withdrawn as police could not locate the injured victim.

Fourteen risk factors were identified.

Common themes: Neighbours, Friends and Families (within First Nation communities)

Recommendation:

To the Ontario Federation of Indian Friendship Centres; Ministry of Aboriginal Affairs and the Ontario Women’s Directorate:

Individuals and organizations providing services and support to Aboriginal communities are reminded that the Kanwayhitowin Campaign (based on the Neighbours, Friends and Family program) is a valuable resource to provide information and education on addressing the issue of domestic violence involving Aboriginal people in Ontario.

Committee Comments: Kanwayhitowin is a Cree word that means “Taking care of each other’s spirit” and is an Aboriginal campaign created to raise awareness about the warning signs and risk factors about domestic violence in Aboriginal communities across Ontario.

The campaign provides training and educational materials to community members so that people close to at-risk or abusive persons will be better able to provide support. This campaign has been adapted from the Ontario Women’s Directorate, Neighbours, Friends and Family (NFF) initiative to reflect a traditional and cultural approach to community healing and wellness. Like the NFF campaign, the approach is multifaceted and focuses on ending the isolation Aboriginal victims feel, empowering Aboriginal abusers to take responsibility and make changes in their lives, empowering community members to take leadership in educating themselves as to the warning signs of domestic violence and strategies for effectively dealing with domestic violence in their communities.

A variety of educational and awareness activities and resources such as brochures, public service announcements, CD ROM, training videos and guest speakers are available from the campaign website at www.kanwayhitowin.ca .

The campaign is administered by the Ontario Federation of Indian Friendship Centers. Further information on the campaign can be obtained at www.ofifc.org.

Case DVDRC-2011-15
OCC file number: 2007-4023

On Sunday March 11, 2007, the 61-year-old female perpetrator tried several times to call her friend, leaving messages to inform him that her husband was dead. Her friend did not respond immediately because he did not consider it urgent, based on his past experience with the perpetrator and believing that she had likely been drinking. The perpetrator had not sought any medical assistance for her husband. When the friend did arrive at the apartment, he tried to take the perpetrator to hospital for psychiatric help, but she refused. The friend then left the apartment and contacted police.

The 42-year-old male victim had likely been dead for a number of hours by the time the police arrived. He had a stab wound to his torso as well as multiple sharp force injuries to his head and cuts to his neck. There was significant blood around the apartment and it appeared that attempts were made to conceal the scene. The perpetrator provided police with several versions of how the incident happened. The perpetrator was found to be violating her probation as her conditions included not drinking alcohol and not having contact with her husband, the victim.

It appears that on the day of the homicide, the victim returned home from work at approximately 8:00 a.m. It is believed that both the perpetrator and victim were drinking together and began to argue over household bills. It is believed that the death occurred sometime between 8:00 a.m. and 10:00 a.m. There were no significant precipitants that could be identified and there were no witnesses.

The death occurred on March 11, 2007 and the perpetrator’s probation order was to end on March 15, 2007.

Conflicting information on the victim indicated that he was a devoted, loving and loyal husband, yet had a history of violent attacks on his partner, most of them occurring while under the influence of alcohol.

The perpetrator had a long history of mental health problems and alcohol abuse. She had a significant criminal record and was known to be both a victim and a perpetrator of domestic violence. The police had been called to the home she shared with the victim on a number of occasions to investigate reports of domestic violence incidents by both parties; in all cases except one, no charges were laid or if they were, they were later withdrawn.

According to the probation file, the perpetrator received extensive treatment while on probation from 2005 until the time of the homicide on March 11, 2007. She had been diagnosed with schizophrenia and was thought to be compliant with anti-depressant and anti-psychotic medication. She appeared to have been assessed by both a psychiatrist and a psychologist while she was in the correctional facility for women.

The perpetrator had extensive involvement with the Elizabeth Fry Society and attended individual counselling sessions on a weekly basis as well as participating in programs for anger management and substance abuse.

Eight risk factors were identified:

Common themes: Probation, isolation of victim due to language barriers

Recommendations:

To the Ministry of Community Safety and Correctional Services:

Probation and Parole Officers should be aware of the Partner Abuse Protocol when dealing with cases of partner abuse, and ensure attention to victim safety, recognizing that engagement with the victim is essential for victim safety.
Coordinated safety plans should be developed with the victim and with partner agencies in the community. In cases where the victim is not linked to any community services, the probation officer should do a safety assessment of the victim’s potential risk for violence and refer them to the appropriate community services, paying particular attention to any special needs of the victim.
Ongoing contact with the victim should occur in order to assess safety concerns and the abuser’s compliance with the probation conditions. This should occur on a regular basis, throughout the probation period. The probation officer should not rely solely on the abuser’s self report of compliance. Annual audits by area managers, as per established performance measures, should be conducted to "ensure that PPOs are supervising the case in accordance with the Partner Abuse Protocol."

Committee Comments: Conditions of probation should include regular monitoring of the abuser’s compliance with conditions, including ongoing home visits and contacts with collaterals in the abuser’s life to assess the credibility of the abuser’s self reports. In this case, the perpetrator appeared to be a master at impression management with the probation officers, but was in complete violation of her conditions. There was no safety check to determine the accuracy of her disclosures.

Probation and Parole Officers should also notify local law enforcement of any concerns in relation to offender compliance so that formal monitoring programs, (e.g. Crime Abatement Strategy, Bail Enforcement Program, etc.) or informal monitoring of offender compliance, can be conducted by law enforcement. This is particularly important in relation to any orders prohibiting or restricting contact between the offender and the victim.

Committee Comments: In this case, the victim was a newcomer to Canada and would have benefited from English as a Second Language (ESL) classes, as well as ongoing counseling focused on his safety, substance use and his own use of violence. He did have a steady job, but he worked an overnight shift and was quite isolated. As a result, he was quite dependent on his wife.

Case DVDRC-2011-16
OCC file number: 2008-10087

On Saturday October 25, 2008, the 37-year-old female perpetrator, her brother, her step-daughter and her step-daughter’s two sisters had been drinking at a friend’s house for several hours. They came back to the apartment that the perpetrator and 48-year-old male victim shared in order to drop off her dog prior to leaving to go to a bar. The women found the victim in the apartment and began to assault him by punching and kicking him. While the brother tried to break up the fight, during the course of the attack, the perpetrator stabbed the victim in the buttock with a large kitchen knife.

The women fled the apartment. The deep knife wound penetrated into the victim’s pelvis area, severing a major blood vessel. His body was discovered later by his roommate.

Two days prior to the stabbing, the perpetrator reported to police that she had been assaulted by the victim. She reportedly had gone to the victim’s apartment and had asked him and his friend for a ride. When the friend refused, she pulled a knife on him. The victim proceeded to disarm her and beat her.

When she later appeared in public with bruises to her face, her friends and family were outraged.

At the time of the homicide, the perpetrator was on probation for an incident in June 2008 in which she had stabbed the victim in the neck. A “stay away” order had been imposed.

The victim had no criminal record although there was an early occurrence report for an incident involving an assault on his ex-wife. There were also occurrence reports for disputes between him and the perpetrator. There are several references to his drinking, although it is not clear how heavily he abused alcohol, if at all.

The perpetrator had a childhood marked by physical and emotional abuse by her alcoholic mother and by sexual abuse perpetrated by her father, grandfather and brother. She reported repeated school failure and early behavioral problems. She had a long history of self-harm by cutting.

She had worked sporadically, although she had not worked for several years due to an injury to her back. The perpetrator had a history of drug abuse (cocaine) and alcohol dependence and was described as an alcoholic.

She had a long criminal history dating from 1995 for fraud and impaired driving and multiple convictions for violence including assault, assault with a weapon, uttering threats and aggravated assault. Three of these latter convictions were for assaults against the victim. Another assault with a weapon resulted from stabbing a man she had been dating. A charge of aggravated assault was laid in 2004 after she was involved in a serious beating of a man. At that time, she was bound by two probation orders for a charge of aggravated assault (March 2006) and failure to abide by a probation order (August 2007). The orders required her not to possess a weapon and not to be within 20 meters of the man she subsequently killed.

The perpetrator had one previous long term relationship which resulted in the birth of three sons, two of whom were taken into care by children’s services in 2004 for verified abuse by her and her common-law boyfriend.

She was described by several witnesses as unstable and the police files refer to her as emotionally disturbed. File information provides several diagnoses, most commonly for major depression and substance abuse disorder. There is reference on her probation file to hospitalization for at least three suicide attempts. She had also received a diagnosis of Borderline and Antisocial Personality Disorders. While on probation, she had been offered several programs including an inpatient substance abuse program and counselling for being a victim of domestic violence, but there is no reference to interventions to address her violence against others. She had been prescribed medication for her depression, but was non-compliant. Her history of participation in counselling and programs was marked by frequent absences and missed sessions

Eighteen risk factors were identified.

Common themes: mutual violence, alcohol/ substance abuse

Recommendations:

To the Ministry of Community Safety and Correctional Services (Probation Services and Policing Services); Ministry of the Attorney General:

It is recommended that social services/ probation examine the potential requirement for an intervention specifically designed for women perpetrators of violence and domestic violence.

Committee comments: This case involved a violent and disturbed woman for whom there was no file evidence that she received any intervention for her violence and substance abuse. The relationship in question involved at least some level of mutual violence. At several points in her contact with agencies, there may have been an opportunity to offer treatment or supervision:

at the time her children were removed
at any time that she was arrested for violent offences and was in prison
while she was under a probation order following a suicide attempt (after which she was placed on a Form 1 under the Mental Health Act.)

To the Ministry of Community Safety and Correctional Services and Ministry of the Attorney General:

The potential for lethal violence by women perpetrators with substantial violent histories, serious substance abuse problems and emotional instability should be taken seriously and when a high risk case is identified, steps should be taken to refer these women to appropriate treatment and more intensive supervision.

To the Ministry of the Attorney General, Victim and Vulnerable Persons Division:

The Victim and Vulnerable Persons Division should consider creating a public education program with information and resources specifically aimed towards assisting male victims of domestic violence.

Committee Comments: It is recognized that male victims of domestic violence may be impacted differently and may experience different societal reactions and responses than those experienced by female victims. Currently, the Neighbours, Friends and Family program provides appropriate education, supports and guidance with focus on female victims of DV, but support for male victims does not fall under the mandate of this program.

Case DVDRC-2011-17
OCC file number: 2007-13876

The 47-year-old perpetrator and his wife of approximately ten years, the 44-year-old victim, were both alcoholics. On October 28, 2007, they went to a local pub and became intoxicated after consuming a large amount of alcohol. The perpetrator had a conversation with another woman and this apparently angered the victim. They began to argue at the pub and the argument continued until they reached their home, where they were overheard by neighbours.

The argument continued in the kitchen and the victim apparently swung at the perpetrator. He retaliated and hit the victim repeatedly about the head. She fell to the floor and the perpetrator kicked her several times. The perpetrator then fell down beside the victim and went to sleep.

He awoke several hours later with the victim still lying beside him. He resumed his assault on her. He then left the kitchen and fell asleep in the living room. He awoke the next morning, changed his clothes and went back to the pub. When he returned home later in the day, he again went to sleep.

The next day, the perpetrator awoke, showered and cleaned himself up. He walked to the police station and confessed that he had murdered the victim. Police and EMS attended the residence and located the victim still lying on the kitchen floor.

The victim worked at various jobs but had a difficult time maintaining her employment because she was an alcoholic. She was also described as being depressed, although there was no evidence that she was clinically diagnosed with depression.

Her family attempted to get her help for her alcoholism and abusive relationship, but she refused. She was described by many neighbours, friends and past employers as unhappy, aggressive and verbally abusive towards the perpetrator. She admitted to being physically abusive towards him. Her verbal abuse was witnessed by many in the neighbourhood.

The perpetrator had been married previously and there was no evidence of abuse in that relationship.

He was an alcoholic who had two convictions for impaired driving. He lost his job after his second conviction, but eventually got work in a factory.

Three risk factors were identified.

Common themes: alcohol abuse by victim and perpetrator, history of mutual abuse between victim and perpetrator

No new recommendations.

Case DVDRC-2011-18
OCC file numbers: 2008-5668, 5684 and 5683

On May 17, 2008, the neighbour who lived in the unit beside the 46-year-old female victim and 41-year-old male perpetrator, heard a loud knock on his door. He opened it to find the 3-year-old son of the victim and perpetrator standing there with a bottle and a note in his hand. The note said “please tell my family I am sorry. Confession in car.” The note included several telephone numbers and indicated that the individuals at the numbers listed should be contacted.

The neighbour went to the victim and perpetrator’s unit, saw smoke coming out the windows, then heard an explosion. The entire unit then went up in flames. Three bodies were later located inside the residence, including the perpetrator, his wife and her 69-year-old mother.

One victim (his wife) died of a stab wound to the heart and the other (her mother) was strangled. The perpetrator died of smoke inhalation.

The perpetrator had a history of violence towards both the victim and others.

The victim and the perpetrator met in October 2002 and were married in May 2003. Arguments started soon after the couple was married and were witnessed or heard by various people. In December 2003, the police were called to the couple’s residence due to a verbal argument. In August 2005, the couple was arguing because the perpetrator wanted the victim to get a note from her doctor stating that she would need help after their baby was born. The victim was eight months pregnant at the time. The perpetrator apparently planned to take the note to immigration officials in order to bolster the process of having his extended family move to Canada to assist with raising the child. During this argument, the perpetrator pulled the victim’s hair and threatened that he would cut open her stomach and kill her, then himself.

Approximately one week later, the victim and perpetrator were again arguing over the note and the victim began to have an anxiety attack. She went to hospital via ambulance and disclosed the prior assault to the social worker there. The police were contacted and an investigation ensued. The perpetrator was charged with assault and three counts of threatening. In October 2005, he was charged with breach of undertaking as he had called the victim on two occasions. He pled guilty to all the charges (minus two threatening charges) and received a suspended sentence and 18 months probation.

Four risk factors were identified.

Common themes: immigration involvement, escalation of violence

No new recommendations.

Case DVDRC-2011-19
OCC file numbers: 20086-15138

On November 21, 2006, the perpetrator and his wife, the 29-year-old victim, were at home when they got into an argument and the perpetrator struck the victim in the head. She fell to the floor and the perpetrator repeatedly kicked her in the abdomen and legs. The couple then went to bed.

During the night, the victim asked for a glass of water. The perpetrator got her water and a short time later, he noticed that she was not breathing. He called 9-1-1, and when the emergency medical services arrived, the victim was found deceased.

The perpetrator admitted to one of the emergency responders that he had struck and kicked his wife prior to going to bed.

In 1998, the victim’s father arranged for her to marry the perpetrator. After marrying, the victim remained in India while the perpetrator traveled to Canada to finish his education. She was a housewife with very little outside contact other than her husband, landlords and others in her temple.

The victim’s family in India was supportive of her and worried about her living in Canada with the perpetrator. The perpetrator had apparently been abusive towards the victim prior to coming to Canada.

The couple did not have any prior contact with police.

Eight risk factors were identified.

Common themes: Neighbours, Friends and Families

No new recommendations.

Case DVDRC-2011-20
OCC file numbers: 2009-5211 and 5210

In March 2009, as a result of financial and other stressors, the 61-year-old female victim entered into a severe bout of depression. Medication did not seem to be helping so the victim sought outside help. She had a neighbour who was studying to become a minister and he considered himself to be a spiritual healer. Both the victim and 79-year-old male perpetrator began counselling with the neighbour/spiritual healer one week prior to their deaths.

On April 30, the neighbour met with the victim and the perpetrator. The victim reported that she was quite depressed and stated that she did not want to live any more.

On May 2, 2009, the perpetrator’s neighbour saw him leave his residence accompanied by the victim. Later that day, the couple’s bodies were found next to the perpetrator’s vehicle in a parking lot near a trail area. Subsequent investigation concluded that the perpetrator had shot the victim, then himself.

A detailed note was located on a table in the kitchen of the perpetrator’s residence. The note recorded that in the past, the victim had suffered from depression for which she had been “doped up and locked up” for several months. She was afraid it would come to that again and the perpetrator had agreed to shoot her should that happen again. The victim was apparently ready to commit suicide and the perpetrator indicated that he could not go on without her.

The victim and the perpetrator met approximately two years prior to their deaths. The victim’s mother lived in the same senior’s complex as the perpetrator. The victim and the perpetrator began socializing and started dating one year prior to their deaths.

The perpetrator was reportedly in good health, led an active life and enjoyed hunting. He had no mental health issues and did not have a criminal record. He had a valid firearms license and owned three registered firearms.

Two risk factors were identified.

Common themes: mental health

No new recommendations.

Case DVDRC-2011-21
OCC file numbers: 2004-8230

On July 1, and into the early morning hours of July 2, 2004, the 40-year-old female victim was out drinking with the 51-year-old male perpetrator. A friend who lived in the same building saw the couple arguing at a bar. The victim and perpetrator subsequently went separate ways during the night and the victim met up with a different man at another tavern. The victim brought the man back to her apartment and the perpetrator was there when they arrived. At 0130 hours, the man left the apartment because he was uncomfortable and sensed the victim and perpetrator were still in a relationship.

A neighbour heard the perpetrator and victim arguing later that night. At 0313 hours, the perpetrator called 9-1-1 to report that “an unknown boyfriend of the victim’s had just stabbed her and fled the apartment.” Police responded and found the victim in her apartment, on the couch, with a stab wound to the chest. She was transported to hospital where she was pronounced dead.

The victim was from a local First Nation community and was known to have a drinking problem and anger issues while intoxicated. She had been banned from attending certain bars because of her aggressive behaviour.

The perpetrator had a history of violence, alcohol abuse and using weapons against women. He had an extensive criminal history dating back to 1969.

The perpetrator had been in three previous intimate relationships prior to his relationship with the victim. He was reportedly very abusive to his former partners, and was known to use extreme physical violence, particularly when he was intoxicated. Some of these incidents included the use of a weapon. However, he had only one previous charge for domestic violence officially on his record, as most of the domestic violence charges against him had been withdrawn.

Fifteen risk factors were identified.

Common themes: repeat domestic violence offenders; Neighbours, Friends and Families

Recommendations:

To the Department of Justice, Canada:

The Minister of Justice for Canada should implement legislation that will provide for minimum sentences for domestic violence offences. It is suggested that for a second conviction, the minimum sentence should be at least 6 months in jail. For a third or subsequent offence, the minimum sentence should be at least 12 months in jail.
It is recommended that legislation be amended so that assault in a domestic context, be listed as an eligible offence for application of long-term offender status.

Committee comments: There are difficulties with the current dangerous offender – long term offender legislation in the context of domestic violence. Presently, an offender would have to commit and be convicted of a serious personal injury offence in order to qualify for application of the status. Therefore, if an offender commits simple assaults in a domestic context on a repeated basis and over a length of time, the Crown is unable to bring forth an application for dangerous offender or long-term offender status. Currently there are a number of listed offences that are not serious personal injury offences that the legislation specifically allows to be considered for application of the dangerous offender or long term offender status (e.g. possession of child pornography). Assault, in a domestic context, should be listed as an eligible offence for long-term offender application.

To the Ministry of the Attorney General, Crown Law Office:

The Ministry of the Attorney General, Crown Law Office, should have enhanced vigilance in identifying serial domestic violence offenders and should seek an application to the court to have the offender declared a long-term or dangerous offender, when appropriate.

Committee comments: This case involved a repeat domestic violence offender who continued to demonstrate a pattern of abusive behaviours across a number of different relationships until the final homicide. This pattern of behaviour is not uncommon with perpetrators of domestic homicide. Despite numerous incidents involving severe domestic violence, charges were frequently withdrawn, so that by the time of the homicide, the perpetrator’s criminal record was relatively sparse. Enhanced vigilance in identifying these repeat offenders would lead to more appropriate consequences for their recidivist behaviours.

To the Ministry of the Attorney General:

The Ministry of the Attorney General should implement a policy that requires the consent of the Assistant Deputy Minister for Criminal Law for any reduction of a murder charge to manslaughter by way of plea resolution for cases that involve domestic violence.

Committee comments: This case represents one of many the committee has reviewed where a domestic violence perpetrator who commits a homicide seems to benefit from the charges being reduced (Dawson, 2004, p. 42, 53) to manslaughter by the Crown based perhaps on the perceived lack of evidence on intent or pre-meditation to kill his partner. Often there may be evidence about alcohol abuse or mutual conflict / violence which muddies the events leading up to the homicide. However, in this case and others that have been reviewed by the committee, the perpetrator has demonstrated a pattern of abuse and violence within both the current and previous intimate relationships, to the extent that the danger of his behaviour and the potential consequences should be apparent in advance of the homicide. The homicide would often seem therefore to be predictable and preventable with hindsight.

We would draw a parallel within the justice system to drinking and driving offences in which the consequences of killing someone on the second or third offence of drinking and driving would draw significant consequences. The committee believes that this recommendation would send an important message to society and perpetrators of domestic violence that domestic homicides won’t be readily plead down to manslaughter in the face of evidence of prior patterns of abuse within that relationship or prior intimate relationships.

References:

Dawson, M. (2004). Criminal justice outcomes in intimate and non-intimate partner homicide cases. Research and Statistics Division, Dept. of Justice Canada.

Case DVDRC-2011-22
OCC file numbers: 2006-13306

On Monday, October 16, 2006, the 55-year-old male perpetrator called police to report that he had killed his 56-year-old wife with a hammer. The victim was found deceased from blunt force head injuries at the residence she shared with her husband. The couple had been married for 31 years and had two adult children.

Just prior to the homicide, a neighbour heard the couple arguing. The perpetrator claimed that he had argued with his wife and told her that she and their daughter were prostitutes. They talked about separating, but the victim was reluctant to do so because they shared the house.

On the day of the incident, the couple had breakfast, then the victim returned to bed and the perpetrator got ready for work. The couple got into a physical altercation and the perpetrator retrieved a hammer. The perpetrator claimed that he felt the victim was going to kill him.

The couple attended a social event just prior to the homicide where several people witnessed them arguing. Family members and other people attending the event noticed the perpetrator’s emotional instability and described him as being deep in thought, depressed, drunk, angry, crazy and scary.

On the day prior to the homicide, the perpetrator indicated that that he would kill the victim if she left him.

Both adult children stated that they often feared for their mother’s safety. They said that their father abused alcohol and was mentally ill and had been abusing their mother for five years. He often accused the victim of cheating on him.

Following the homicide, a psychiatrist documented that the perpetrator had an acute adjustment disorder, depression and mixed personality disorder with no psychosis.

Twelve risk factors were identified.

Common themes: Neighbours, Friends and Families, alcohol, mental health

No new recommendations.

Case DVDRC-2011-23
OCC file numbers: 2007-255

The 40-year-old female victim and 41-year-old male perpetrator had been separated for three weeks prior to the homicide. The perpetrator rented a basement apartment while the victim stayed in the house with the couple’s four children.

For three to four months prior to the homicide, the perpetrator was having paranoid thoughts and was convinced that the victim was having an affair. The perpetrator confronted the person he suspected the victim was having an affair with; he later apologized for the confrontation. The perpetrator also thought that the victim was trying to poison him by putting something in his food.

A friend and former co-worker knew the couple for two years and knew they were having domestic problems. This friend and his wife went to the couple’s house in an attempt to provide counselling. The perpetrator said he would kill someone in the family. The friend didn’t know what to do. The friend spoke with the victim one month prior to the homicide and she reported that things were getting better.

The victim’s mother had an instinct that her daughter was in danger. The victim however, told her that everything was fine. The mother thought the perpetrator was harming the victim so she told her daughter not to see the perpetrator after separating. The perpetrator called the victim’s mother and brother several times in the three months prior to the homicide. He told them that they should get the victim back to her home country, or he would kill her.

On the day of the homicide, the perpetrator told a co-worker that he would not be coming back after lunch. The perpetrator and the victim drove to a coffee shop, bought lunch and then drove to a residence where the perpetrator killed the victim in her vehicle in the driveway. He beat her and used a sweater to smother her.

The perpetrator attended a police station and confessed to the homicide.

Ten risk factors were identified.

Common themes: Neighbours, Friends and Families; mental health of the perpetrator

No new recommendations.

Case DVDRC-2011-24
OCC file numbers: 2007-13863

The 26-year-old male victim was killed after being stabbed by the female perpetrator, his 43-year-old common-law wife.

The couple had been arguing over a two week period and the tension had peaked approximately four days prior to the incident. The victim had reconnected with a past girlfriend and had indicated he planned to leave his relationship with the perpetrator. The perpetrator was aware that the victim was planning on moving out.

The perpetrator had a history of depression and alcoholism. Records indicate that she had a history of cutting her wrists and stress counselling had been provided. A few months prior to the homicide, the perpetrator had relocated after following the victim to a new community. She had cut her wrists two weeks prior to the homicide and had been prescribed sedative and antidepressant medications after visiting a family physician. She had been binge drinking and not eating for several days.

The perpetrator was not employed. She had four children from previous relationships and two of the children (daughters aged 14 and 11) resided with the couple. The perpetrator expressed both love and hate for the victim. The daughters stated that the perpetrator had told the victim on several occasions that she was going to kill him. Four weeks prior to the homicide, neighbours had heard the perpetrator threaten the victim with death.

On October 29, 2007 at approximately 7:00 p.m., the victim made a call to 9-1-1, telling the operator that his girlfriend was out of control and had been drinking. He indicated that children were present in the house. The perpetrator was being loud and the operator asked what she was doing. The victim indicated that the perpetrator was ripping his shirt and then the phone connection was interrupted. The victim called back on his cellular phone because the perpetrator had cut the landline. The operator heard the victim say, “let go of me.” When questioned by the operator, the victim indicated that nobody had been injured.

Police attended the residence. The police report indicated that the victim had said the perpetrator had been drinking and was verbally aggressive and confrontational. The victim told police that there had not been any violence or threat of violence but that he did not want it to get violent. The girls described their mom (the perpetrator) as being very depressed and they were not sure what would happen next. The victim indicated to police that he could not take the perpetrator’s drinking and irrational behavior anymore and that he would be separating from her. The police report does not indicate if a referral to victim services was offered.

Police removed the perpetrator from the home and took her to the nearby residence of an acquaintance. The police contacted the girls’ biological father, but since he lived several hours away, he was unable to come and get them that evening. The police planned a “priority fax CAS request” the next morning.

The perpetrator had apparently told the acquaintance’s boyfriend that she had ripped the victim’s shirt. The police however, did not document any injuries on the couple. According to witnesses interviewed following the homicide, there were signs of injury on both the victim and perpetrator. The daughters stated that their mother told police that it was the victim that had caused her bruises, but the daughters claimed that the injuries resulted from her falling down while intoxicated.

The perpetrator returned to her own residence at 2:55 a.m. on October 30, 2007. The victim was asleep on the couch and awakened when the perpetrator entered. The victim apparently broke some beers that the perpetrator was attempting to drink and told her to go to bed.

The perpetrator went to her room, but about 30 minutes later, was heard by the girls to be saying that she needed strength and was going to kill the victim and stab him in the heart. The daughters called 9-1-1 as their mother had a knife. The perpetrator proceeded to stab and kill the victim prior to arrival of police.

Twenty risk factors were identified.

Common themes: Neighbours, Friends and Families; substance and alcohol abuse; safe separation; responses/services/resources for male victims; responses/services/resources for female perpetrators

Recommendations:

To the police service involved:

It is recommended that the police service involved with the 9-1-1 calls on October 29, 2007 consider an internal review of this case. The police service should review the response of the attending officers to ensure that all policies, procedures and protocols in relation to domestic violence occurrences were followed, particularly as they relate to ensuring that the same policies and procedures are applied to male victims of domestic violence.

Committee Comments: Police were in attendance at the residence for a domestic dispute only hours before the fatal stabbing occurred. The primary aggressor, the female, was removed from the residence to a nearby location, from which she apparently very easily made her way back home. The Committee had concerns that because the victim of the aggression in this case was male, police may not have had as high a level of concern as they might, had the victim been female.

To the Children’s Aid Society (CAS) involved:

The CAS involved with the family should conduct an internal review to examine its provision of services and assessment of risk for this family prior to the homicide.
Committee comments: Between 1999 and 2007, the CAS received several referrals from a variety of sources, alleging that the mother (i.e. the perpetrator) had substance abuse problems and that there were ongoing problems with domestic conflict in the couple’s relationship. Many of these referrals were not investigated; in the investigations that did occur, collaterals were not contacted and no referrals or substance abuse testing were requested or provided. The perpetrator had a long history of substance abuse and was intoxicated on the night she killed her common-law partner in the presence of her two children.

To the Ministry of Child and Youth Services and the Ontario Association of Children’s Aid Societies:

Children’s Aid Societies should be required to conduct internal reviews when a domestic violence death occurs in a family that had received the services of the CAS within the 12 months preceding the death, and where domestic violence issues had been identified.

Committee comments: Under a Joint Directive, dated March 31, 2006, all deaths of children receiving services of the CAS within 12 months are subject to reporting by the CAS to the Office of the Chief Coroner. An in-depth internal review by the CAS may be required in many of these cases. The DVDRC is of the view that, given the potential impact of domestic violence on children, similar internal reviews should be conducted even when children have not been killed. Lessons learned from such reviews could inform and shape future policies and practices.

To the Ministry of Community Safety and Correctional Services (Policing Services Division):

All police services should receive annual training/education on programs and services offered by Victim Services in order to assist officers in responding more effectively to the criminal and non-criminal issues victims face following an incident of domestic violence. Police should be reminded to immediately refer all victims of domestic violence (male and female) to Victim Services to ensure timely intervention and assistance.

Committee comments: As primary stakeholders in the care of victims, police, through an immediate referral to Victim Services, will help ensure that victims receive immediate crisis intervention, safety planning, emotional support, and practical assistance. Other important considerations also include financial support for emergency home repairs, crime scene clean-up, transportation, accommodation and meals, as well as private counseling that will help to reduce the short- and long-term effects of domestic violence.

Case DVDRC-2011-25
OCC file numbers: 2007-8033

On July 3, 2007, the 16-year-old female victim and the 17-year-old male perpetrator were outside of the victim’s home with a group of friends. The perpetrator asked to speak to the victim in private. An argument ensued because the victim reportedly owed the perpetrator money for drugs that he had sold her. This angered the victim, so she retrieved a knife from inside her home. She brandished the knife at the perpetrator who then pushed the victim to the ground and walked away. The victim again approached the perpetrator with the knife and he once more pushed her to the ground and then kicked her in the stomach. The victim got up and for the third time, pointed the knife at the perpetrator. He then went to a home where he knew the tenant. He retrieved a kitchen knife and returned to the victim. He stabbed her in the chest and as she was falling over, hit her in the back of the head with the butt of the knife.

The perpetrator fled the scene, but was later apprehended. The victim died of the stab wound prior to being treated by emergency medical services.

The victim did not work or attend school and was known to use drugs. She had dated the perpetrator for a short period, but the relationship had apparently ended a few months prior with the couple remaining friends.

The victim had previously been arrested, charged and ordered out of the school jurisdiction because she assaulted a fellow student. She had also assaulted two police officers and was charged. She was out on bail at the time of her death and was breaching conditions of that bail. The condition of her bail was not to be in possession of any weapons.

The perpetrator had been suspended for violent behaviour at school and was attending an alternate program. He had been charged with several violent offences and was wanted on a warrant and breaching court conditions at the time of the murder.

Four risk factors were identified.

Common themes: history of violence for both the victim and perpetrator

No new recommendations.

Case DVDRC-2011-26
OCC file numbers: 2006-12261 and 13862

The victim was an 83-year-old female who was strangled by the perpetrator, her 85-year-old husband, on September 12, 2006. The perpetrator stabbed himself immediately following the death of his wife, but survived for several weeks, eventually succumbing to complications and pneumonia on October 12, 2006. As the perpetrator was in custody at the time of his death, a mandatory coroner’s inquest was conducted in December 2008. There were no recommendations arising from the inquest.

The victim had medical problems, including heart disease and hypertension, although none were deemed to be imminently serious. She was reportedly active and had lots of friends.

The perpetrator was a veteran of the Second World War. He had been diagnosed with depression by his family physician approximately three years prior to the homicide.

The family physician had known the couple for ten years. When visiting the physician, the couple attended their appointments together and were never interviewed independently of one another. The last time the perpetrator was seen by the physician was the day before the homicide. It appears in the notes that the physician wrote “not suicidal.” There was no documentation of questions related to homicidal thoughts. The perpetrator had been experiencing insomnia for many months and many people knew about his sleep issues. From the records reviewed, it does not appear that the perpetrator was referred for additional psychiatric services.

The perpetrator’s depression seemed to be worsening in the week prior to the homicide.

The victim and perpetrator had been married for 55 years and did not have any children. There was no history of domestic violence or other criminality. There were no financial concerns identified.

One risk factor was identified.

Common themes: domestic violence in the elderly

Recommendations:

To geriatric health care providers:

Health care providers are reminded to inquire about thoughts of homicide, in addition to suicide, when interacting with elderly patients suffering from depression.

Committee comments: In the article Domestic homicide and homicide-suicide: the older offender, Bourget, Gagné and Whitehurst (2010) found that in the elderly, homicide was frequently followed by suicide by the perpetrator. They also found that several victims had pre-existing medical conditions, indicating that the offenses may have been committed by individuals who were caregivers to their ill spouses. Their research found that, “most of the perpetrators had a mental illness, usually depressive disorder, but few had received psychiatric help. The impact of mental illness on domestic homicide-suicide is indicated, underscoring the importance of identifying existing psychopathology.” (Bourget, Gagné and Whitehurst, 2010, p.305)

Health care providers are encouraged to interview couples separately, particularly when mental health issues may be present.

Committee comments: Like many elderly couples, this couple often attended medical appointments together. In cases where there may be mental health or other issues, and where one spouse may be inhibited from speaking openly in front of the other, it may be beneficial to interview the individuals separately.

References:

Bourget, D., Gagné, P. & Whitehurst,L. (2010). Domestic homicide and homicide-suicide: the older offender. J Am Acad Psychiatry Law 38:305-11.

Case DVDRC-2011-27
OCC file numbers: 2008-14044

On November 5, 2008, the 51-year old female victim asked a friend to take care of her 58-year-old husband (the perpetrator) in the event that anything ever happened to her. She also indicated that she was in the process of revising her will and that the perpetrator was not getting any money because she was still upset about an affair he had ten years prior. This had resulted in them separating for a period of time.

On November 7, 2008, the perpetrator told a friend that he had recently been diagnosed with a gall bladder tumor and was going to have it removed. The victim indicated that the perpetrator was not coping well with this news. Various individuals indicated that the perpetrator was not his usual self.

The victim appeared to be agitated and she was concerned about the perpetrator’s increased drinking and his medical problems. She told one of her friends that he could get mean when he drank and he would at times get mad at her for working too much.

On November 9, 2008, at approximately 8:00 a.m. the perpetrator’s friend arrived at the couple’s residence to pick him up for a hunting trip. He had called and spoken to the perpetrator before arriving at the house and everything seemed fine. The friend saw that the perpetrator had left his hunting gear beside the house so the friend packed the perpetrator’s belongings into his vehicle and then waited for about 25 minutes. He then saw the garage door open and could see the perpetrator inside ‘stumbling around like he was drunk.’ The friend asked the perpetrator if he was okay and he replied that his wife was dead and that he had shot her. The friend noticed that there was a bump on the perpetrator’s head, but saw no signs of blood.

The victim was found inside the home with massive trauma to the head from gunshot wounds.

There were several firearms found in the vicinity of the victim and firearms and ammunition were scattered around the house. Tests subsequently determined that the perpetrator had high levels of alcohol in his system.

The perpetrator was retired police officer. Various friends and acquaintances described the perpetrator as aggressive, obsessive, scary and irrational, while others indicated that he could be nasty, sarcastic and a bully. Members of the victim’s family indicated that they were not close to the perpetrator and that they felt uncomfortable around him because of his temper and rudeness, particularly when he had been drinking. The perpetrator had a criminal record for: verbal domestic assault (1997), use of counterfeit money (1998) and dispute with a neighbour (2006).

Eight risk factors were identified.

Common themes: vulnerability of victims when the perpetrator is a police officer, perpetrator was not unemployed, but he was retired and this may have caused stressors; health issues of perpetrator.

Recommendations:

To the Ministry of Community Safety and Correctional Services (MCSCS), Policing Services Division; and the Ontario Association of Chiefs of Police (OACP)

It is recommended that police officers receive additional/supplemental education and training about victim vulnerability in cases of domestic violence, particularly as it relates to victims of domestic violence committed by police officers.

Committee comment: In addition to common reasons why victims may be reluctant to disclose violence in their relationship, police must understand that victims of police officers may have additional reasons that prevent them from disclosing. These could include the fact that the perpetrator has access to a gun; knows how to manipulate the system to avoid penalty or shift blame; may be a fellow officer to those responding to a call or, if in a different jurisdiction, may be known to be a police officer. In addition, the victim may have concerns the case will not be investigated as thoroughly as it might be for other civilians, because of the perpetrator’s status in the law enforcement community.

It is recommended that an anonymous helpline be established for all police personnel and their families, similar to what exists for physicians in Ontario, where they would have access to immediate assistance and crisis intervention as well as referral to specialized counseling services.

Committee comment: Although there was no recorded history of domestic violence in this couple’s relationship, witnesses indicated that there was a history of domestic abuse, particularly when the perpetrator had been drinking. The victim had told friends that the accused had threatened her in the past, including threatening her with a gun. On one occasion during a domestic situation, the police were called, but no charges were laid.

The victim apparently did not report much to people about their relationship because her husband was a police officer and she did not want to jeopardize his pension. After one occurrence the victim had been in touch with Victim Services and, at the time, told the worker not to call her at home and indicated that her husband was a police officer and an alcoholic and she had been dealing with it for quite a while.

Case DVDRC-2011-28
OCC file numbers: 2009-6501

The 45-year-old female intended victim and 50-year-old male perpetrator started a relationship in 2003 and lived common-law until 2004. Shortly after they started living together, there were incident reports involving threats and verbal abuse as well as periodic assaults. The relationship was marked by intermittent break ups and reconciliations until the final break up in March 2009 (three months prior to the homicide).

The perpetrator was described as jealous and possessive. The intended victim’s 25-year-old daughter stated that the perpetrator had tried to isolate her mother from friends and family. She stated that her mother had previously been taken to the hospital on at least one occasion following an assault by the perpetrator. Most of these assaults were reported to police.

A very serious assault in 2004 started with the perpetrator pouring bleach into his ex-girlfriend’s fish tank and grabbing her by the throat and strangling her into unconsciousness. She reported waking up and finding the perpetrator sexually assaulting her.

In April 2005, an application was made to have the perpetrator deemed a Dangerous Person because he admitted to being suicidal. His ex-girlfriend stated that she feared that the perpetrator would kill her, then himself.

In 2006, the ex-girlfriend was assaulted and sustained injuries to her head and neck. The perpetrator was charged with Assault and Threaten Death. These charges were subsequently withdrawn in court.

In March 2007, the notation of “Dangerous Person” was removed from the perpetrator’s file maintained in the Canadian Police Information Centre (CPIC) database [CPIC is composed of five distinct service areas which are responsible for the delivery and sharing of national police, law enforcement, criminal justice, and public safety information].

The perpetrator stopped staying over at the intended victim’s house in late December 2008. Three months prior to the homicide in March 2009, she broke off the relationship completely and had a Peace Bond taken out which restricted his contact with her. Nevertheless, the perpetrator demonstrated increasingly threatening and obsessive behaviour towards his ex-girlfriend by making contact with her by texting and calling her at home and at work and ultimately going to her house, where he broke in.

The ex-girlfriend had contacted Victim Services and received counseling and safety planning and was provided with a Domestic Violence Emergency Response alarm. As part of the safety planning, she changed all the locks on her doors of her house and also her phone number. On March 7, 2009 she called the police and the perpetrator was arrested and pled guilty to a charge of criminal harassment; he received a sentence of nine days. When released, he immediately continued to call her, so he was arrested on April 9, 2009. This time, he received a sentence of 30 days for Criminal Harassment, and a “no contact” order was imposed. On the perpetrator’s release from prison in May 2009, he again continued to contact and threaten the woman. The perpetrator had lost his job and was unemployed at this time.

On May 30, 2009, the perpetrator had been hiding in a bedroom closet in the house he used to share with his ex-girlfriend. The woman lived in the house with her adult daughter and on the evening of the attack, the woman’s mother was staying with her to help move the perpetrator’s belongings out of the house the next day. The perpetrator later reported he had been drinking brandy in the closet while hiding with a knife and a hammer and was becoming angrier as he listened to his ex-girlfriend talk to her mother and daughter about getting rid of some of the gifts he had given her during their 5-6 year sporadic relationship. After the women went to bed, the perpetrator first attacked the 25-year-old daughter with a hammer; she successfully fought him off. He then attacked and severely injured his ex-girlfriend. As he made his way out of the house, he ran into the woman’s mother who was trying to call for help. He attacked his ex-girlfriend’s mother before exiting the house. The woman’s mother subsequently died of her injuries.

There did not appear to be any history of a problematic relationship between the perpetrator and his ex-girlfriend’s mother. It was believed that the mother was an unintended victim and that she was simply in his way as he tried to escape.

Twenty-one risk factors were identified.

Common themes: safe separation; monitoring of high-risk offenders; choking as a significant risk factor.

Recommendations:

To the Ministry of Community Safety and Correctional Services (MCSCS):

The MCSCS should consider reviewing its existing training material related to the management of high risk domestic violence cases and Intensive Supervision Offenders (ISOs). Measures should be taken to ensure updated, ongoing training to all probation and parole officers involved with ISOs, emphasizing:

the importance of following the domestic violence protocol;
a focus on the identification of pertinent risk factors related to each case and appropriate evidence- based measures to be taken to mitigate risk;
case reviews conducted by the DVDRC where the offenders were under supervision of MCSCS.

The review should include an audit of participation rates in this specialized training.

It is recognized that the MSCSC has undertaken recent policy reforms to address issues related to high risk (intensive) case supervision for domestic violence perpetrators. It is recommended that an internal review should be conducted of all domestic violence homicide cases supervised since the implementation of these policies, where the offender re-offended while under supervision of the MCSCS. Lessons learned from these reviews could be incorporated into staff training and further policy reform.
The Intensive Supervision Unit (ISU) should review its referral criteria and consider expanding its mandate to include offenders with a pattern of recurrent assaults against women and/or a history of choking/strangling their victims. The ISU supervision strategy should be audited to ensure that its services include not only more frequent contact with the offender, but also ancillary wrap-around services (e.g., ongoing communication with the potential victim, referral to, and communication with police and treatment providers).
Communication between treatment providers and between probation services and the victim or potential victims (e.g. new partner), should be a regular and essential component of intensive case supervision. Communication strategies for all treatment providers should be set in policy.
Given the high number of risk factors identified in this case, it was deemed by the DVDRC to be very high risk. It is recommended that for similar cases of very high risk, MCSCS should put in place a mandatory referral to local police services for assessment of the appropriateness of placing the offender under High Risk police supervision. This would allow for enhanced safety planning strategies for the potential victim, as well as more aggressive monitoring and potential interventions with the offender when probation and/or parole violations occur.

Case DVDRC-2011-29
OCC file numbers: 2009-629

Sometime between January 3, 2009 and January 22, 2009, the 37-year-old female victim and her 31-year-old boyfriend (the perpetrator) argued when they were alone in their apartment. They fought because the perpetrator would not turn off the computer and go to bed. The perpetrator punched the victim on the right side of her head with his fist. He then held a pillow over her head and suffocated her until she was dead.

The victim’s mother attempted repeatedly to contact her daughter, but the perpetrator always provided excuses why she was not available to talk. On January 22, 2009 the mother went to the residence that her daughter shared with the perpetrator, but she was denied entry by the perpetrator. The mother telephoned police and when they attended, the victim’s body was located under piles of clothing.

The perpetrator fled the scene and subsequently telephoned police to advise them that he had killed the victim.

The victim had a developmental and learning disability. She had the mental capacity of a five-year-old, but was independent enough to live on her own. The victim apparently did not converse well, and reportedly became emotional very easily. She reportedly had poorly controlled diabetes, mental health issues (including threats of suicide) and had multiple visits to hospital. She received financial support through a disability pension. In 2008, the perpetrator was added to the victim’s budget thereby increasing her disability pension cheques.

The perpetrator was raised in a remote First Nation community in northwestern Ontario. He lived with his parents until he was 12 years old, when he was removed from the home by Child and Family Services. From that time until he was 16 years old, he lived in various foster and group homes. His family was not close and his parents abused alcohol. He was physically and sexually abused as a youth. He returned to live with his parents when he was 17-years-old and was heavily involved in substance abuse, including gasoline sniffing.

The perpetrator was described as being calm, easy going and laid back. He was a “computer game extremist” and spent most of his time on the computer. The perpetrator had been involved in three adult relationships and had a history of abusing his partners. He had an extensive criminal record including 20 convictions from 1997 to 2008.

At the time of the homicide, he was unemployed and living with the victim. He was also bound by two probation orders following convictions for assault, assault cause bodily harm and breach of probation in relation to the victim. The conditions included an order to have no communication with the victim. He stated that he avoided seeing his Probation Officer because he was afraid of being arrested as he was still seeing the victim, when he was ordered not to. The perpetrator was wanted on a warrant for breach of probation and had been charged for breaching probation several times.

Following the homicide, the perpetrator was diagnosed with Anti-Social Personality Disorder and Polysubstance Abuse in remission. Schizophrenia was ruled out and any past psychosis was believed to have been in relation to his past substance abuse. He may have suffered from chronic low-grade depression.

Fourteen risk factors were identified.

Common themes: mental health issues.

No new recommendations.

Case DVDRC-2011-30
OCC file numbers: 2009-8225 and 11545

On June 22, 2009, the 63-year-old female victim contacted a lawyer requesting assistance to change her will.

Between June 27-29, 2009, the victim and her boyfriend, the 55-year-old male perpetrator were at the victim’s home in the bedroom. The perpetrator loaded a shot gun and shot the victim in the face while she was lying on the bed. He then turned the gun on himself firing a round into his face, reloaded the gun and fired another round into his chest. He died of his injuries.

The victim lived in a First Nation community in northern Ontario. She had previously disclosed to others that she had been sexually abused by her father and two brothers.

The victim had reportedly attended Residential Schools when she was a child and was significantly affected by the experience. In 1966, the victim was involved in a motor vehicle collision where she witnessed her friend die. She suffered from chronic back pain as a result of injuries sustained in the collision. She had been diagnosed with depression, delirium secondary to alcohol abuse, pathological grief, social phobia and post traumatic stress disorder. She had been apprehended under the Mental Health Act within the last year of her life.

The victim was addicted to drugs and alcohol in the later stages of her life. She had a period of sobriety, but became addicted again. She was reported to drink alcohol daily and use heroin and marijuana. There was also some evidence to suggest that she supplied local teenagers with marijuana.

The perpetrator was a First Nation male. Little is known about his family as most of them were deceased.

The perpetrator worked in a factory as a general labourer. He was described as a good worker, but a loner who suffered from social phobia. He did not have a criminal record.

The perpetrator was clinically diagnosed with depression. He had expressed suicidal ideation and he often mentioned thoughts of committing suicide to his brother. He was apprehended under the Mental Health Act in June 2007.

The perpetrator was a severe alcoholic who drank beer and used marijuana daily. He had been diverted to out-patient programs, but was very resistant to treatment. He was urged to participate in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) groups but apparently without success.

He had several guns in his possession.

Six risk factors were identified.

Common themes: mental health issues, access to firearms, addictions

No new recommendations.

Case DVDRC-2011-31
OCC file numbers: 2009-5946 and 5947

The couple and their infant daughter moved back to Ontario in April 2009 after temporarily relocating to Alberta to accommodate the perpetrator’s work arrangement. Their time in Alberta was apparently very stressful.

During the first few weeks upon returning to Ontario, the 25-year-old female victim planned to separate from her husband and sought alternative living arrangements and daycare for their 11-month-old child, the second victim. During this period, the perpetrator became increasingly depressed. One evening, the perpetrator went on a drinking binge, called the victim and threatened to commit suicide if she left him.

On May 11, the perpetrator contacted a number of counselling services for assistance. One counsellor saw the couple on May 12, 2009. The counsellor saw the couple together and did not assess the high risk nature of the situation. On May 14, 2009, the victim attended for an individual counselling session. It does not appear that the counsellor proactively probed for the level of risk in the situation.

On the evening of May 14, 2009, the victim told the perpetrator that she wanted a divorce.

On May 15, 2009, the perpetrator cancelled his appointment with the marriage counsellor. On that day, the victim thought she was going to help the perpetrator move his belongings to a friend’s place and he would stay there for the weekend.

On the afternoon of May 15, 2009, the perpetrator stabbed the victim to death. The perpetrator attempted to hide the deceased victim in the bedroom closet. The couple’s infant daughter was positioned under the victim’s body in the closet. The cause of death for the child was undetermined, but it is likely that she suffocated under the weight of her mother’s body.

Following the homicides, the perpetrator drove to Montreal and checked into a hotel. During his stay, he drank excessively and had numerous contacts with an escort service. On May 17, 2009, the perpetrator jumped to his death while at the hotel.

Thirteen risk factors were identified.

Common themes: actual or pending separation

Recommendation:

To the Ontario Association of Social Workers; College of Certified Social Workers and Social Service Workers; Ontario Psychological Association; Ontario Association of Marriage and Family Therapists; Ontario Psychotherapy Association and the Canadian Counselling and Psychotherapy Association.

It is recommended that all marriage and family therapists receive specialized training about victim vulnerability and perpetrator risk in cases of domestic violence.

Committee comments: All counsellors should be trained to proactively identify and screen for domestic violence (DV), assess the level of ongoing risk of DV in each situation, understand the need for engaging reluctant victims and assisting them with safety planning knowledge and skills. In their work with potential perpetrators, they should be able to assess the risk for depression, substance use, suicidal and homicidal ideation, level of obsession with the victim, history of DV, separation anxieties, etc. In addition to the common reasons why victims and abusers may be reluctant to voluntarily disclose the presence of DV, it is important for marriage and family therapists to teach their clients about what DV is as many clients are not aware of the nature and dynamics of DV and the escalating risks associated with separation. As well, marriage and family therapists must understand that victims will not be safe to disclose their concerns about DV in the presence of the abuser. Marriage and family therapists must design a way to interview each partner separately as a standard part of their practice in order to screen and proactively engage their clients in DV education.

In this case, the perpetrator actively reached out to a number of counsellors for help just a few days before he killed his wife and child, then himself. He accepted the first appointment he was offered and the next day the couple showed up together at the office of the marriage and family counsellor and were interviewed in a joint interview. According to police records and counselling notes, there was no record of proactive documentation, assessment or intervention for the safety of the family. A follow-up individual appointment was conducted with the victim on the following day, but there was no attempt to address safety issues at that time despite the obvious presence of many risk factors identified in this review.

Case DVDRC-2011-32
OCC file numbers: 2008-3744

The 41-year-old male perpetrator was married to the 44-year-old female victim and had two children (ages 6 and 8), but was also having an affair with a former co-worker. He had told his lover that he was divorced and that his ex-wife lived in another community. He promised his lover that they would live together in the family home.

The perpetrator had gone online and researched various suicide methods and how to fight off ligature strangulation.

On April 3, 2008, after the children had gone to school, the victim was in the office of their home. The perpetrator secured a black ‘zip tie’ (used to tie signs to posts) around the victim’s neck. There was a struggle and the victim scratched the perpetrator deeply on the nose and behind his ear. The perpetrator overpowered the victim and the victim died as a result of the strangulation.

The perpetrator then sent an email from the office computer to his work email address posing as the victim. The text of the message indicated that she was going to kill herself and that by the time the message was received she would be gone. The message was intended to make it look like the victim had taken her own life.

After sending the email, the perpetrator locked all the doors to the home and left for work. Once there, he called 9-1-1 after supposedly receiving the “suicide” email. Police responded to the residence and found the victim to be deceased on the floor of the bedroom.

The victim did not have a criminal record and had not reported any domestic violence to police, family or friends.

The perpetrator had no criminal record, but there was an incident where he pulled a knife during an argument with his brother.

One risk factor was identified.

No new recommendations.

Case DVDRC-2011-33
OCC file number: 2005-13052

The 28-year-old female victim had been involved in an abusive relationship with the 30-year-old male perpetrator for approximately four years. The couple had broken up several times during the relationship.

In September 2005, during the week prior to her death, the victim had again broken off her relationship with the perpetrator. The perpetrator had just completed his 18 month probation for Assault. He continued to harass the victim with threatening phone calls and had broken into her apartment on two occasions and stolen money and property from her. She had made four phone calls to police during the week prior to her death. Subsequent to these calls, the police had warned the perpetrator to stay away from the victim. The victim’s mother (who lived in another province), had also called the police on behalf of her daughter stating that she was afraid that if the police did not restrain him, her daughter would be killed. The police apparently responded that they were unable to give her information on the situation because of confidentiality issues.

On the night of the homicide, the police were scheduled to go to the victim’s house to record her complaint about the break-ins and theft. The victim cancelled the appointment with the police and indicated that she did not want the perpetrator charged, but wanted him out of her house. The police indicated that they could not charge the perpetrator with breaking into the house because it was still considered his residence.

On September 17, 2005, while at home and on the phone with a friend, the victim heard the perpetrator breaking in again. She urged the friend to call the police for her. When the police arrived four minutes later, they found the victim in an unconscious state. The perpetrator was in the house, clearly intoxicated and claimed that the victim had passed out from drinking.

Based on the perpetrator’s report, Emergency Medical Services (EMS) treated the victim for suspected overdose. The victim died later that night from blunt force injury to the neck, consistent with neck compression.

There was no indication that the victim abused substances. She worked at several retail jobs within her community. The victim did not have any children. She appeared eager to leave the community and start a new life away from the perpetrator.

The perpetrator had a criminal history for theft, vandalism, harassment, threatening, and assault, dating back to 2002. Most of these offences had been directed against women partners. There was one conviction for assault against a former partner and several occurrence reports for domestic violence against a former girlfriend and the victim. He began to abuse drugs and alcohol in high school and his drug of choice appears to have been cocaine/crack. Three previous partners reported abusive behaviour including: controlling behaviour, destruction of property, punching walls, pushing, strangling, extreme jealousy, harassment and threatening death. Alternatively, another ex-partner stated that they had had a long-term relationship that was not abusive.

The perpetrator was described as jealous and possessive and would restrict the victim’s activities and access to her friends. This behaviour was more prevalent when the perpetrator was under the influence of drugs. The perpetrator had reportedly confined the victim to her house by stealing her keys and had pushed her down the stairs on multiple occasions.

In the week before her death, the victim had become very frightened of the perpetrator. The victim had called police several times two days prior to her death to report threatening phone calls and break-ins by the perpetrator. The advice the victim received from police was to lock her windows and doors.

In the period prior to the homicide, the perpetrator was charged with Assault and Failure to Comply and given an 18 month probation sentence. During this time, he attended and completed an anger management program. The perpetrator was assessed as high risk and while under supervision by Probation, the focus of the session notes suggested the supervision was directed towards monitoring his success in finding and maintaining employment and compliance with payment of a fine. In the supervision notes, the perpetrator referred to his girlfriends as strippers. This did not appear to have been challenged by his case managers. There appeared to be no attempt to have him involved in counseling for domestic violence beyond his attendance in the anger management program.

Nineteen risk factors were identified.

Common themes: Neighbours, Friends and Family; pending separation; high risk offender with significant history of domestic violence

Recommendations:

Recommendations 1-5 from DVDRC 2011-28 (previously reviewed by the DVDRC) directed to the Ministry of Community Safety and Correctional Services, also apply to this case involving a high risk (or intensive supervision) offender.

Committee Comments: This case involved a high risk perpetrator whose probation supervision did not appear to be directed towards mitigating the threat he posed to his intimate partner despite the risk being noted on the probation file (LSI) and a history of abuse of previous intimate partners in addition to the victim. Specifically, the focus of the case management appeared to be on the offender’s compliance with payment of a fine and finding and maintaining work, not on the risk posed to potential victims. There was no file reference to indicate that Probation and Parole ever contacted the victim, and the perpetrator’s reference to his partner being a stripper was not challenged. There was no documented exchange of information between the treatment provider (from the anger management program) and the Probation and Parole Office (PPO). There was no indication on the file that the anger management program addressed intimate partner violence or whether it was more generic in nature.

Chapter Four: Learning from DVDRC Reviews

In 2011, the DVDRC reviewed at total of thirty-three cases. Of these, four cases involved perpetrators who were female and five involved perpetrators and/or victims who were identified as Aboriginal/First Nation. There was some overlap as two of the female perpetrators were also Aboriginal/First Nation. Although the sample size of cases reviewed by the DVDRC is relatively small, it was felt that further analysis and discussion of the specific issues and concerns pertaining to domestic violence within Aboriginal communities and female perpetrators of domestic violence, was warranted.

Domestic Violence in Aboriginal Communities: An Overview of DVDRC Findings

Historically, during the course of a coroner’s investigation in Ontario, information pertaining to the ethnic background of a deceased has generally not been collected. More recently however, the Office of the Chief Coroner has tried to specifically note deceased individuals who were identified as Aboriginal/First Nation. This is done by the investigating and/or Regional Supervising Coroner “coding” the case in the Coroner’s Investigation System (the database of all coroner’s investigations in the province) with an involvement code that identifies the decedent as Aboriginal/First Nation.

When a case is reviewed by the Domestic Violence Death Review Committee (DVDRC), particular attention is given to identifying ethnic and cultural references within the case material provided. It is recognized that there may be some cases where the ethnicity and cultural background of the perpetrator and/or victim is unknown or undeclared. It is possible therefore that not all cases involving persons of Aboriginal/First Nations background have been identified by the DVDRC.

The DVDRC has reviewed ten domestic homicide cases where at least one of the parties involved was identified (usually through a review of the investigative materials) as Aboriginal/First Nation; this accounts for 7% of the total number of cases reviewed by the DVDRC since its inception in 2003. Five of the ten cases were reviewed in 2011.

This small sample size of ten domestic homicide and/or homicide-suicide cases involving individuals identified as Aboriginal/First Nation has yielded the following:

eight of the cases were homicides and two were homicide-suicides
There were a total of 14 deaths reviewed (12 homicides and 2 suicides)
four of the deaths were from stabbing, five from gunshot wounds, four from trauma (beating/assault) and one from asphyxia
seven of the perpetrators were male and three were female
of the 12 homicide victims, seven were adult females, three were adult males and two were children
the average age for adult victims was 40.9 years

From these ten cases, the following risk factors were identified as significant:

nine cases involved prior threats/attempts to commit suicide and/or violence outside of the family
eight cases involved a history of domestic violence and/or excessive alcohol/drug use and/or the victim and perpetrator living common-law
seven cases involved a perpetrator who was depressed and/or an escalation of violence and/or a perpetrator who failed to comply with authority
six cases involved a perpetrator who was unemployed and/or a perpetrator who witnessed domestic violence as a child
five cases involved individuals with other mental health/psychiatric problems and/or prior assault with a weapon.

Over the years, the DVDRC has made recommendations pertaining to the need for ongoing cross-cultural training for professionals that work with Aboriginal victims and/or perpetrators; the need for the development of Aboriginal-specific programs and services aimed at Aboriginal victims of violence; the importance of the government providing resources necessary to support Aboriginal-specific programs; and the need for Aboriginal-focused public awareness programs.

These recommendations include:

Cross-cultural and cultural competence training should be a mandatory component of all training programs for front line workers, such as police, healthcare, and social workers. (Cases 2003–02, 2003-05 and 2003-11)
Training workshops have to be developed and delivered by trained experts from the cultural communities being served. (2003 – 02)
Kanawayhitowin is an Aboriginal public awareness campaign that was launched in the fall of 2007 to raise awareness about the signs of woman abuse in First Nations communities, so that people who are close to at-risk women or abusive men can provide support. It reflects a traditional and cultural approach to community healing and wellness. Educational materials include brochures, public service announcements, a training video and CD-ROM. We recommend that the Ontario women’s Directprate consider making this campaign available to all Aboriginal communities across the province. (2007 – 03)
We recommend that First Nation communities be prioritized by government to address enormous lack of resources available to them, including making available culturally appropriate service providers that would be adequately trained in providing an effective response to the complex issues facing Aboriginal families. These issues include the impact of intergenerational trauma on families with the consequence of high rates of mental health issues, addictions, domestic violence, unemployment and living in chronic states of poverty. (2007 – 03)
It is recommended that Aboriginal-focused public awareness programs paralleling the Neighbours, Friends and Families campaign be implemented and made available to all First Nation communities across the province. (2008 – 14)
Individuals and organizations providing services and support to Aboriginal communities are reminded that the Kanwayhitowin Campaign (based on the Neighbours, Friends and Family program) is a valuable resource to provide information and education on addressing the issue of domestic violence involving Aboriginal people in Ontario. (2011-14)

Domestic Violence in Aboriginal Communities: A National Overview

On a national level, research has indicated that Aboriginal people experience higher rates of domestic violence and homicide compared to non-Aboriginal people. The rate of domestic violence among Aboriginal people is three times higher than for non-Aboriginal people. Research has indicated that the rate for domestic homicide is eight times higher for Aboriginal women and thirty-eight times higher for Aboriginal men compared to non-Aboriginal men and women in Canada.

From a national perspective, researchers have identified several risk factors that may contribute the higher incidence of domestic violence and homicide among Aboriginal peoples.

These risk factors include:

colonization (i.e. the historical experience of Aboriginal people including residential schooling, loss of land, loss of resources, loss of native language, physical and sexual violence, intergenerational trauma, and experienced racism)
unemployment
cohabitating or living common-law
living in rural areas
youth
lower educational attainment
alcohol abuse
larger average family size

All of the above risk factors appear to be overrepresented among Aboriginal people experiencing domestic violence. Research on domestic violence among Aboriginal populations has found that unemployment, lower educational attainment and alcohol abuse are associated with an increased risk of violence.

DVDRC findings within a National Context:

Due to the small sample size of reviewed domestic homicide cases involving Aboriginal people, the DVDRC is cautious when interpreting these findings and in not generalizing the results to the overall Aboriginal population. The findings from the ten reviews thus far however, appear consistent with more comprehensive nationwide research which indicates that the risk factors of unemployment, substance abuse, living common-law and living in a rural environment, are significant indicators of domestic violence within Aboriginal/First Nation communities. It is recognized that some of these factors may be related to the impact of colonization, such as depression, exposure to violence in childhood, and other psychiatric problems. A prior history of domestic violence has been identified as a significant risk factor for both Aboriginal and non-Aboriginal homicides and homicide-suicides reviewed by the DVDRC.

Future Directions: Addressing Domestic Violence in Aboriginal Communities in Ontario

In 2007, the Ontario Native Women’s Association and the Ontario Federation of Indian Friendship Centres released the Strategic Framework to End Violence Against Aboriginal Women. The framework was distributed to federal and provincial leaders and government officials and Aboriginal leaders from First Nations, Métis communities, and service organizations. The framework identified the following eight strategic directions that required further action and attention: research, legislation, policy, programs, education, community development, leadership and accountability.

The Ontario Federation of Indian Friendship Centres, the Ontario Native Women’s Association, the Independent First Nations and the Métis Nation of Ontario released a Report Card that reviewed progress on the implementation of the framework for the years 2007 -2010. It was noted that, “there have been some minor developments but improvements and further investments are required. A comprehensive policy that endorses the framework and allocates resources to establish priorities and actions in partnership with [government] ministries and Aboriginal partners is required.”

The findings of the DVDRC appear to be consistent with the identified needs for increased awareness and action towards reducing the incidence of domestic violence within the Aboriginal/First Nation communities. It is recognized that these communities may have risk factors that are distinct and unique from those of non-Aboriginal communities, based on their historical, cultural and geographical characteristics.

In 2011, the DVDRC made the following recommendation:

Individuals and organizations providing services and support to Aboriginal communities are reminded that the Kanwayhitowin Campaign (based on the Neighbours, Friends and Family program) is a valuable resource to provide information and education on addressing the issue of domestic violence involving Aboriginal people in Ontario.

(See summary for DVDRC-2011-14 for additional information on the Kanwayhitowin Campaign.)

Domestic Violence and Gender: The findings of reviews by the DVDRC

In 2011, the Domestic Violence Death Review Committee reviewed four cases where the perpetrators were female and the victims were male. Since its inception in 2003, the DVDRC has reviewed a total of ten cases involving female perpetrators; this reflects 7% of all cases reviewed. In seven of these ten cases, it appears that the female perpetrator was (or had been), a victim of domestic violence at some time herself.

It is recognized that female perpetrators of domestic violence may require interaction and programming that is gender-specific and aimed at addressing particular issues and needs such as a history of victimization. Researchers and advocates believe that treatment programs aimed at male perpetrators of domestic violence would not be effective for female perpetrators since female perpetrators tend to have more pronounced abuse victimization histories. Some programs that target female perpetrators have been developed where the women were held accountable for their actions, yet their history of victimization was acknowledged. Whether the context of the violence indicates that the female perpetrator was acting in self-defense, retaliation, or was the primary aggressor in the relationship, there is an identified need for current interventions that address these specific issues.

The cases reviewed in 2011 highlight the need for specialized services for female perpetrators of domestic violence and resulted in the following recommendations:

It is recommended that social services/probation examine the potential requirement for an intervention specifically designed for women perpetrators of violence and domestic violence. (2011-16)

at the time her children were removed
at any time that she was arrested for violent offences and was in prison
while she was under a probation order following a suicide attempt (after which she was placed on a Form 1 under the Mental Health Act.)

The potential for lethal violence by women perpetrators with substantial violent histories, serious substance abuse problems and emotional instability should be taken seriously and when a high risk case is identified, steps should be taken to refer these women to appropriate treatment and more intensive supervision. (2011-16)

The Victim and Vulnerable Persons Division should consider creating a public education program with information and resources specifically aimed towards assisting male victims of domestic violence. (2011-16)

Committee Comments: It is recognized that male victims of domestic violence may be impacted differently and may experience different societal reactions and responses than those experienced by female victims. Currently, the Neighbours, Friends and Family program provides appropriate education, supports and guidance with focus on female victims of DV, but support for male victims does not fall under the mandate of this program.

Future Direction – Gender specific domestic violence programs

Many Partner Assault Response (PAR) agencies have now tailored batterer intervention programs to female perpetrators. Although these programs may still use the Duluth model (a combination of cognitive-behavioural techniques and feminist theory), which is regularly used in male batterer programs, the programs tailored for women take the approach that women used violence in self-defense rather than to gain power and control. One study compared and contrasted two intimate partner violence intervention programs, one tailored to male perpetrators and one tailored to female perpetrators. 9 The results indicated that men felt their intervention was more punitive in nature because they had to undergo regular drug tests and they were removed from group for attendance problems. The female group was considered victim-centered with the use of a strong therapeutic style from facilitators.

There is very little research pertaining to intervention programs aimed at female primary aggressors that are not victims of intimate partner violence and there are very few interventions tailored to these particular women.

An example of a program created for women who have used force in their intimate relationships is the VISTA program for women. VISTA, created in 2002 by the Jersey Battered Women’s Services in New Jersey (www.jbws.org ), is a unique program for women who have used coercion, control, force, and/or violence in their intimate relationships. The VISTA philosophy is that women who use non-self-defensive physical force against their intimate partners, be they domestic violence survivors or not, are putting themselves and others at greater risk of harm and therefore need contextualized advocacy, support, and intervention.

Eligibility requirements of VISTA include women who have used non-self-defensive force in their intimate relationship with a current or former partner. This includes: women who are survivors of intimate partner violence who began to retaliate; women who were survivors of intimate partner violence in a previous relationship but chose to use force in another relationship; and women who had never experienced intimate partner violence and were the primary aggressor in their relationships.

VISTA is considered a curriculum-based, psycho-educational support group. It is a 20-week program with sessions lasting an hour and a half. The women in the group learn about the dynamics of domestic violence and they gain knowledge and skills to facilitate safer lifestyles. Specifically, group topics include identifying forceful behaviours, anger, defense mechanisms, healthy boundaries, effects of force on children, conflict resolution and healthy relationships. The overall goals of the program are to identify and then reduce the personal shame the women may feel for having used force, address feelings of responsibility for having used force, and increase awareness and use of non-forceful behaviours.

In Ontario, many PAR programs have begun to address the specific needs of female perpetrators. The Partner Intervention Program is a group intervention project of Changing Ways Incorporated in London, Ontario - developed for women who are charged with domestic assault and referred through the criminal justice system. The program consists of three modules. The first module provides a focus on consideration of each woman's experience of intimate relationships. During this module women are invited to share in a narrative form an individualized family and relationship history, including how past trauma may have impacted on women's lives and perceptions of relationships. The goal of this module is that each woman has the opportunity for self-reflection, and for sharing information relevant to the context of her current situation, while maintaining accountability for her actions at the same time.

The second module provides an emphasis on information sharing, education, and skills development. Topics during this module include: understanding anger, the difference between anger and aggression, cognitive distortions, conflict resolution strategies, cognitive-behavioural theory, positive self-talk, active listening, and communication skills. The goal of this module is to provide an opportunity for increased self-awareness specifically in terms of cognitive distortions and how these distortions may impact on thinking and decision making.

The third module provides a focus on future planning for self-care and maintaining healthy relationships. Topics during this module include: relationship safety planning, the impact on children of being exposed to abuse, developing a support network, community resources, and practicing self-care. The goal of this module is to provide an opportunity for women to recognize the value and importance of self-care, women's rights to self-determination and safety, and how healthy self-empowerment promotes safety in intimate relationships.

Further Information:

Alberta Council of Women’s Shelters (2009). ACWS Orientation Manual-Introduction. Retrieved October 5, 2011 from: http://www.acws.ca/documents/1Introduction.pdf.

Archer, J. (2000). Sex differences in aggression between heterosexual partners: a meta-analytic review. Psychological Bulletin, 126(5), 651-680.

Bennet, L. & Williams, O. (2001). Intervention program for men who batter. In C. Renzetti & J. Edleson (Eds.), Sourcebook on violence against women (pp. 261-277). Thousand Oaks, CA: Sage.

Carney, M.M. & Buttell, F.P. (2004). A multidimensional evaluation of a treatment program for female batterers: a pilot study. Research on Social Work Practice, 14(4), 249-258.

Carney, M.M., Buttell, F., & Dutton, D. (2007). Women who perpetrate intimate partner violence: a review of the literature with recommendations for treatment. Aggression and Violent Behavior, 12, 108-115.

Dasgupta, S.D. (2002). A framework for understanding women’s use of nonlethal violence in intimate heterosexual relationships. Violence Against Women, 8(11), 1364-1389.

Farr, K.A. (1986). Dominance bonding through the good old boys sociability groups. Sex Roles, 18, 259-277.

Gabora, N., Stewart, L., Lilley, K. & Allegri, N. (2007). A profile of female perpetrators of intimate partner violence: Implications for treatment. Correctional Operations and Programs. Ottawa, ON: Correctional Service Canada.

Henning, K., Jones, A., & Holdford, R. (2003). Treatment needs of women arrested for domestic violence: A comparison with male offenders. Journal of Interpersonal Violence, 18, 839−856.

Larance, L.Y. (2006). Serving women who use force in their intimate heterosexual relationships: an extended view. Violence Against Women, 12(7), 622-640.

Miller, S.L., Gregory, C. & Iovanni, L. (2005). One size fits all? A gender-neutral approach to a gender-specific problem: contrasting batterer treatment programs for male and female offenders. Criminal Justice Policy Review, 16(3), 336-359.

Ontario Domestic Violence Death Review Committee (Ontario DVDRC). (2010). Annual report to the Chief Coroner. Toronto, ON: Office of the Chief Coroner.

Ontario Women’s Justice Network (2009). Mandatory Charging. Retrieved September 30, 2011 from: http://www.owjn.org/owjn_2009/legal-information/criminal-law/271-mandatory-charging.

Rennison, C., & Welchans, S. (2000). Intimate partner violence. Bureau of Justice Statistics Report (NCJ 178247). Washington, DC: U.S. Department of Justice.

Statistics Canada (2011). Family Violence in Canada: A Statistical Profile. Ottawa: Ministry of Industry.

Straus, M.A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family, 41, 75-88.

Stuart, G.L., Moore, T.M., Gordon, K.C., Hellmuth, J.C., Ramsey, S.E., & Kahler, C.W. (2006). Violence Against Women, 12(7), 609-621.

Swan, S.C. & Snow, D.L. (2006). The development of a theory of women’s use of violence in intimate relationships. Violence Against Women, 12(11), 1026-1045.

For further information, please contact:

Office of the Chief Coroner
Domestic Violence Death Review Committee
26 Grenville Street
Toronto, ON
M7A 2G9
416-314-4000

Appendix A: Domestic Violence Death Review Committee Terms of Reference

Purpose:

The purpose of this committee 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.

Definition of Domestic Violence Deaths:

All homicides that involve the death of a person, and/or his/her child(ren) committed by the person’s partner or ex-partner from an intimate relationship.

Objectives:

To provide and coordinate a confidential multi-disciplinary review of domestic violence deaths pursuant to Section 15(4) of the Coroners Act, R.S.O. 1990, Chapter c. 37, as amended.
To offer expert opinion to the Chief Coroner regarding the circumstances of the event(s) leading to the death in the individual cases reviewed.
To create and maintain a comprehensive database about the victims and perpetrators of domestic violence fatalities and their circumstances.
To help identify the presence or absence of systemic issues, problems, gaps, or shortcomings of each case to facilitate appropriate recommendations for prevention.
To help identify trends, risk factors, and patterns from the cases reviewed to make recommendations for effective intervention and prevention strategies.
To conduct and promote research where appropriate.
To stimulate educational activities through the recognition of systemic issues or problems and/or:

referral to appropriate agencies for action;
where appropriate, assist in the development of protocols with a view to prevention;
where appropriate, disseminate educational information.

To report annually to the Chief Coroner the trends, risk factors, and patterns identified and appropriate recommendations for preventing deaths in similar circumstances, based on the aggregate data collected from the Domestic Violence Death Reviews.

Note: All of the above described objectives and attendant committee activities are subject to the limitations imposed by the Coroners Act of Ontario Section 18(2) and the Freedom of Information and Protection of Privacy Act.

Appendix B: Ontario Domestic Violence Death Review Committee Risk Factor Coding Form

A= Evidence suggests that the risk factor was absent

P= Evidence suggests that the risk factor was present

Unk = Unknown


Risk Factor	Code (A,P, Unk)
1. History of violence outside of the family by perpetrator
2. History of domestic violence
3. Prior threats to kill victim
4. Prior threats with a weapon
5. Prior assault with a weapon
6. Prior threats to commit suicide by perpetrator
7. Prior suicide attempts by perpetrator* (if check #6 and/or #7 only count as one factor)
8. Prior attempts to isolate the victim
9. Controlled most or all of victim’s daily activities
10. Prior hostage-taking and/or forcible confinement
11. Prior forced sexual acts and/or assaults during sex
12. Child custody or access disputes
13. Prior destruction or deprivation of victim’s property
14. Prior violence against family pets
15. Prior assault on victim while pregnant
16. Choked/Strangled victim in the past
17. Perpetrator was abused and/or witnessed domestic violence as a child
18. Escalation of violence
19. Obsessive behaviour displayed by perpetrator
20. Perpetrator unemployed
21. Victim and perpetrator living common-law
22. Presence of stepchildren in the home
23. Extreme minimization and/or denial of spousal assault history
24. Actual or pending separation
25. Excessive alcohol and/or drug use by perpetrator
26. Depression – in the opinion of family/friend/acquaintance - perpetrator
27. Depression – professionally diagnosed – perpetrator (If check #26 and/or #27 only count as one factor)
28. Other mental health or psychiatric problems – perpetrator
29. Access to or possession of any firearms
30. New partner in victim’s life
31. Failure to comply with authority – perpetrator
32. Perpetrator exposed to/witnessed suicidal behaviour in family of origin
33. After risk assessment, perpetrator had access to victim
34. Youth of couple
35. Sexual jealousy – perpetrator
36. Misogynistic attitudes – perpetrator
37. Age disparity of couple
38. Victim’s intuitive sense of fear of perpetrator
39. Perpetrator threatened and/or harmed children
Other factors that increased risk in this case? Specify:

Risk Factor Descriptions

Perpetrator = The primary aggressor in the relationship

Victim = The primary target of the perpetrator’s abusive/maltreating/violent actions

Any actual or attempted assault on any person who is not, or has not been, in an intimate relationship with the perpetrator. This could include friends, acquaintances, or strangers. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family members; friends; neighbours; co-workers; counsellors; medical personnel, etc.).
Any actual, attempted, or threatened abuse/maltreatment (physical; emotional; psychological; financial; sexual, etc.) toward a person who has been in, or is in, an intimate relationship with the perpetrator. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family members; friends; neighbours; co-workers; counselors; medical personnel, etc.). It could be as simple as a neighbour hearing the perpetrator screaming at the victim or include a co-worker noticing bruises consistent with physical abuse on the victim while at work.
Any comment made to the victim, or others, that was intended to instill fear for the safety of the victim’s life. These comments could have been delivered verbally, in the form of a letter, or left on an answering machine. Threats can range in degree of explicitness from “I’m going to kill you” to “You’re going to pay for what you did” or “If I can’t have you, then nobody can” or “I’m going to get you.”
Any incident in which the perpetrator threatened to use a weapon (e.g., gun; knife; etc.) or other object intended to be used as a weapon (e.g., bat, branch, garden tool, vehicle, etc.) for the purpose of instilling fear in the victim. This threat could have been explicit (e.g, “I’m going to shoot you” or “I’m going to run you over with my car”) or implicit (e.g., brandished a knife at the victim or commented “I bought a gun today”). Note: This item is separate from threats using body parts (e.g., raising a fist).
Any actual or attempted assault on the victim in which a weapon (e.g., gun; knife; etc.), or other object intended to be used as a weapon (e.g., bat, branch, garden tool, vehicle, etc.), was used. Note: This item is separate from violence inflicted using body parts (e.g., fists, feet, elbows, head, etc.).
Any recent (past 6 months) act or comment made by the perpetrator that was intended to convey the perpetrator’s idea or intent of committing suicide, even if the act or comment was not taken seriously. These comments could have been made verbally, or delivered in letter format, or left on an answering machine. These comments can range from explicit (e.g., “If you ever leave me, then I’m going to kill myself” or “I can’t live without you”) to implicit (“The world would be better off without me”). Acts can include, for example, giving away prized possessions.
Any recent (past 6 months) suicidal behaviour (e.g., swallowing pills, holding a knife to one’s throat, etc.), even if the behaviour was not taken seriously or did not require arrest, medical attention, or psychiatric committal. Behaviour can range in severity from superficially cutting the wrists to actually shooting or hanging oneself.
Any non-physical behaviour, whether successful or not, that was intended to keep the victim from associating with others. The perpetrator could have used various psychological tactics (e.g., guilt trips) to discourage the victim from associating with family, friends, or other acquaintances in the community (e.g., “if you leave, then don’t even think about coming back” or “I never like it when your parents come over” or “I’m leaving if you invite your friends here”).
Any actual or attempted behaviour on the part of the perpetrator, whether successful or not, intended to exert full power over the victim. For example, when the victim was allowed in public, the perpetrator made her account for where she was at all times and who she was with. Another example could include not allowing the victim to have control over any finances (e.g., giving her an allowance, not letting get a job, etc.).
Any actual or attempted behaviour, whether successful or not, in which the perpetrator physically attempted to limit the mobility of the victim. For example, any incidents of forcible confinement (e.g., locking the victim in a room) or not allowing the victim to use the telephone (e.g., unplugging the phone when the victim attempted to use it). Attempts to withhold access to transportation should also be included (e.g., taking or hiding car keys). The perpetrator may have used violence (e.g., grabbing; hitting; etc.) to gain compliance or may have been passive (e.g., stood in the way of an exit).
Any actual, attempted, or threatened behaviour, whether successful or not, used to engage the victim in sexual acts (of whatever kind) against the victim’s will. Or any assault on the victim, of whatever kind (e.g., biting; scratching, punching, choking, etc.), during the course of any sexual act.
Any dispute in regards to the custody, contact, primary care or control of children, including formal legal proceedings or any third parties having knowledge of such arguments.
Any incident in which the perpetrator intended to damage any form of property that was owned, or partially owned, by the victim or formerly owned by the perpetrator. This could include slashing the tires of the car that the victim uses. It could also include breaking windows or throwing items at a place of residence. Please include any incident, regardless of charges being laid or those resulting in convictions.
Any action directed toward a pet of the victim, or a former pet of the perpetrator, with the intention of causing distress to the victim or instilling fear in the victim. This could range in severity from killing the victim’s pet to abducting it or torturing it. Do not confuse this factor with correcting a pet for its undesirable behaviour.
Any actual or attempted form physical violence, ranging in severity from a push or slap to the face, to punching or kicking the victim in the stomach. The key difference with this item is that the victim was pregnant at the time of the assault and the perpetrator was aware of this fact.
Any attempt (separate from the incident leading to death) to strangle the victim. The perpetrator could have used various things to accomplish this task (e.g., hands, arms, rope, etc.). Note: Do not include attempts to smother the victim (e.g., suffocation with a pillow).
As a child/adolescent, the perpetrator was victimized and/or exposed to any actual, attempted, or threatened forms of family violence/abuse/maltreatment.
The abuse/maltreatment (physical; psychological; emotional; sexual; etc.) inflicted upon the victim by the perpetrator was increasing in frequency and/or severity. For example, this can be evidenced by more regular trips for medical attention or include an increase in complaints of abuse to/by family, friends, or other acquaintances.
Any actions or behaviours by the perpetrator that indicate an intense preoccupation with the victim. For example, stalking behaviours, such as following the victim, spying on the victim, making repeated phone calls to the victim, or excessive gift giving, etc.
Employed means having full-time or near full-time employment (including self-employment). Unemployed means experiencing frequent job changes or significant periods of lacking a source of income. Please consider government income assisted programs (e.g., O.D.S.P.; Worker’s Compensation; E.I.; etc.) as unemployment.
The victim and perpetrator were cohabiting.
Any child(ren) that is(are) not biologically related to the perpetrator.
At some point the perpetrator was confronted, either by the victim, a family member, friend, or other acquaintance, and the perpetrator displayed an unwillingness to end assaultive behaviour or enter/comply with any form of treatment (e.g., batterer intervention programs). Or the perpetrator denied many or all past assaults, denied personal responsibility for the assaults (i.e., blamed the victim), or denied the serious consequences of the assault (e.g., she wasn’t really hurt).
The partner wanted to end the relationship. Or the perpetrator was separated from the victim but wanted to renew the relationship. Or there was a sudden and/or recent separation. Or the victim had contacted a lawyer and was seeking a separation and/or divorce.
Within the past year, and regardless of whether or not the perpetrator received treatment, substance abuse that appeared to be characteristic of the perpetrator’s dependence on, and/or addiction to, the substance. An increase in the pattern of use and/or change of character or behaviour that is directly related to the alcohol and/or drug use can indicate excessive use by the perpetrator. For example, people described the perpetrator as constantly drunk or claim that they never saw him without a beer in his hand. This dependence on a particular substance may have impaired the perpetrator’s health or social functioning (e.g., overdose, job loss, arrest, etc). Please include comments by family, friend, and acquaintances that are indicative of annoyance or concern with a drinking or drug problem and any attempts to convince the perpetrator to terminate his substance use.
In the opinion of any family, friends, or acquaintances, and regardless of whether or not the perpetrator received treatment, the perpetrator displayed symptoms characteristic of depression.
A diagnosis of depression by any mental health professional (e.g., family doctor; psychiatrist; psychologist; nurse practitioner) with symptoms recognized by the DSM-IV, regardless of whether or not the perpetrator received treatment.
For example: psychosis; schizophrenia; bi-polar disorder; mania; obsessive-compulsive disorder, etc.
The perpetrator stored firearms in his place of residence, place of employment, or in some other nearby location (e.g., friend’s place of residence, or shooting gallery). Please include the perpetrator’s purchase of any firearm within the past year, regardless of the reason for purchase.
There was a new intimate partner in the victim’s life or the perpetrator perceived there to be a new intimate partner in the victim’s life
The perpetrator has violated any family, civil, or criminal court orders, conditional releases, community supervision orders, or “No Contact” orders, etc. This includes bail, probation, or restraining orders, and bonds, etc.
As a(n) child/adolescent, the perpetrator was exposed to and/or witnessed any actual, attempted or threatened forms of suicidal behaviour in his family of origin. Or somebody close to the perpetrator (e.g., caregiver) attempted or committed suicide.
After a formal (e.g., performed by a forensic mental health professional before the court) or informal (e.g., performed by a victim services worker in a shelter) risk assessment was completed, the perpetrator still had access to the victim.
Victim and perpetrator were between the ages of 15 and 24.
The perpetrator continuously accuses the victim of infidelity, repeatedly interrogates the victim, searches for evidence, tests the victim’s fidelity, and sometimes stalks the victim.
Hating or having a strong prejudice against women. This attitude can be overtly expressed with hate statements, or can be more subtle with beliefs that women are only good for domestic work or that all women are “whores.”
Women in an intimate relationship with a partner who is significantly older or younger. The disparity is usually nine or more years.
The victim is one that knows the perpetrator best and can accurately gauge his level of risk. If the women discloses to anyone her fear of the perpetrator harming herself or her children, for example statements such as, “I fear for my life”, “I think he will hurt me”, “I need to protect my children”, this is a definite indication of serious risk.
Any actual, attempted, or threatened abuse/maltreatment (physical; emotional; psychological; financial; sexual; etc.) towards children in the family. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family; friends; neighbours; co-workers; counselors; medical personnel, etc).

Appendix C: Summary of Recommendations – 2011 Case Reviews

Case #	Recommendation
2011-2	The Law Society of Upper Canada should adopt a policy of ensuring that lawyers who do deal with family clients are aware of the risk and safety issues in domestic violence cases.
2011-2	Domestic violence and risk assessment should be part of the mandatory Ethics & Professional Responsibility course to be required by law schools for all students starting with the class of 2015.
2011-2	Domestic violence should be part of the now mandatory CLE requirement for practicing lawyers, at least for those who practice family law.
2011-7	Psychiatrists and other mental health workers are reminded that documentation about suicidal and homicidal ideation are important components of assessing a patient for either involuntary admission or suitability for release from hospital.
2011-7	When assessing patients either for involuntary admission or release from hospital, a variety of sources of information should routinely be sought, including family members.
2011-14	Individuals and organizations providing services and support to Aboriginal communities are reminded that the Kanwayhitowin Campaign (based on the Neighbours, Friends and Family program) is a valuable resource to provide information and education on addressing the issue of domestic violence involving Aboriginal people in Ontario.
2011-15	Probation and Parole Officers should be aware of the Partner Abuse Protocol when dealing with cases of partner abuse, and ensure attention to victim safety, recognizing that engagement with the victim is essential for victim safety.
2011-15	Coordinated safety plans should be developed with the victim and with partner agencies in the community. In cases where the victim is not linked to any community services, the probation officer should do a safety assessment of the victim’s potential risk for violence and refer them to the appropriate community services, paying particular attention to any special needs of the victim.
2011-15	Ongoing contact with the victim should occur in order to assess safety concerns and the abuser’s compliance with the probation conditions. This should occur on a regular basis, throughout the probation period. The probation officer should not rely solely on the abuser’s self report of compliance. Annual audits by area managers, as per established performance measures, should be conducted to "ensure that PPOs are supervising the case in accordance with the Partner Abuse Protocol."
2011-15	Probation and Parole Officers should also notify local law enforcement of any concerns in relation to offender compliance so that formal monitoring programs, (e.g. Crime Abatement Strategy, Bail Enforcement Program, etc.) or informal monitoring of offender compliance, can be conducted by law enforcement. This is particularly important in relation to any orders prohibiting or restricting contact between the offender and the victim.
2011-16	It is recommended that social services/probation examine the potential requirement for an intervention specifically designed for women perpetrators of violence and domestic violence.
2011-16	The potential for lethal violence by women perpetrators with substantial violent histories, serious substance abuse problems and emotional instability should be taken seriously and when a high risk case is identified, steps should be taken to refer these women to appropriate treatment and more intensive supervision.
2011-16	The Victim and Vulnerable Persons Division should consider creating a public education program with information and resources specifically aimed towards assisting male victims of domestic violence.
2011-21	The Minister of Justice for Canada should implement legislation that will provide for minimum sentences for domestic violence offences. It is suggested that for a second conviction, the minimum sentence should be at least 6 months in jail. For a third or subsequent offence, the minimum sentence should be at least 12 months in jail.
2011-21	It is recommended that legislation be amended so that assault in a domestic context, be listed as an eligible offence for application of long-term offender status.
2011-21	The Ministry of the Attorney General, Crown Law Office, should have enhanced vigilance in identifying serial domestic violence offenders and should seek an application to the court to have the offender declared a long-term or dangerous offender, when appropriate.
2011-21	The Ministry of the Attorney General should implement a policy that requires the consent of the Assistant Deputy Minister for Criminal Law for any reduction of a murder charge to manslaughter by way of plea resolution for cases that involve domestic violence.
2011-24	It is recommended that the police service involved with the 911 calls on October 29, 2007 consider an internal review of this case. The police service should review the response of the attending officers to ensure that all policies, procedures and protocols in relation to domestic violence occurrences were followed, particularly as they relate to ensuring that the same policies and procedures are applied to male victims of domestic violence.
2011-24	The CAS involved with the family should conduct an internal review to examine its provision of services and assessment of risk for this family prior to the homicide.
2011-24	Children’s Aid Societies should be required to conduct internal reviews when a domestic violence death occurs in a family that had received the services of the CAS within the 12 months preceding the death, and where domestic violence issues had been identified.
2011-24	All police services should receive annual training/education on programs and services offered by Victim Services in order to assist officers in responding more effectively to the criminal and non-criminal issues victims face following an incident of domestic violence. Police should be reminded to immediately refer all victims of domestic violence (male and female) to Victim Services to ensure timely intervention and assistance.
2011-26	Health care providers are reminded to inquire about thoughts of homicide, in addition to suicide, when interacting with elderly patients suffering from depression.
2011-26	Health care providers are encouraged to interview couples separately, particularly when mental health issues may be present.
2011-27	It is recommended that police officers receive additional/supplemental education and training about victim vulnerability in cases of domestic violence, particularly as it relates to victims of domestic violence committed by police officers.
2011-27	It is recommended that an anonymous helpline be established for all police personnel and their families, similar to what exists for physicians in Ontario, where they would have access to immediate assistance and crisis intervention as well as referral to specialized counseling services.
2011-28	The MCSCS should consider reviewing its existing training material related to the management of high risk domestic violence cases and Intensive Supervision Offenders (ISOs). Measures should be taken to ensure updated, ongoing training to all probation and parole officers involved with ISOs, emphasizing: • the. importance of following the domestic violence protocol; • a focus on the identification of pertinent risk factors related to each case and appropriate evidenced based measures to be taken to mitigate risk; • case reviews conducted by the DVDRC where the offenders were under supervision of MCSCS. The review should include an audit of participation rates in this specialized training.
2011-28	It is recognized that the MSCSC has undertaken recent policy reforms to address issues related to high risk (intensive) case supervision for domestic violence perpetrators. It is recommended that an internal review should be conducted of all domestic violence homicide cases supervised since the implementation of these policies, where the offender reoffended while under supervision of the MCSCS. Lessons learned from these reviews could be incorporated into staff training and further policy reform.
2011-28	The Intensive Supervision Unit (ISU) should review its referral criteria and consider expanding its mandate to include offenders with a pattern of recurrent assaults against women and/or a history of choking/strangling their victims. The ISU supervision strategy should be audited to ensure that its services include not only more frequent contact with the offender, but also ancillary wrap-around services (e.g., ongoing communication with the potential victim, referral to, and communication with police and treatment providers).
2011-28	Communication between treatment providers and between probation services and the victim or potential victims (e.g. new partner), should be a regular and essential component of intensive case supervision. Communication strategies for all treatment providers should be set in policy.
2011-28	Given the high number of risk factors identified in this case, it was deemed by the DVDRC to be very high risk. It is recommended that for similar cases of very high risk, MCSCS should put in place a mandatory referral to local police services for assessment of the appropriateness of placing the offender under High Risk police supervision. This would allow for enhanced safety planning strategies for the potential victim, as well as more aggressive monitoring and potential interventions with the offender when probation and/or parole violations occur.
2011-31	It is recommended that all marriage and family therapists receive specialized training about victim vulnerability and perpetrator risk in cases of domestic violence.

Ministry of Community Safety and Correctional Services :: 2011 Report

Chief Coroner

Publications & Reports

Domestic Violence Death Review Committee
2011 Annual Report

Table of Contents

Message from the Chair

Committee Membership

Executive Summary

Chapter One: Introduction and Overview

History

Mandate

Membership

Definition of Domestic Violence

Method for Reviewing Cases

Review and Report Limitations

Annual Report

Disclaimer

Chapter Two: Statistical Overview: A fresh new look

Collection of Data

Types of Data

Statistical Overview: Homicides with Domestic Violence Involvement (2002-2009)

Statistical Overview: Cases reviewed by the DVDRC (2003-2011)

Statistical Overview: Cases reviewed by the DVDRC in 2011

Chapter Three: Case Reviews and Recommendations - 2011

Chapter Four: Learning from DVDRC Reviews

Domestic Violence in Aboriginal Communities: An Overview of DVDRC Findings

Domestic Violence in Aboriginal Communities: A National Overview

DVDRC findings within a National Context:

Future Directions: Addressing Domestic Violence in Aboriginal Communities in Ontario

Domestic Violence and Gender: The findings of reviews by the DVDRC

Future Direction – Gender specific domestic violence programs

Appendix A: Domestic Violence Death Review Committee Terms of Reference

Appendix B: Ontario Domestic Violence Death Review Committee Risk Factor Coding Form

Appendix C: Summary of Recommendations – 2011 Case Reviews

Domestic Violence Death Review

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Ministry of Community Safety and Correctional Services :: 2011 Report

Chief Coroner

Publications & Reports

Domestic Violence Death Review Committee 2011 Annual Report

Table of Contents

Message from the Chair

Committee Membership

Executive Summary

Chapter One: Introduction and Overview

History

Mandate

Membership

Definition of Domestic Violence

Method for Reviewing Cases

Review and Report Limitations

Annual Report

Disclaimer

Chapter Two: Statistical Overview: A fresh new look

Collection of Data

Types of Data

Statistical Overview: Homicides with Domestic Violence Involvement (2002-2009)

Statistical Overview: Cases reviewed by the DVDRC (2003-2011)

Statistical Overview: Cases reviewed by the DVDRC in 2011

Chapter Three: Case Reviews and Recommendations - 2011

Chapter Four: Learning from DVDRC Reviews

Domestic Violence in Aboriginal Communities: An Overview of DVDRC Findings

Domestic Violence in Aboriginal Communities: A National Overview

DVDRC findings within a National Context:

Future Directions: Addressing Domestic Violence in Aboriginal Communities in Ontario

Domestic Violence and Gender: The findings of reviews by the DVDRC

Future Direction – Gender specific domestic violence programs

Appendix A: Domestic Violence Death Review Committee Terms of Reference

Appendix B: Ontario Domestic Violence Death Review Committee Risk Factor Coding Form

Appendix C: Summary of Recommendations – 2011 Case Reviews

Domestic Violence Death Review

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Domestic Violence Death Review Committee
2011 Annual Report