Domestic Violence Death Review Committee Recommendations based on area of concern (2003-2014)

There is a need to have appropriate assessment tools available to those who work with victims and perpetrators of domestic violence to better assess the potential for lethal violence in their lives. Correspondingly, once the risk is identified, victims and perpetrators of domestic violence need access to appropriate services and programs. The person at risk requires access to:

• a specialized and comprehensive risk assessment by an appropriate agency;

• skilled assistance to engage the victim in developing a safety planning process;

risk management, for both the victim and the perpetrator.

All front-line professionals that deal with individuals and families in crisis should adopt an appropriate risk assessment process and a mechanism or protocol at a local level to facilitate and enhance communication between agencies and professionals when a person is identified to be at risk. For example, such a protocol should permit any professional evaluating a high risk case to contact the local police service’s case manager or domestic violence coordinator to establish a case conference to ensure appropriate tracking and response to the case.

There is a need for greater use of case conferencing systems that share information and action plans between justice partners, health professionals, and counsellors regarding safety issues and “high risk” cases.

It is recommended that child welfare and protection agencies screen for domestic violence in all cases. As part of the process, it is necessary for them to locate, interview, and assess all partners involved. Where there is evidence of domestic violence, they must take the necessary steps to use their authority under the Children and Family Services Act to make appropriate interventions with the abuser to protect the mother and child.

It is recommended that the Ministry of Attorney General take the lead in consultations with justice and community stakeholders and develop a provincial plan to high risk management of domestic violence cases that present with indicators of potential dangerousness or lethality.

To the MCSCS, Policing Standards; and OACP: It is recommended that Police Services require responding officers to complete a lethality screen on each and every domestic occurrence, whether or not criminal charges are laid. This lethality screen should be modeled after similar tools in existence such as Domestic Violence Lethality Assessment Protocol for the Maryland Coordinated Community, or Dr. Jacquelyn Campbell’s Danger Assessment tool.

It is recommended that MCSCS review their current procedures for assessing risks posed by domestic violence perpetrators to assist in case planning and management and that they ensure adequate funding is in place for batterer intervention programs.

It is recommended that in every domestic violence case, there be a requirement that risk be assessed. If a high-risk case is identified, it needs to be specifically red flagged for further follow up.

It is recommended that once a case has been identified as a high risk case, then there must be a systems response so that the case can be actively managed. This would require that the justice partners involved with the case meet to discuss management options and strategies. Such dedicated teams already exist in parts of Ontario and should be the model for other communities to follow. 

2008
(2008 – 02)

A common risk assessment tool should be developed and mental health practitioners should be trained to effectively and systemically utilize the tool to identify potential risks.

2008
(2008 – 06)

When assessing applications for support, the Family Responsibility Office (FRO) should ask applicants to identify potential safety threats, including violence that may arise from support enforcement activities.

2008
(2008 – 11)

In cases of severe incidents of harm that include death threats and strangulation, even if there is no documented history of domestic violence, there needs to be recognition of the severity of a single, but critical assault at a bail hearing and evidence put forward for this incident to be considered a higher risk case and thus managed in that manner.

2008
(2008 – 15)

Appropriate risk assessment tools need to be used by mental health professionals when dealing with victims and perpetrators of domestic violence.

2010
(2010 – 16)

Police risk assessment should be mandatory for every domestic violence call, regardless of whether there is a prior history of domestic violence, and should not be dependent upon a charge being laid or not.

2010
(2010 – 07)

The DVSR should be used not only to indicate the presence of violence risk-enhancing factors, but also to identify those areas where case management could mitigate the risk for future violence.  When risk factors such as substance abuse, mental health concerns, employment issues etc. are identified, efforts should be made to provide appropriate references or involve appropriate services to alleviate those risk factors.

2011
(2011-02)

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.

2013
(2013-01)

To the Ministry of the Attorney General, Ministry of Community Safety and Correctional Services, the Ontario Network of Victim Services Providers and the Ontario Network of Sexual Assault and Domestic Violence Treatment Centres:
1. Justice partners (including police, Crown, probation and parole), together with shelter and victim services workers, are encouraged to develop a systems-approach to managing cases involving victims who are at high risk for intimate partner violence. 

2013
(2013-08)

To the Ontario Alliance of Mental Health Practitioners, Ontario Psychological Association, Ontario Psychiatric Association, College of Physicians and Surgeons of Ontario, The College of Psychologists of Ontario, and the Ontario Association of Social Workers:
1. Mental health professionals (i.e. psychiatrists, psychologists and social workers) should enhance learning opportunities on the assessment and treatment of domestic violence perpetrators. 

2013
(2013-08)

To the Ministry of the Attorney General:
2. The Ministry of the Attorney General (MAG) should review policies dealing with perpetrators referred to the Partner Assault Response (PAR) program to ensure that they receive screening at intake for level of denial of their offence, in comparison to police and court findings. The courts should ensure that PARs receive a detailed account of the offence, including any victim statements, and that PARs use this to assess the client's level of denial/accountability. Perpetrators who maintain a high level of denial at program completion should be required to repeat the PAR program, or receive other community referrals. 

2013
(2013-14)

To the Ministry of Community Safety and Correctional Services, Policing Services Division, and the Ontario Association of Chiefs of Police:
1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be at high risk requiring special vigilance. Even when there is no reported history of violence between the couple, these cases require a protocol that includes appropriate risk assessment and subsequent attention to safety planning when there was alleged prior abuse against any children in the relationship. Such a protocol needs to be accompanied by appropriate training focused on addressing the potential danger for the victim and/or the child if either has been subject to previous abuse by the perpetrator during separation. 

2014
(2014-08)

To the Ministry of Community Safety and Correctional Services:
1. That a working group of police and risk assessment experts explore the feasibility of developing a brief lethality assessment protocol for domestic calls that do not involve charging for domestic violence.

2014
(2014-08)

To the Ministry of Community Safety and Correctional Services:
2. That a working group of police and risk assessment experts develop a process for conducting an internal review in police services where a death occurred despite the history of a family’s several help-seeking contacts with the police where calls were deemed low risk. Lessons learned from these real life situations could serve as a teaching tool in subsequent domestic violence training programs for police officers. 

2014
(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies
1. The Children’s Aid Society (CAS) involved with this family should conduct an internal review to examine its assessment of risk, not only for child abuse or neglect, but also for intimate partner violence.

2014
(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies
3. It is recommended that the Ministry of Children and Youth Services update and enhance the training available to all CASs regarding assessing potential for domestic and intimate partner violence and ensure that it reflects the most recent literature and best practices. It is recommended that the training of front line CAS workers and supervisors include training on issues related to intimate partner violence.

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.
4. It is recommended that all medical schools and their departments of psychiatry in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. Safety is a top priority, therefore, it must be ensured that trainees at all levels obtain competency in risk assessment and risk management techniques.

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.
5. It is recommended that the facts and circumstances of the case (with identifiers removed) be used to assist in the education of members of the Canadian Professional Counsellors Association (CPCA) about the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.
6. It is recommended that continuing education of CPCA members include an emphasis on the importance of understanding the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-11)

To the Ministry of the Attorney General
3. Recommend that prompt victim contact by PAR when high risk is identified, and consideration of victim referrals for newcomers or where ESL. When a perpetrator completes the intake assessment with the PAR provider, and there is evidence of high risk to the victim – the PAR agency should immediately notify the police, the referral source, the victim and the perpetrator. A partner contact needs to occur immediately in order to assess her safety and provide necessary referrals, safety assessment, supports, risk management and ongoing follow-up. The PAR program needs to pay particular attention to the issues of a victim who is a newcomer to Canada, and in particular cases where isolation and language barriers may escalate risks to her. 

2014
(2014-12)

To the Ontario Association of Naturopathic Doctors, the Canadian Association of Naturopathic Doctors, the Canadian College of Naturopathic Medicine, and the College of Naturopaths of Ontario:
1. It is recommended that all schools of naturopathic medicine in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on all aspects of domestic violence, including the psychological/emotional/verbal abuse that many victims experience. Furthermore, naturopathic doctors who work with potential perpetrators should be able to assess the risk for depression, substance use, suicidal and homicidal ideation, history of domestic violence, mental health issues and separation anxieties. 

2014
(2014-16)

To the Ministry of Education:
It is recommended that that school professionals be given training on developing safety plans for students once the student has been assessed as being at risk for suicide and that these students be given priority for support by the school. Guidelines should be developed to recognize the unique circumstances and risk of these students and the importance of connecting them to school-based supports. This could include a transition or planning meeting prior to the student returning to school so that information can be shared among team members. 

2014
(2014-16)

To the Ministry of Education and the Ministry of Health and Long-Term Care:
1. It is recommended that formal partnerships be developed between hospitals that provide psychiatric assessment and public schools to allow schools to communicate with and create safety plans for students who have been admitted as patients due to suicidal thoughts or behaviour. 

There is a need for ongoing training in the issues of domestic violence and potential lethality for police, social workers/counsellors, clergy, and physicians.

Police and other front-line workers (health/educational/social) need to be made aware of the resources available in their respective communities to address issues of family breakdown, conflict, and mental health, and to make referrals when necessary.

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.

All victims experiencing any form of domestic violence should be referred to and directly involved in a safety planning process whenever abuse is disclosed to social workers/counsellors, shelter, or other services for abused persons, such as physicians, the police, and victim services.

It is recommended that each police service appoint an appropriate number of officers, specially trained in the issues of domestic violence, as case managers. The case managers’ duties would include reviewing all domestic violence cases, identifying, i.e., “red-flagging” any high risk matters, and tracking the cases as they proceed to completion.

It is recommended that front line service providers (police, shelter worker, paramedics, medical staff0 receive training in recognizing that the effects of drug and/or alcohol addictions on the victim can sometimes cloud the assessment of underlying domestic abuse.

Persons working in occupations with access to firearms, such as police, may experience barriers in the workplace to the disclosure of mental health and emotional problems. It is recommended that a change in the organizational culture be initiated to establish a climate conducive to such disclosure, without fear of recrimination or employment restrictions.

It is recommended that where feasible and practical, police services should give consideration to supervised control of issue firearms when officers are off duty.

It is recommended that police put processes into practice to identify, monitor, and manage high-risk cases, and to vigorously enforce bail conditions arising from a violent offence or threat of violence. Further, it is recommended that police services institute a dedicated police unit that has links to community-based experts to deal specifically with high-risk domestic violence cases, to ensure an appropriate case management response in such cases.

2004
(2004 – 01, 02, 03, 04, 05, 06, 07, 08, 09)

It is recommended that the Ministry of Community Safety and Correctional Services, Policing Standards Section either develop a stand-alone model to manage high risk domestic violence cases, or include domestic violence in the current standard that addresses high-risk cases.

2004
(2004 – 08)

It is recommended that police services put processes into practice to ensure that 911 call-takers and dispatch personnel receive specialized training in domestic violence. Guidelines should be established with prioritized questions to assist 911 call-takers and dispatch personnel to assess immediate risk to the caller and to first responders.

2004
(2004 – 03, 05, 08)

It is recommended that a protocol be established between police and crown counsel to ensure that persons proposed as surety: 1) be properly investigated as to their suitability to act as surety; 2) be fully informed about their responsibilities as surety both in writing and on the court record; and 3) be warned, in writing and on the court record, as to their potential liability under estreatment and as party to a criminal offence in the event they breach their duty.

2004
(2004 – 03, 05, 08)

It is recommended that, in cases of domestic violence, the police give persons proposed as surety written or video information about the risk factors for potential lethality, and that receipt of that material be confirmed on the court record.

2004
(2004 – 08)

It is recommended that a protocol be established for immediately entering restraining orders into the CPIC (Canadian Police Information Centre) system so that if there is a breach, the police can act immediately under the Family Law Act. 

2006
(2006 – 09)

To the Ministry of Community Safety and Correctional Services (MCSCS), Policing Standards Division; and the Ontario Association of Chiefs of Police (OACP): Police services across Ontario as well as Police Colleges should encourage monitoring of high-risk domestic violence perpetrators who could be red-flagged because of the extreme dangers that they pose to their ex-partners and children. This should include proactive approach to victims and perpetrators without the need for further calls to the police, and may involve a coordinating function with other service providers such as Child Protection Agencies.

2006
(2006 – 09)

To the MCSCS. Policing Standards Division; OACP; and OACAS: Police and CAS training should reinforce that risk assessment is not an end in itself but rather an ongoing process that requires safety planning, risk education and coordination of a community plan.

2007
(2007 – 04)

Police services across Ontario should consider implementing procedures that stipulate that when there are grounds to arrest and/or charge a person in relation to a domestic assault, and where there are public safety issues, or a delay in processing the charges, the accused should immediately be placed on the Canadian Police Information Centre (CPIC) as a Special Interest Police (SIP) entry, advising that grounds exist to arrest.

2007
(2007 – 03)

It is recommended that there be ongoing training for police on the most effective response to domestic violence cases where there is a history of homicidal and suicidal threats, a recent separation, and where prior history includes domestic violence, serious substance abuse and/or child abuse.

2007
(2007 – 11)

It is recommended that police services reinforce with their members the requirements of the Domestic Violence Occurrences (LE24) and Firearm Occurrences (LE029) of the Provincial Adequacy Standard Guidelines regarding the seizure of firearms during the course of Domestic Violence Occurrences. This training should be conducted on an annual basis placing emphasis on ensuring officers are appropriately educated on their authorities to conduct weapons seizures with and without a warrant.

2008
(2008 – 01)

It is recommended that police put processes into practice to identify, monitor, and manage high-risk cases, and to vigorously enforce bail conditions arising from a violent offence or threat of violence.

2008
(2008 – 11)

In cases of strangulation or head injury, police personnel should consider taking a victim to the hospital to receive immediate medical attention, especially to medical personal who have specialized training in recognizing the repercussions of such serious situations (i.e. DV/SAC nursing teams are currently housed in many emergency departments across the province and are often under-utilized).

2008
(2008 – 11)

In cases of severe incidents of harm that include death threats and strangulation, even if there is no documented history of domestic violence, there need to be recognition of the severity of a single, but critical assault at a bail hearing and evidence put forward for this incident to be considered a higher risk case and thus managed in that manner.

2008
(2008 – 14)

It is recommended that the Domestic Violence Supplementary Report (DVSR) be enhanced to require a verbatim narrative response to risk assessment questions where the answer is “yes” or “unknown”. Further, that this enhanced DVSR be mandated, prohibiting any deviation or change in the content, for use by all police services, including First Nation police services.

2008
(2008 – 14)

It is recommended that all First Nation police services reinforce with their members the requirements of the Domestic Violence Occurrences (LE24) and Firearms Occurrences (LE029) of the Provincial Adequacy Standard Guidelines regarding mandatory charge, completion of the Domestic Violence Supplementary Report (DVSR) and the seizure of firearms during the course of domestic violence occurrences. This training should be conducted on an annual basis placing an emphasis on ensuring officers are appropriately educated on their authorities to conduct weapons seizures with and without a warrant.

2009
(2009 – 03)

It is recommended that Police Services and Police Associations continue to be committed to supporting the mental health and well being of their members and to collectively enhance their support and promotion of ready access to employee assistance networks.  

2009
(2009 – 03)

Awareness of the unique demands facing female police officers in a male dominated police profession must be recognized and support mechanisms developed. 

2009
(2009 – 03)

Progressive initiatives focused on vicarious trauma and stress management for police personnel should be developed and proactively delivered as a means of raising shared awareness.  Identification, intervention and prevention are every member’s responsibility. 

2009
(2009 – 03)

The suicide and suicide-homicide literature reviews that formed the basis of the, “Report to the London Police Service and London Community on the Deaths of _______ and _______”, should be made readily available through the Ministry of Community Safety and Correctional Services – Policing Services Division, the Ontario Association of Chiefs of Police and the Canadian Association of Chiefs of Police. 

2009
(2009 – 03)

Police services should enhance supports for the mental health and wellness of their members by building liaisons with community services and introducing innovative models like the Psychological Services Section of the Calgary Police Service.  Psychologists who are experts in the complexities of emergency services, vicarious trauma and the sub-culture of policing are essential to garnering trust and removing barriers to access.  Consistency of access to a Police Psychologist or team of psychologists is paramount to achieving early intervention and prevention. 

2010
(2010 – 16)

Police training should include instruction on how to deal with resistant or reluctant victims of domestic violence.  

2010
(2010 – 16)

It is recommended that the Working Group co-chaired by the Ministry of Community Safety and Correctional Services and the OPP, expedite the process to distribute a modified Domestic Violence Supplementary Report (DVSR) to police in Ontario.

2010
(2010 – 07)

Incidents reported to, or investigated by Police as Domestic Violence, regardless of whether a verbal incident only or whether criminal charges are laid, should result in the completion of the Domestic Violence Supplementary Report (DVSR). 

2011
(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
(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
(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
(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.

2012
(2012-08)

Police Services, Victim Services, Community Care Access Centres and health care providers to the elderly are reminded of the following resources that provide valuable information pertaining to the identification and response to elder abuse in Ontario:

Neighbours, Friends and Families for Older Adults - “It’s Not Right!” Campaign

•   www.neighboursfriendsandfamilies.ca
  
•  Ontario Network for the Prevention of Elder Abuse - www.onpea.org

2012
(2012-08)

Victim Services workers are reminded that they should immediately contact police when they become aware that conditions of an order have been breached; consideration should also be given to establishing and/or revising safety planning and/or risk management measures.

2012
(2012-08)

Police Services are reminded that conditions of release should clearly emphasize the non-discretionary nature of no-contact orders and that victims may need to be reminded/advised that the orders also apply to them not contacting the perpetrator (or alleged perpetrator). 

2013
(2013-04)

To the Ministry of the Attorney General:

3. Family courts should develop a triage function for an initial assessment of cases to determine the degree of urgency required to hear the matter; the need for additional resources and community referrals to assure safety planning; and appropriate risk management interventions to reduce domestic violence and child abuse. 

2013
(2013-14)

To the Ministry of Community Safety and Correctional Services, Policing Services Division, and the Ontario Association of Chiefs of Police:

1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be at high risk requiring special vigilance. Even when there is no reported history of violence between the couple, these cases require a protocol that includes appropriate risk assessment and subsequent attention to safety planning when there was alleged prior abuse against any children in the relationship. Such a protocol needs to be accompanied by appropriate training focused on addressing the potential danger for the victim and/or the child if either has been subject to previous abuse by the perpetrator during separation. 

2014
(2014-08)

To the Ministry of Community Safety and Correctional Services:

1. That a working group of police and risk assessment experts explore the feasibility of developing a brief lethality assessment protocol for domestic calls that do not involve charging for domestic violence. 

2014
(2014-08)

To the Ministry of Community Safety and Correctional Services:

2. That a working group of police and risk assessment experts develop a process for conducting an internal review in police services where a death occurred despite the history of a family’s several help-seeking contacts with the police where calls were deemed low risk. Lessons learned from these real life situations could serve as a teaching tool in subsequent domestic violence training programs for police officers. 

2014
(2014-10)

To the Involved Police Service

7. It is recommended that the Domestic Violence Coordinator of the Police Service review the Service’s various interactions with the victim and perpetrator, with a view to ensuring that all appropriate policies, procedures and directives were followed. Where appropriate, lessons learned from the review could be incorporated into ongoing domestic violence training and updates for service members. 

2014
(2014-13)

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

1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve victims with disabilities (in this case, blindness). Cases involving women with disabilities often involve less obvious forms of domestic violence (e.g. withholding a wheelchair; holding back medication) because of the victim’s potential reliance on her abuser and/or her increased vulnerability to the abuser because of his/her disability. 

Probation officers should utilize a common risk assessment tool as it relates to woman abuse and lethality.  Although probation officers routinely use the LSI tool, often the dynamics and issues related to abusive relationships are not identified or dealt with, in any involvement. The explanation for this is that the focus of the intervention is on ‘criminal behaviour’.

Probation officers should receive training on the inter-relationship between substance abuse issues and intimate partner violence so that they can better respond and intervene with individuals who have a multiplicity of issues.  This training would assist probation officers to effectively intervene with individuals who are in abusive and high risk relationships.

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." 

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.

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

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.

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
(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. 

2012-06

As in cases involving male offenders, parole and probation cases involving women perpetrators of crime should apply a supervision strategy that includes:

• identification of the level risk to others posed by women with a history of antisocial behaviour;
• identification of the factors associated with their risk to others, and
• offender participation in interventions and management strategies that address these risk factors.  Factors related to the offender’s self-esteem and victimization should be a focus of intervention only in so far as they are formulated as clear contributors to criminal behaviour. 

2012-06

Program interventions or case supervision strategies for women offenders should be designed relying on recent research findings regarding evidenced-based practice from the effective corrections’ literature.  The following principles should be the framework for these planned intervention strategies/programs:

• Risk (requiring that interventions target the higher risk offenders for more intensive service);
• Need (interventions should target those dynamic (i.e., changeable) factors empirically associated with the individual’s criminality); and
• Responsivity (interventions should target the factors using established cognitive behavioural techniques pitched to the cognitive level of the offender). 

Factors related to offender’s self-esteem and personal victimization should be a focus of intervention only in so far as they are formulated as clear contributors to criminal behaviour. 

Interventions for substance abuse should link the abuse of substances to the individual offender’s pattern of criminal and violent behaviour.

2012
(2012-10)

Conditions of probation should include regular monitoring of the offender’s compliance with conditions, specifically reporting requirements and counseling conditions.  Supervision would benefit from ongoing collateral contacts to confirm the status of the offender’s situation and the credibility of self-reported information.  When the offender has failed to meet the terms, progressive enforcement must align with level of risk.  When repeated verbal or written cautions fail to bring about change, a fail-to-comply charge should be pursued.

All front-line professionals that deal with individuals and families in crisis should adopt an appropriate risk assessment process and a mechanism or protocol at a local level to facilitate and enhance communication between agencies and professionals when a person is identified to be at risk. For example, such a protocol should permit any professional evaluating a high risk case to contact the local police service’s case manager or domestic violence coordinator to establish a case conference to ensure appropriate tracking and response to the case.

It is recommended that every effort be made by family members, friends, and community professionals to have firearms removed from individuals who are going through a separation in their relationships and showing signs of depression or suicidal or homicidal ideation.

It is recommended that awareness and education programs address the culture of silence surrounding domestic violence and its apparent acceptance that still exists in some families and small communities.

It is recommended that all healthcare providers be taught to be mindful of the dynamics of domestic violence and the potential for lethality, especially when working with patients who have a history of alcohol and/or drug abuse, depression, anxiety, or suicidal ideation. When domestic violence is identified in the patient’s life, the potential for lethality should be assessed by the healthcare provider, or the patient should be referred to others with an expertise in making such assessments.

The Committee recommends that healthcare providers use risk assessment tools to assess the potential for domestic violence/abuse, suicide, and/or homicide.

It is recommended that all training material for professionals and public education programs emphasize the harmful nature of emotional and psychological abuse.

It is recommended that family members, friends, and community professionals be educated to contact police immediately and report their concerns when they are aware of individuals who have potential access to firearms and who are in a relationship where domestic violence is suspected. This is particularly important when the couple is through a separation or the individual is showing signs of depression or suicidal or homicidal thoughts.

It is recommended that professionals and persons in authority be educated in terms of giving victims of domestic violence the proper information and guidance, whether they seek their advice in a formal or informal setting. There should be follow up with the victims to ensure they were given sufficient information to make an informed decision. This recommendation is directed to include professionals such as police officers, lawyers, and doctors.

It is recommended that health and social service professionals assess the possibility of childhood histories of exposure to domestic violence and develop intervention strategies to recognize this factor as part of an overall treatment plan.

2005
(2005 – 11)

It is recommended that the College of Physicians and Surgeons of Ontario caution psychiatrists offering an opinion on child custody and access arrangements for separating parents that the opinion should be based on assessment of both parents and children as well as having collateral sources of information. Furthermore, the Ontario Psychiatric Association should provide and/or promote continuing medical education regarding the dynamics of domestic violence and the risk factors for lethality associated with separation, divorce, custody and access issues.

2006
(2006 – 12)

It is recommended that the College of Physicians of Canada ensure that educational interventions for family physicians and family medicine residents on mental illness highlight the way that such problems elevate the risk for lethality in situations of ongoing IPV. 

2007
(2007 – 02)

It is recommended that healthcare providers be taught to be mindful of the dynamics of domestic violence and the potential for lethality, especially when working with patients who have a history of drug abuse, depression, anxiety, and suicidal ideation, particularly when there is high conflict in their marriage and a history of numerous separations.

2007
(2007 – 03)

It is suggested that healthcare providers take a more proactive stance, particularly when working with patients in crisis situations, to ask those patients if there are any safety concerns in their intimate relationships. If the provider senses there are concerns, we recommend they use such danger assessment tool, which will assist both the healthcare provider and the patient to better understand if there is a risk of lethality.

2007
(2007 – 11)

It is recommended that provincial Mental Health and Addictions Strategies include screening for domestic violence as a best practice. Mental health and addictions professionals who are working with women need to be provided with assessment tools that will allow them to assess and determine the level of risk.

2007
(2007 – 12)

It is recommended that all healthcare providers must be mindful of the dynamics of domestic violence and the potential for lethality. Where concerns may be raised for the patient’s safety, an appropriate screening tool must be considered, as it may assist both the healthcare provider and the patient to better understand the lethality risks, and proactively plan appropriately for safety (i.e. calling the police, going to a shelter or safe place, meeting with a specialist in safety planning). If the patient is reluctant to take these steps on her own, she may need to be accompanied.

2008
(2008 – 06)

Training for all mental health professionals should include assessment and intervention strategies dealing with male depression and the link between depression, suicidal ideation and domestic homicide. 

2008
(2008 – 06)

When assessing applications for support, the Family Responsibility Office (FRO) should ask applicants to identify potential safety threats, including violence that may arise from support enforcement activities.

2010
(2010 – 07)

It is recommended that health care facilities consider formulating (and/or reviewing and revising as necessary) protocols, policies and procedures to provide specific practice guidelines, in order to ensure an immediate and proactive response to information reported to them of a “No Contact Order” between a patient and a visitor.

2011
(2011-07)

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
(2011-07)

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
(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
(2011-26)

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

2012
(2012-08)

Police Services, Victim Services, Community Care Access Centres and health care providers to the elderly are reminded of the following resources that provide valuable information pertaining to the identification and response to elder abuse in Ontario:

Neighbours, Friends and Families for Older Adults - “It’s Not Right!” Campaign

• www.neighboursfriendsandfamilies.ca
• Ontario Network for the Prevention of Elder Abuse - www.onpea.org

2012
(2012-08)

When dealing with possible victims of domestic violence, health care providers are reminded of the need for a formalized risk assessment to guide interventions and prioritize safety planning.

2012
(2012-09)

Personal Support Workers should receive specialized training in the dynamics of domestic violence and working with vulnerable victims.  This training should include recognizing the signs and symptoms and how to effectively respond in the event they suspect the client is being abused.  It is important that the training focuses on all aspects of domestic violence, including the psychological/emotional/verbal abuse that many victims experience.

2012
(2012-13)

Individuals and organizations providing health care services and support to aging couples with declining or poor heath should receive enhanced education and training about their increased risk of intimate partner homicide-suicide, particularly if the male is in the caretaker role for his female partner or there has been some other major life event.

2012
(2012-13)

It is recommended that the Ontario Women’s Directorate increase public awareness about the increased risk of intimate partner homicide-suicide among aging couples, particularly if there is declining health and/or the male is in the caretaker role for his female partner.

2013
(2013-04)

To the Ministry of Child and Youth Services (MCYS):

1. In order to address the need for improved service coordination in cases where a parent’s adult mental health is a concern, it is recommended that MCYS require that CASs, in collaboration with mental health services in their communities, develop a protocol for working with parents experiencing mental health difficulties. Such a protocol should, at minimum, outline the importance of discharge planning when patients are leaving the hospital to resume their parenting role. In addition, a protocol could include a collaborative case conference format which will assist with critical and dynamic information sharing allowing for a more coordinated service response, enhancing safety for children in these cases. 

2013
(2013-04)

To the Ontario Association of Children Aid Societies (OACAS):

2. It is recommended that OACAS develop training for child protection staff that will assist them in working collaboratively with mental health professionals in order to better assess the impact of a parent’s mental health issues, discharge plan and medical treatment on parenting capacity. 

2013
(2013-08)

To the Ontario Alliance of Mental Health Practitioners, Ontario Psychological Association, Ontario Psychiatric Association, College of Physicians and Surgeons of Ontario, The College of Psychologists of Ontario, and the Ontario Association of Social Workers:

1. Mental health professionals (i.e. psychiatrists, psychologists and social workers) should enhance learning opportunities on the assessment and treatment of domestic violence perpetrators. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

4. It is recommended that all medical schools and their departments of psychiatry in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. Safety is a top priority, therefore, it must be ensured that trainees at all levels obtain competency in risk assessment and risk management techniques. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

5. It is recommended that the facts and circumstances of the case (with identifiers removed) be used to assist in the education of members of the Canadian Professional Counsellors Association (CPCA) about the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

6. It is recommended that continuing education of CPCA members include an emphasis on the importance of understanding the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-11)

To the Ontario Hospital Association and the Ministry of Health and Long-Term Care:

1. Information should be embedded into pre-natal curriculums regarding risk during pregnancy and resources available to assist. During pregnancy, a woman may be at heightened risk of domestic violence, especially in her third trimester. The curriculum for prenatal programs should include a presentation and resource material regarding violence against women to assist if this is occurring in her relationship. Reference: Talk to Me Program – Mount Sinai Hospital 

2014
(2014-12)

To the Ontario Association of Naturopathic Doctors, the Canadian Association of Naturopathic Doctors, the Canadian College of Naturopathic Medicine, and the College of Naturopaths of Ontario:

1. It is recommended that all schools of naturopathic medicine in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on all aspects of domestic violence, including the psychological/emotional/verbal abuse that many victims experience. Furthermore, naturopathic doctors who work with potential perpetrators should be able to assess the risk for depression, substance use, suicidal and homicidal ideation, history of domestic violence, mental health issues and separation anxieties. 

2014
(2014-16)

To the Ministry of Education and the Ministry of Health and Long-Term Care:

1. It is recommended that formal partnerships be developed between hospitals that provide psychiatric assessment and public schools to allow schools to communicate with and create safety plans for students who have been admitted as patients due to suicidal thoughts or behaviour. 

The requirement for third parties to report child abuse when a child’s safety and life is placed at risk needs to be more widely publicized.

School boards should institute curriculum-based healthy relationship programs as an essential part of the education system.

It is recommended that child welfare and protection agencies receive ongoing training to recognize the risk factors for domestic violence. Furthermore, this training should address effective interventions that promote the safety of mothers and children.

It is recommended that child welfare and protection agencies address the following issues:

• All child welfare organizations should follow the provincial policy currently in place, known as the CAS/VAW Collaboration Agreement. This policy informs how both the violence against women and child welfare sectors must work together in situations where there is violence against women. It also ensures that perpetrators are held accountable to the fullest extent possible within the parameters of each sector’s mandate.
• Specialized training and education should be provided for all child welfare staff on the most effective ways to intervene in domestic violence cases. Currently, assessment focuses primarily on the mother’s ability to protect her children. There is minimal focus, if any, on intervening directly with the offender on risk reduction and containment, and assessing if access should be permitted, particularly if the abuser remains untreated.
• Present assessment reports that address a comprehensive analysis of domestic violence issues, including the risk factors for potential lethality, should be provided to Family Court judges so they have the necessary information prior to making decisions regarding custody and access to children.
• It is suggested that there be a quality assurance component built in to the child welfare sector to ensure that best practices and standards of care for interventions are maintained.
•  Child welfare workers need to have the opportunity to increase their skill and comfort level in acting to locate, interview, and assess abusers to safely intervene in ways that enhance the safety of mothers and children and to hold abusers accountable.

Child welfare workers need to have the opportunity to increase their skill and comfort level in interviewing women at risk and how to connect them to support systems in the community to enhance the safety of mothers and children.

It is recommended that lawyers in family law practice receive continuing education on understanding and recognizing the dynamics of domestic violence and the risk factors for lethality associated with separation, divorce, and custody and access.

It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be a time of high risk requiring special vigilance. These cases require the development of a high-risk case management protocol specific to domestic violence cases. Such a protocol needs to be accompanied by appropriate training focused on addressing the dual goals of victim safety (intervention) and offender risk reduction/containment (case management).

It is recommended that the province review the Children’s Law Reform Act and work in collaboration with the federal government’s review of the Divorce Act to ensure that domestic violence is given a prominent role in judicial decision-making when considering child custody. Similarly, the Child and Family Services Act should also be reviewed to ensure consistency with the legislation noted above in requiring specific consideration of the presence and effect of domestic violence in custody matter.

It is recommended that before deciding on the nature of access, assessment reports for Family Court judges, prepared by qualified assessors with domestic violence training, should be considered. This assessment is especially valid when dealing with someone who has a history of domestic violence as demonstrated by a prior criminal record for related offences.

It is recommended that child welfare and protection agencies screen for domestic violence in all cases. As part of the process, it is necessary for them to locate, interview, and assess all partners involved. Where there is evidence of domestic violence, they must take the necessary steps to use their authority under the Children and Family Services Act to make appropriate interventions with the abuser to protect the mother and child.

2004
(2004 – 03, 04)

It is recommended that the province develop a discussion paper and inter-ministerial guidelines for all cases involving domestic violence, children and custody, or access disputes. The paper and guidelines should encourage enhanced coordinated practices and protocols within and between the family and criminal courts, as well as court-related services such as victim-witness services, mediation, supervised access, CAS, batterer intervention programs, and probation supervision.

2005
(2005 – 10)

It is recommended that domestic violence be a regular part of the curriculum in family law courses at faculties of law in Ontario, the bar admission course, as well as continuing education programs for family law lawyers.

2005
(2005 – 01)

It is recommended that when Children’s Aid Society (CAS) conducts a child abuse investigation, each parent should be interviewed separately. The issue of domestic violence should be an integral part of their risk assessment process.

2006
(2006 – 05)

To the Ministry of Children and Youth Services, and the Ontario Association of Children’s Aid Societies (OACAS): It is recommended that a protocol be established to ensure that when Children’s Aid Societies (CAS) receive information about domestic abuse from other professionals such as school guidance counsellors, that the information be forwarded in a structured way to all appropriate authorities, including police so that monitoring of such cases should involve and link all appropriate agencies.

2006
(2006 – 09)

To the Ministry of Children and Youth Services, and the Ontario Association of Children’s Aid Societies: Efforts should be made to enhance training and protocols regarding domestic violence to ensure that a full risk assessment of victims and perpetrators is undertaken, to include assessment of the potential danger posed to children during separation.

2006
(2006 – 12)

It is recommended that the Ministry of Education encourage school boards to make professional development and distribution of resource material on domestic violence a priority. Ontario has available materials ranging from educators’ resource guides to curriculum material on domestic violence, consistent and integrated basis. (E.g. Handbook for Educators, Choices, 4^th R).  The goal of the training should be to prepare all staff to help youth/children who are victims of domestic violence (dating violence) or who have been exposed to domestic violence. Assisting these students may mean providing support, guidance and referrals to appropriate community services. Staff need to be prepared to deal with disclosures that may transpire in a formal (counselling session) or informal (after class) setting, and be prepared to follow-up with students who may be dealing with chronic problems in this area.

2006
(2006 – 09)

To the MCSCS, Policing Standards Division, OACP, and OACAS: Police and CAS training should reinforce that risk assessment is not an end in itself but rather an ongoing process that requires safety planning, risk reduction and coordination of a community plan.

2006
(2006 – 12)

It is recommended that the Ministry of Education mandate pre-service courses on domestic violence at Faculties of Education in Ontario in order to prepare educators for their future roles in this area such as responding to children living with domestic violence or promoting violence prevention programs.

2007
(2007 – 10)

It is recommended that CAS refer cases with multiple risk factors like alleged child abuse, parental alcoholism and domestic violence to high risk case management.

2007
(2007 – 11)

It is recommended that the Ministry of Children and Youth Services through the Child Welfare Secretariat be directed to consider requiring children welfare organizations to conduct internal reviews on domestic violence deaths that occur on files open within the past 12 months where domestic violence is known to be present. Lessons learned through this process should be shared provincially for review by the Ministry of Children and Youth Services.

2008
(2008 – 01)

It is recommended that the Ministry of Children and Youth Services and the Ontario Association of Children’s Aid Societies provide enhanced training on a standardized risk/danger assessment tool and enforce the use of this tool in all cases where domestic violence and harassment are present.  Once the level of risk has been identified for the victim, an adequate safety plan must be implemented. As well, it is essential that contact be made with the perpetrator to assist in the risk assessment and risk management process.

2008
(2008 – 12)

The Ministry of Children and Youth Services, in consultation with the Ontario Association of Children’s Aid Societies, should enhance standards for CAS interventions in DV cases by requesting DV perpetrators be involved in specific provincially approved batterers' programs before allowing unsupervised visits with children or terminating the CAS involvement in a case.

2008
(2008 – 12)

The MCYS, in consultation with the OACAS, should ensure an internal death review is conducted by the CAS in any case where a parent or child has been a domestic homicide victim and where there has been active CAS involvement within the previous year, or possibly longer.                  

2011
(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
(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.

2013
(2013-04)

To the Ministry of Child and Youth Services (MCYS):

1. In order to address the need for improved service coordination in cases where a parent’s adult mental health is a concern, it is recommended that MCYS require that CASs, in collaboration with mental health services in their communities, develop a protocol for working with parents experiencing mental health difficulties. Such a protocol should, at minimum, outline the importance of discharge planning when patients are leaving the hospital to resume their parenting role. In addition, a protocol could include a collaborative case conference format which will assist with critical and dynamic information sharing allowing for a more coordinated service response, enhancing safety for children in these cases. 

2013
(2013-04)

To the Ontario Association of Children Aid Societies (OACAS):

2. It is recommended that OACAS develop training for child protection staff that will assist them in working collaboratively with mental health professionals in order to better assess the impact of a parent’s mental health issues, discharge plan and medical treatment on parenting capacity. 

2013
(2013-14)

To the Ministry of Community Safety and Correctional Services, Policing Services Division, and the Ontario Association of Chiefs of Police:

1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be at high risk requiring special vigilance. Even when there is no reported history of violence between the couple, these cases require a protocol that includes appropriate risk assessment and subsequent attention to safety planning when there was alleged prior abuse against any children in the relationship. Such a protocol needs to be accompanied by appropriate training focused on addressing the potential danger for the victim and/or the child if either has been subject to previous abuse by the perpetrator during separation. 

2014
(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies

1. The Children’s Aid Society (CAS) involved with this family should conduct an internal review to examine its assessment of risk, not only for child abuse or neglect, but also for intimate partner violence. 

2014

(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies

2. All Children’s Aid Societies should be strongly encouraged to conduct an internal review whenever a domestic violence death occurs in a family that had received services of the Society within the preceding 12 months of the death, and where potential domestic violence issues had been identified. 

2014
(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies

3. It is recommended that the Ministry of Children and Youth Services update and enhance the training available to all CASs regarding assessing potential for domestic and intimate partner violence and ensure that it reflects the most recent literature and best practices. It is recommended that the training of front line CAS workers and supervisors include training on issues related to intimate partner violence. 

There is a need to better educate the public about the dynamics of domestic violence and appropriate response where such dynamics are recognized in potential abusers or victims.

Public education should target potential victims and perpetrators of domestic violence. The education should:

• Include the fact that risk of violence increases substantially during the time that a partner is leaving the relationship;
• Address the needs of depressed and suicidal men who require counselling and risk reduction interventions, such as the removal of firearms from the home to prevent the escalation of the circumstances that result in the tragedies we have reviewed;
• Be directed towards persons of all cultures, languages, and faiths; and

Address the need to overcome cultural barriers and the feeling “shame” as related to mental health issues, with the goal of reducing stigma.

Training workshops have to be developed and delivered by trained experts from the cultural communities being served.

Every community where a domestic violence related homicide takes place should be supported to undertake a community-based education process focusing on prevention. It is recommended that a central provincial resource be identified to provide resources, support, and expertise to assist that community to use the tragedy as a catalyst for action. Ensuring that members of the local community take the lead in planning the educational process, the provincial government should provide necessary assistance, such as funding for public education materials, meetings, and other public awareness events. This is provincial response to each domestic violence would ensure that each community is supported in creating its own unique response that promotes collective awareness of spousal and child abuse, and can help make a difference in the prevention of future deaths.

There is a continuing need to better educate both the public and professionals who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence and the need to take appropriate action with potential abusers, victims, and their children. In particular, this education has to include an awareness of the risk factors for potential lethality.

It is recommended that child welfare and protection agencies receive ongoing training to recognize the risk factors for domestic violence. Furthermore, this training should address effective interventions that promote the safety of mothers and children.

It is recommended that lawyers in family law practice receive continuing education on understanding and recognizing the dynamics of domestic violence and the risk factors for lethality associated with separation, divorce, and custody and access.

It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be a time of high risk requiring special vigilance. These cases require the development of a high-risk case management protocol specific to domestic violence cases. Such a protocol needs to be accompanied by appropriate training focused on addressing the dual goals of victim safety (intervention) and offender risk reduction/containment (case management).

It is recommended that awareness and education programs address the culture of silence surrounding domestic violence and its apparent acceptance that still exists in some families and small communities.

2004
(2004 – 01, 09)

It is recommended that front line service providers (police, shelter workers, paramedics, and medical staff) receive training in recognizing that the effects of drug and/or alcohol addictions on the victim can sometimes cloud the assessment of underlying domestic abuse.

2004
(2004 – 04, 05, 08)

It is recommended that the Ontario Court of Justice consider using high-risk cases where judicial interim releases occurred, as reviewed by the DVDRC, as case scenarios as part of the ongoing educational programs for Justices of the Peace who conducts the majority of bail hearing in the province.

2005
(2005 – 07)

It is recommended that the significance of prior perpetrator suicide attempts or threats be emphasized in domestic violence training and education as a risk factor in forecasting the prospects of future lethal harm to not only themselves, but also others.

2005
(2005 – 08)

It is recommended that family members, friends, and community professionals be educated to contact police immediately and report their concerns  when they are aware of individuals who have potential access to firearms and who are in a relationship where domestic violence is suspected. This is particularly important when the couple is going through a separation or the individual is showing signs of depression or suicidal or homicidal thoughts.

2005
(2005 – 10)

It is recommended that professionals and persons in authority be educated in terms of giving victims of domestic violence the proper information and guidance, whether they seek their advice in a formal or informal setting. There should be follow up with the victims to ensure they were given sufficient information to make an informed decision. This recommendation is directed to include professionals such as police officers, lawyers, and doctors.

2005
(2005 – 01)

It is recommended that mental health professional including psychiatrist, psychologists, social workers, as well as risk assessment, high risk case management, and intervention strategies including safety planning for the woman, her children, and family members.

• This training needs to make safety of victims and children a priority irrespective of who the referred patient/client may be.
• Assessments should include collateral information from all relevant sources, including family, friends, police, and children protection services, with respect to the potential risk to the woman and her children posed by perpetrator’s behaviour.

Concerns about any risks to children must be reported to children protection services

2005
(2005 – 10)

It is recommended that domestic violence be a regular part of the curriculum in family law courses at faculties of law in Ontario, the bar admission course, as well as continuing education programs for family law lawyer.

2005
(2005 – 10)

It is recommended that all workplaces design and implement a policy to address domestic violence as it relates to the workplace. The policy should include:

• Educating employees about the issue of domestic violence to help them identify an abusive relationship in which they may be involved and about how to reach out to co-workers;
• Training employers and managers to identify the signs of abuse and respond appropriately to employees who are victims and perpetrators of domestic violence;
• Providing a resource list of appropriate referral agencies;
• Providing an organized response to direct threats of domestic violence that occur in the workplace;

Developing and implementing a safety plan for the victim to ensure that a number of security measures are in place for her protection.

2005
(2005 - 10)

To the Ministry of Labour: It is recommended that all workplaces design and implement a policy to address domestic violence as it relates to the workplace. The policy should include:

• Educating employees about the issues of domestic violence in order to help them identify an abusive relationship in which they may be involved, and about how to reach out to co-workers for assistance.
• Training employers and managers to identify the signs of abuse and to respond appropriately to employees who are victims and/or perpetrators of domestic violence.
• Providing a resource list of appropriate referral agencies.
• Providing an organized response to direct threats of domestic violence that occur in the workplace.

Developing and implementing a safety plan for the victim to ensure that a number of security measures are in place for her protection.

2005
(2005 – 06)

It is recommended that all training material for professionals and public education programs emphasize the harmful nature of emotional and psychological abuse.

2005
(2005 – 01)

It is recommended that social services assisting immigrant women and their children have access to ongoing training in terms of education, awareness, and interventions on issues relating to domestic violence, including risk management, and community support.

2006
(2006 – 02)

It is recommended that the Ontario Women’s Directorate continue to develop and implement public education programs about Domestic Violence (e.g. The Neighbours, Friends and Families Campaign).

2006
(2006 – 02)

It is recommended that the Ontario Psychiatric Association, in conjunction with the Canadian Psychiatric Association, develop and/or promote educational materials that highlight the correlation between depression and the risks associated with intimate partner violence (IPV).

2006
(2006 – 09)

It is recommended that the College of Family Physician of Canada actively develop and/or promote educational tools that highlight the unique role family physicians have in identifying domestic violence.

2006
(2006 – 02)

It is recommended that creative ways must be provided to offer family members appropriate information and support in cases where they have concerns about a family member’s safety.

2006
(2006 – 04)

It is recommended that the College of Family Physicians of Canada, the Ontario Psychiatric Association, in conjunction with the Canadian Psychiatric Association, and the Society of Obstetricians and Gynecologists of Canada develop and/or promote educational interventions that highlight the role of physicians in identifying a history of abuse in assessing patient’s health concerns. Studies indicate that minimal intervention can lead to disclosures of intimate partner violence, with resulting positive outcomes (e.g. increased use of victim services; more safety behaviours; less physical abuse).

2006
(2006 – 02)

It is recommended that the Ontario Women’s Directorate continue to develop and implement public education programs about Domestic Violence (e.g. The Neighbours, Friends and Families Campaign). 

2006
(2006 – 05)

It is recommended that all Government agencies involved with victims and perpetrators continue to educate the public about domestic violence and should include information on the dynamics and/or warning signs of domestic violence and an awareness of the risk factors for potential lethality. There is also a need to educate on where and how to ask for help, and when to take appropriate action with potential abusers, victims, and their children.

2006
(2006 – 05)

To the Ministry of Education: It is recommended that the Ministry ensure that teachers, administrators and support staff receive ongoing training on recognition of risk factors for domestic violence, including effective intervention that promotes the safety of the child.

2006
(2006 – 05)

It is recommended that the College of Physicians of Canada develop and/or promote educational programs that highlight the dynamics and/or warning signs of domestic violence and the potential for lethality, especially when working with patients who have a history of alcohol and/or drug abuse, depression, anxiety or anger.

2006
(2006 – 06)

To the Ontario Women’s Directorate (OWD): Public awareness campaigns are needed that highlight how to recognise (and respond appropriately) when a strained relationship is becoming a potentially lethal one. Important additional risk factors are high stress situations like extreme financial pressure and imminent family breakdown.

2006
(2006 – 07)

It is recommended that the Ontario Psychiatric Association, in conjunction with the Canadian Psychiatric Association, develop and/or promote educational materials that highlight the correlation between depression and the risks associated with intimate partner violence (IPV). 

2006
(2006 – 09)

The Ontario Women’s Directorate should encourage public and private sector employers to raise awareness about their role and responsibility for domestic violence victims and perpetrator in the event that warning signs are visible in the workplace.

2006
(2006 – 09)

To the MCSCS; OACAP: It is recommended that police receive ongoing training in the dynamics of Domestic Violence to assist officers with assessing situations and laying charges where appropriate.

2006
(2006 – 09)

The College of Family Physicians of Canada should develop and/or promote educational tools that ensure that appropriate risk assessment and safety planning is under taken whenever patients disclose ongoing intimate partner violence (IPV). 

2006
(2006 – 09)

To Universities and Community Colleges offering social work programs and to professional associations of social workers (Ontario College Of Social workers: Curricula should include pre-service and continuing education programs on risk assessment for victims and perpetrators of domestic violence.

2006
(2006 – 09)

To the Ministry of Children and Youth Services, and the Ontario Association of Children’s Aid Societies: Efforts should be made to enhance training and protocols regarding domestic violence to ensure that a full risk assessment of victims and perpetrators is undertaken, to include assessment of the potential danger posed to children during separation.

2006
(2006 – 09)

To the MCSCS, Policing Standards Division; OACAP; and OACAS: Police and CAS training should reinforce that risk assessment is not an end in itself but rather an ongoing process that requires safety planning, risk reduction and coordination of a community plan.

2006
(2006 – 10)

It is recommended that the Ontario Women’s Directorate, through its public education campaigns and professional education programs (through police, social services, mental health, and medical associations) address the need for a differentiated approach to victims of domestic violence who may not recognize the dangers posed by the (ex) partner to themselves and their children.

2006
(2006 – 12)

It is recommended that The Ministry of Education mandate pre-service courses on domestic violence at Faculties of Education in Ontario in order to prepare educators for their future roles in this area such as responding to children living with domestic violence or promoting violence prevention programs.

2006
(2006 – 13)

To the Ontario Women’s Directorate and Ministry of Education: Public awareness programs (such as OWD’s Neighbours, Friends and Families) and Ministry initiates on domestic violence should include emphasis on the reality that intimate relationships in adolescence pose similar concerns as in adult relationships.

2007
(2007 – 01)

It is recommended that all Government agencies involved with victims and perpetrators continue to educate the public about domestic violence including information on the dynamics and/or warning signs of domestic violence and an awareness of the risk factors for potential lethality.  In addition, such programs should include information on where and how to ask for help and when to take appropriate action with potential abusers, victims, and their children. These programs should also underscore the fact that Intimate Partner Violence (IPV) and postpartum depression can have a similar negative impact on a woman’s functioning and well-being.

2007
(2007 – 01)

It is recommended that organizations involved in educating health professionals, such as the College of Family Physicians of Canada, Canadian Paediatric Society, the Society of Obstetricians and Gynaecologists, and the College of Midwifery of Ontario, promote educational programs that explore the dynamics and/or warning signs of domestic violence and the potential for lethality, especially when working with patients who have depression and/or anxiety. In addition, such programs need to highlight for practitioners caring for women and/or their children that IPV can lead to and/or exacerbate an underlying depression.

2007
(2007 – 04)

We recommend that Ontario Works ensure that all of its employees are well trained in recognizing situations of domestic violence and assisting their clients in obtaining the services they require.

2007
(2007 – 02)

It is recommended that there be ongoing training for police on the most effective response to domestic violence cases especially where there is a history of homicidal and suicide threats, separations, obsession with the victims, prior incidents of domestic violence and/or child abuse.  The development of a high-risk case management protocol specific to these complicated domestic violence cases needs to be accompanied by additional training focused on addressing the dual goals of victim safety and offender risk reduction.

2007
(2007 – 02)

It is recommended that OWD continue to educate both the public and professionals who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence and suicide prevention. Also, OWD should provide information to help the public and professionals understand their role in assisting abusers, victims and their children. 

2007
(2007 – 04)

Recognizing the critical role that police play in responding to domestic violence calls, particularly in rural and remote communities where frequently they are the only resource available to families in trouble, police officers require ongoing training in the dynamics of domestic violence especially when faced with reluctant and ambivalent victims and perpetrators who have a history of past domestic violence, suicidal behaviour and addictions.

2007
(2007 – 04)

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 OWD consider making this campaign available to all Aboriginal communities across the province.

2007
(2007 – 04)

It is recommended that the Ministry of Education who provides funding for Adult Education, alternative education programs, and regular school programs that may involve young parents, ensure that education and training is provided to individuals who deal with young parents in such programs on how to respond to suspected or known cases of intimate partner violence among their clients.

2007
(2007 – 08)

There must be more public education regarding the risk that suicidality poses, not only to suicidal person but also to others involved with him/her. Within the Health Care system, men who are in relationships and who threatens or attempt suicide should consistently be screened for abusive behaviour in their relationships. Part of this screening process must involve some contact with the female partner to offer information and support regarding disclosure of abuse, services and supports available, etc. 

2007
(2007 – 10)

It is recommended that all agencies ensure adequate training and supervision in assessing domestic violence within same-sex relationships in cases where children are involved. It is also recommended that Children’s Aid Societies follow-up on a referral with all parties involved with the child or children.

2007
(2007 – 08)

It is recommended that Community agencies in partnership with Government should explore the creation of an easily accessible, non-threatening mechanism for friends and family to get information and consult with a trained individual regarding situations where they have concerns that a woman is at risk from her intimate partner. This resource could provide direction where they are not sure how to intervene and/or how to help protect the victim’s safety.

2007
(2007 – 10)

It is recommended that there be ongoing training for police on the most effective response to domestic violence cases where there is a history of homicidal and suicidal threats, a recent separation, and where prior history includes domestic violence, serious substance abuse and/or child abuse.

2007
(2007 – 10)

It is recommended that OWD continue to educate the members of the public who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence and provide information on practical steps that can be taken to reduce the risk for assault and lethality. 

2007
(2007 – 10)

It is recommended that social service providers, including police, physicians, and child protection services receive proper training regarding the dynamics of domestic violence in same-sex relationships.

2007
(2007 – 10)

It is recommended that the public be educated on the dynamics of domestic violence, including in same-sex relationships.

2007
(2007 – 12)

There is a continuing need to better educate family members, friends, and colleagues who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence and the need to take appropriate action with potential abusers, victims, and their children. In particular, this education has to include an awareness of risk factors for potential lethality. This is particularly important when the couple is going through a separation or the individual is showing signs of depression or suicidal or homicidal thoughts. The risk increases even further if the perpetrator has an addiction problem.

2007
(2007 – 13)

It is recommended that police officers receive additional/supplemental training, which focuses on the recognition that domestic violence does not always present itself in an obvious way, such as in a domestic violence assault, but may be imbedded in other types of criminal acts. Where domestic violence is at the root of any criminal act, the investigation must be completed within the context and application of the domestic violence policies of the respective services. Victims may be reluctant to disclose violence in their relationship, and this requires a sensitive but thorough intervention. Police must understand that reluctant victims may be at greater risk of continued violence and thereby are in greater need of proactive police response.

2007
(2007 – 12)

Given the high co-occurrence between addictions and domestic violence, we expand on previous recommendations to include more education for counsellors who work with clients with addiction problems who may be perpetrators of domestic violence. We recommend routine screening in every case and where there are indicators of domestic violence; we would recommend a thorough assessment of risk and risk management of the case including contact with the victim to engage in safety planning. We would not expect addiction counsellors to become experts in domestic violence work but we would recommend that they collaborate closely with the VAW sector in their community.

2007
(2007 – 14)

It is recommended that all potential sureties be required to watch an educational videotape on their role as it relates to domestic violence cases (e.g. Huron County Crown video). As well, that each police department assign a police officer to routinely call all sureties in high risk cases to check on bail compliance and the stability of the accused.

2008
(2008 – 01)

There is a need to better educate the public about the dynamics of domestic violence and appropriate responses where such dynamics are recognized in potential abusers or victims.

2008
(2008 – 01)

It is recommended that the Ministry of Children and Youth Services and the Ontario Association of Children’s Aid Societies provide enhanced training on a standardized risk/danger assessment tool and enforce the use of this tool in all cases where domestic violence and harassment are present.  Once the level of risk has been identified for the victim, an adequate safety plan must be implemented. As well, it is essential that contact be made with the perpetrator to assist in the risk assessment and risk management process.

2008
(2008 – 02)

A common risk assessment tool should be developed and mental health practitioners should be trained to effectively and systemically utilize the tool to identify potential risks.

2008
(2008 – 02)

Probation officers should receive training on the inter-relationship between substance abuse issues and intimate partner violence so that they can better respond and intervene with individuals who have a multiplicity of issues.  This training would assist probation officers to effectively intervene with individuals who are in abusive and high risk relationships.

2008
(2008 – 02)

When an individual attempts suicide, there should be appropriate follow-up, support and referral to agencies that can explore the issues that resulted in the attempt.  Criminal justice responses and interventions are generally not as effective as interventions from social and community based organizations and services.  

2008
(2008 – 04)

It is recommended that the Ontario Women’s Directorate continue to educate the members of the public who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence and provide information on practical steps that can be taken to reduce the risk for assault and lethality at the time of relationship breakdown.  

2008
(2008 – 05)

There is a continuing need to better educate family members, friends, and colleagues who come into contact with victims and perpetrators of domestic violence about the dynamics of domestic violence.  Public education should include action plans for persons who encounter individuals involved in domestic violence, and in particular address the increased risk associated to separation or pending separation and workplace stalking issues. In particular, this education should include a methodology to identify the risk factors for potential lethality and the specific steps to take when they are identified.

2008
(2008 – 06)

It is recommended that the Ministry of the Attorney General design and implement a public education campaign that explains Restraining Orders in an understandable manner to laypersons.

2008
(2008 – 12)

There needs to be broader public awareness about the danger of separation with a DV perpetrator directed at DV victims and the risks in maintaining ongoing relationships that jeopardize the safety of women and children.

2008
(2008 – 14)

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
(2008 – 15)

Neighbours, friends and family should be educated about the dynamics of domestic violence and the need to take appropriate action.        

2008
(2008 – 15)

Mental health professionals should have training in the dynamics of domestic violence, including high risk case management and intervention strategies, in particular, safety planning.

2009
(2009 – 03)

The importance of ensuring ongoing education for all police service personnel and their families on domestic violence, suicide, mental health issues and balanced health and wellness cannot be overstated.  To that end, support for provincial and national research and analyses emphasizing these aspects unique to the Canadian police culture, including strengths and stressors, is recommended.  

2009
(2009 – 09)

It is recommended that the Ministry of Community Safety and Correctional Services provide public education on the risks involved with online dating sites and other social networking applications.  The information should focus on what is considered to be criminal and/or harassing conduct and provide guidance on what safety measures should be undertaken and/or reported to police.  Students in Ontario schools receive this type of information as part of the current awareness of cyber-bullying and inappropriate use of the Internet, but many adults may not be aware of Internet safety precautions.

2010
(2010 – 03)

Public education campaigns need to provide information on the co-occurrence of domestic violence and child maltreatment and emphasize to both professionals and community members the importance of notifying Child Protective Services (CPS) if either form of abuse is identified.  Research has indicated that there is a substantial overlap between domestic violence and child abuse.  CPS professionals are trained to assess both types of abuse and provide the necessary supports to help the family.

2010
(2010 – 07)

The OACUSA should develop a consistent and comprehensive plan, in collaboration with health and counselling services available on campus, to educate students on the nature and risks of violence in dating relationships through public education campaigns and outreach programs to students dealing with intimate violence. 

2010
(2010 – 14)

Public education campaigns (e.g. Neighbours, Friends, and Families) should address the increased risk for domestic homicide when there is a history of domestic violence and the presence of mental illness in a potential perpetrator.  The campaign should stress the seriousness of the risk posed by a mentally ill individual who is threatening to harm his/her partner and/or is threatening self-harm.  Specifically, the campaign should outline the steps to be taken when attempting to obtain help for a mentally ill family member, including treatment options and referrals to support services.

2011
(2011-02)

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
(2011-02)

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
(2011-02)

Domestic violence should be part of the now mandatory CLE requirement for practicing lawyers, at least for those who practice family law.

2011
(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
(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.

2012
(2012-13)

It is recommended that the Ontario Women’s Directorate increase public awareness about the increased risk of intimate partner homicide-suicide among aging couples, particularly if there is declining health and/or the male is in the caretaker role for his female partner.

2013
(2013-04)

To the Ontario Association of Children Aid Societies (OACAS):

2. It is recommended that OACAS develop training for child protection staff that will assist them in working collaboratively with mental health professionals in order to better assess the impact of a parent’s mental health issues, discharge plan and medical treatment on parenting capacity. 

2013
(2013-14)

To the Ministry of Community Safety and Correctional Services, Policing Services Division, and the Ontario Association of Chiefs of Police:

1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve child custody and access, which may be at high risk requiring special vigilance. Even when there is no reported history of violence between the couple, these cases require a protocol that includes appropriate risk assessment and subsequent attention to safety planning when there was alleged prior abuse against any children in the relationship. Such a protocol needs to be accompanied by appropriate training focused on addressing the potential danger for the victim and/or the child if either has been subject to previous abuse by the perpetrator during separation. 

2013
(2013-19)

To the Ministry of Labour and Ontario Woman’s Directorate:

1. The Ministry of Labour should work collaboratively with the Ontario Women’s Directorate in workplaces across Ontario to promote awareness of domestic violence and community supports for victims and perpetrators through distribution of Neighbours, Friends and Family materials and information sessions. 

2014
(2014-05)

To the Ministry of Community and Social Services:

1. Social Assistance (Ontario Works & Ontario Disability Support Program) Case Workers should receive specialized training in the dynamics of domestic violence. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on: all aspects of domestic violence including the psychological/emotional/verbal abuse that many victims experience; recognizing high risk cases such as when there is a recent or pending separation between the couple and depression on the part of the perpetrator; and education about supports in the community for victims and their children (e.g., women shelters). 

2014
(2014-07)

To the Ontario Women’s Directorate:

1. Encourage the Neighbours, Friends and Families Campaign for Immigrant and Refugee Communities (http://www.immigrantandrefugeenff.ca/) to develop a specific outreach campaign for the Sri Lankan community.

2014
(2014-07)

To the Ministry of Labour:

2. Review compliance in Ontario workplaces with the provisions in the Occupational Health & Safety Act that require employers to have a program for preventing and responding to domestic violence that could cause harm to an employee at work, and that require instruction on that program. 

2014
(2014-08)

To the Ministry of Community Safety and Correctional Services:

2. That a working group of police and risk assessment experts develop a process for conducting an internal review in police services where a death occurred despite the history of a family’s several help-seeking contacts with the police where calls were deemed low risk. Lessons learned from these real life situations could serve as a teaching tool in subsequent domestic violence training programs for police officers. 

2014
(2014-10)

To the Ministry of Children and Youth Services and Children’s Aid Societies

3. It is recommended that the Ministry of Children and Youth Services update and enhance the training available to all CASs regarding assessing potential for domestic and intimate partner violence and ensure that it reflects the most recent literature and best practices. It is recommended that the training of front line CAS workers and supervisors include training on issues related to intimate partner violence. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

4. It is recommended that all medical schools and their departments of psychiatry in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. Safety is a top priority, therefore, it must be ensured that trainees at all levels obtain competency in risk assessment and risk management techniques. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

5. It is recommended that the facts and circumstances of the case (with identifiers removed) be used to assist in the education of members of the Canadian Professional Counsellors Association (CPCA) about the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

6. It is recommended that continuing education of CPCA members include an emphasis on the importance of understanding the dynamics of domestic violence and the risk factors of lethality so that they can adequately assess and counsel clients with relationship problems. 

2014
(2014-10)

To the Involved Police Service

7. It is recommended that the Domestic Violence Coordinator of the Police Service review the Service’s various interactions with the victim and perpetrator, with a view to ensuring that all appropriate policies, procedures and directives were followed. Where appropriate, lessons learned from the review could be incorporated into ongoing domestic violence training and updates for service members. 

2014
(2014-11)

To the Ontario Hospital Association and the Ministry of Health and Long-Term Care:

1. Information should be embedded into pre-natal curriculums regarding risk during pregnancy and resources available to assist. During pregnancy, a woman may be at heightened risk of domestic violence, especially in her third trimester. The curriculum for prenatal programs should include a presentation and resource material regarding violence against women to assist if this is occurring in her relationship. Reference: Talk to Me Program – Mount Sinai Hospital 

2014
(2014-11)

To Immigration Canada:

2. Programs that promote support safe integration for newcomers to Canada should be implemented. Curriculum in English as a Second Language, and cultural centres can provide information regarding a victim’s rights in Canada. The issue of violence against women should be discussed along with resources available to support the victim. 

2014
(2014-12)

To the Ontario Association of Naturopathic Doctors, the Canadian Association of Naturopathic Doctors, the Canadian College of Naturopathic Medicine, and the College of Naturopaths of Ontario:

1. It is recommended that all schools of naturopathic medicine in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on all aspects of domestic violence, including the psychological/emotional/verbal abuse that many victims experience. Furthermore, naturopathic doctors who work with potential perpetrators should be able to assess the risk for depression, substance use, suicidal and homicidal ideation, history of domestic violence, mental health issues and separation anxieties. 

2014
(2014-13)

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

1. It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve victims with disabilities (in this case, blindness). Cases involving women with disabilities often involve less obvious forms of domestic violence (e.g. withholding a wheelchair; holding back medication) because of the victim’s potential reliance on her abuser and/or her increased vulnerability to the abuser because of his/her disability. 

2014
(2014-13)

To the Ontario Women’s Directorate:

2. It is recommended that the Ontario Women’s Directorate develop and implement public education programs about domestic violence with a specific focus on women with disabilities and their increased risk of domestic violence, less obvious forms of violence that they may be experiencing, and the various agencies that are available to help this population. 

2014
(2014-13)

To the Ministry of Community and Social Services, Canadian National Institute for the Blind, Community Living Ontario, and other agencies providing services to persons with disabilities:

3. It is recommended that agencies or organizations who work with women living with disabilities receive training about their increased risk of violence, including domestic violence, such as the various ways that women with disabilities may experience violence because of their increased vulnerability in some cases. 

2014
(2014-16)

To the Ministry of Education:

1. It is recommended that school professionals (e.g. social workers, psychologists, and school counsellors) be trained on the need to work collaboratively when students with suicidal behaviour or risks are identified. School professionals should be trained to actively pursue information from other professionals inside and outside the education system, as well as collateral sources. 

2014
(2014-16)

To the Ministry of Education:

Ensure that educational programs are implemented for adolescent students to help them identify abusive and controlling behaviours in the context of both platonic and romantic relationships. These programs should also help students identify these behaviours to allow for intervention or safety planning. In particular, students should receive education on the issue of blackmailing-over -text in the context of suicide threats so that they will be encouraged to seek the assistance of adults.

2014
(2014-16)

To the Ministry of Education:

It is recommended that that school professionals be given training on developing safety plans for students once the student has been assessed as being at risk for suicide and that these students be given priority for support by the school. Guidelines should be developed to recognize the unique circumstances and risk of these students and the importance of connecting them to school-based supports. This could include a transition or planning meeting prior to the student returning to school so that information can be shared among team members. 

2014
(2014-16)

To the Ministry of Education:

It is recommended that training be provided to school professionals and students about the impact relationship dynamics can have on the risk of suicidal behaviour. 

2014
(2014-16)

To the Ministry of Education and the Ministry of Health and Long-Term Care:

1. It is recommended that formal partnerships be developed between hospitals that provide psychiatric assessment and public schools to allow schools to communicate with and create safety plans for students who have been admitted as patients due to suicidal thoughts or behaviour. 

It is recommended that awareness and education programs address the culture of silence surrounding domestic violence and its apparent acceptance that still exists in some families and small communities.

It is recommended that intake workers at women’s shelters use standardized risk assessment tools to thoroughly assess and manage the potential risk of the woman seeking assistance. Current existing risk assessment tolls should be tailored to meet the needs of community-based violence against women services and the women they serve. Further, all workers should receive training on the use of such standardized risk assessment tools.

It is recommended that, in any community where there are a number of shelters available to assist victims of domestic violence, a central registry of available beds for victims, as well as a means of transportation to the available facility, be established.

It is recommended that shelters be supported to create ways to effectively coordinate services and referrals to minimize the need for a woman seeking shelter to navigate the system on her own, and to maximize the ways shelters can work together to provide a seamless and supportive response to the woman and her children.

All of the above recommendations require adequate resources to ensure victim safety and reduce perpetrator risk. They address the lack of programming and services, and the recognition that all programming and services require the necessary resources to become operational. These resources include, but are not limited to:

• Support for helping the victim to be removed from the situation if appropriate;
• Affordable alternative housing;
• Counselling services for victims and families; and
• Other community and cultural based support systems and services for victims, perpetrators, and children exposed to domestic violence.

It is obvious that the demand for these resources will increase with better risk assessments, interventions, and risk management strategies.

It is recommended that a protocol be established for the complete investigation of domestic violence fatalities where the facts involve both homicide and suicide.

It is recommended that when a case is identified as “high risk,” an appropriate response is necessary, requiring adequate resources to effectively respond to and manage the risk.

It is recommended that additional resources be made available to develop or provide access to domestic violence services for people living in northern (rural and remote) communities.

It is recommended that appropriate resources be allocated to implement those recommendations herein directed to the training and provision of the necessary tools to protect children and assess the risk associated to domestic violence.

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.

It is recommended that affordable housing, child care, and income support must be made available so that women trapped in abusive relationships can escape the danger as threats escalate into potentially lethal situations.

Funding and resources should be provided to create joint training opportunities for those working in mental health agencies and those working in violence against women services to ensure a more integrated and holistic response that can more effectively respond to the complexities of individual situations. 

Adequate levels of support and resources should be made available to services that can respond to individuals with multiple problems so that interventions can be organized to meet the particular needs of the individual, as opposed to being organized to meet the needs of a particular agency.

2008
(2008 – 04)

It is recommended that criteria used in determining financial grants for the development of all information packages on domestic violence, training packages or any public education announcements should include a mandatory segment on the potential risk of lethal violence at the time of relationship break-down and provide family and friends with recommendations on how to support a “safe” break-up/separation.

2013
(2013-04)

To the Ministry of the Attorney General:

3. Family courts should develop a triage function for an initial assessment of cases to determine the degree of urgency required to hear the matter; the need for additional resources and community referrals to assure safety planning; and appropriate risk management interventions to reduce domestic violence and child abuse. 

2013
(2013-19)

To the Ministry of Labour and Ontario Woman’s Directorate:

2. The Ministry of Labour and the Ontario Women’s Directorate is encouraged to work with domestic violence experts, Health and Safety Ontario and the Ontario Federation of Labour to establish a non-profit initiative to engage employers in the work of preventing and responding to domestic violence. The new non-profit initiative should provide workplace specific information, resources and advice for employers. 

2014
(2014-11)

To the Ontario Hospital Association and the Ministry of Health and Long-Term Care:

1. Information should be embedded into pre-natal curriculums regarding risk during pregnancy and resources available to assist. During pregnancy, a woman may be at heightened risk of domestic violence, especially in her third trimester. The curriculum for prenatal programs should include a presentation and resource material regarding violence against women to assist if this is occurring in her relationship. Reference: Talk to Me Program – Mount Sinai Hospital 

2014
(2014-11)

To Immigration Canada:

2. Programs that promote support safe integration for newcomers to Canada should be implemented. Curriculum in English as a Second Language, and cultural centres can provide information regarding a victim’s rights in Canada. The issue of violence against women should be discussed along with resources available to support the victim.

The committee recommends that the provincial policy stating that, upon conviction for a domestic violence offence, the Crown seek an order requiring an offender to attend a batterer intervention program such as Partner Assault Response (PAR) as part of a probation term, be followed.

It is recommended that the province review the Children’s Law Reform Act and work in collaboration with the federal government’s review of the Divorce Act to ensure that domestic violence is given a prominent role in judicial decision-making when considering child custody. Similarly, the Child and Family Services Act should also be reviewed to ensure consistency with the legislation noted about in requiring specific consideration of the presence and effect of domestic violence in custody matters.

To the Ministry of the Attorney General, and the Ministry of Community Safety and Correctional Services: It is recommended that when the courts have mandated intervention/counselling programs related to domestic violence incidents, there be some mechanism to ensure that the conditions and orders are monitored and followed up, regardless of whether the accused person is the primary offender/aggressor or not.

It is recommended that the Federal Government revisit the Firearms Act to study the feasibility of a legislative amendment to require the registration of crossbows as restricted weapons.

The province should identify a process to ensure enforcement of attendance at court-mandated programs for batterers. Enforcement should include effective methods of tracking and monitoring offenders, mechanisms for systematically identifying levels of risk and risk management that is inter-disciplinary and inter-sectoral in nature.

The Ministry of Community Safety and Correctional Services should expand police standards in domestic violence cases to include risk assessment for all calls for assistance with a history of domestic violence, even when no assaults have taken place.

The term “choking” should be changed to the term “strangulation” in the Criminal Code as that term more accurately reflects a serious, intentional act of harm to a victim. “Choking” is a medical term describing aspiration of food bolus or object and is not appropriate in a domestic violence context, whereas strangulation refers to the application of pressure to the neck.

It is recommended that the Domestic Violence Supplementary Report (DVSR) be enhanced to require a verbatim narrative response to risk assessment questions where the answer is “yes” or “unknown”. Further, that this enhanced DVSR be mandated, prohibiting any deviation or change in the content, for use by all police services, including First Nation police services.

In order to assist Citizenship and Immigration Canada (CIC) and the Canadian Border Services Agency (CBSA) in fulfilling their duties and responsibilities, information pertaining to any domestic violence occurrence involving immigration applicants and/or their families or sponsors, should be communicated between local law enforcement or social service agencies and the federal immigration authorities.

2009
(2009 – 02)

Citizenship and Immigration Canada should develop training programs in the dynamics of domestic violence for all its agents and officers. Such training should emphasize that withdrawal of sponsorship or denial of immigration applications/claims may result in a volatile situation that could lead to violence.  It should prepare agents and officers who may be adjudicating claims from remote locations to consider making appropriate local referrals to law enforcement and social service agencies when dealing with applicants, their families and/or sponsors where there is a history or reported threats of domestic violence.

2009
(2009 – 09)

It is recommended to the federal Minister of Public Safety that applications for a firearm Possession Acquisition Licence (PAL) should include a medical waiver signed by the applicant. This would allow investigators access to information pertaining to the mental health of the applicant.  There should also be higher standards and more restrictions for individuals applying for a firearms PAL when they have had previous licenses revoked or removed.   

2009
(2009 – 09)

It is recommended that the Ministry of the Attorney General require that Partner Assault Response (PAR) programs should be mandated as part of sentencing for domestic violence perpetrators when there is a documented history that the offence before the courts is not an isolated incident with either the current or prior victim(s).

2010
(2010 – 13)

All employers in Ontario should be required to develop policies on measures they can take in their workplace(s) to prevent and/or provide effective responses to workplace domestic violence. Employers should also be required to provide training to all employees on recognizing the warning signs of domestic violence, as well as initiating the appropriate responses when they do recognize warning signs or witness incidents. Managers and supervisors should receive additional training in providing appropriate assistance to victims or co-workers who report concerns.

2011
(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
(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
(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.

2013
(2013-08)

To the Ministry of the Attorney General:

2. The Ministry of the Attorney General (MAG) should review policies dealing with perpetrators referred to the Partner Assault Response (PAR) program to ensure that they receive screening at intake for level of denial of their offence, in comparison to police and court findings. The courts should ensure that PARs receive a detailed account of the offence, including any victim statements, and that PARs use this to assess the client's level of denial/accountability. Perpetrators who maintain a high level of denial at program completion should be required to repeat the PAR program, or receive other community referrals. 

2014
(2014-07)

To the Ministry of Labour:

2. Review compliance in Ontario workplaces with the provisions in the Occupational Health & Safety Act that require employers to have a program for preventing and responding to domestic violence that could cause harm to an employee at work, and that require instruction on that program. 

2014
(2014-10)

Recommendations related to the training of psychiatrists and counsellors.

4. It is recommended that all medical schools and their departments of psychiatry in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. Safety is a top priority, therefore, it must be ensured that trainees at all levels obtain competency in risk assessment and risk management techniques. 

2014
(2014-10)

To the Involved Police Service

7. It is recommended that the Domestic Violence Coordinator of the Police Service review the Service’s various interactions with the victim and perpetrator, with a view to ensuring that all appropriate policies, procedures and directives were followed. Where appropriate, lessons learned from the review could be incorporated into ongoing domestic violence training and updates for service members. 

2014
(2014-12)

To the Ontario Association of Naturopathic Doctors, the Canadian Association of Naturopathic Doctors, the Canadian College of Naturopathic Medicine, and the College of Naturopaths of Ontario:

1. It is recommended that all schools of naturopathic medicine in Ontario ensure that domestic violence, as well as risk assessment, safety planning, and risk management, are a mandated part of their training programs and certification processes. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on all aspects of domestic violence, including the psychological/emotional/verbal abuse that many victims experience. Furthermore, naturopathic doctors who work with potential perpetrators should be able to assess the risk for depression, substance use, suicidal and homicidal ideation, history of domestic violence, mental health issues and separation anxieties. 

It is recommended that a protocol be established between police and Crown counsel to ensure that persons proposed as surety: 1) be properly investigated as to their suitability to act as surety; 2) be fully informed about their responsibilities as surety both in writing and on the court record; and 3) be warned, in writing and on the court record, as to their potential liability under estreatment and as party to a criminal offence in the event they breach their duty.

It is recommended that, in cases of domestic violence, the police give persons proposed as surety, written or video information about the risk factors for potential lethality, and that receipt of that material be confirmed on the court record.

The Ontario Association of Children’s Aid Societies and Ontario Family Law Bar Association should jointly develop protocols regarding children who appear to be in danger in the context of parental separations with a history of domestic violence. These children may not qualify for CAS protection because their mother appears to be trying to manage a safety plan as a private family matter. However, the CAS may be in a better position to limit any unsupervised access as a temporary measure pending a thorough assessment by the family court.

It is recommended that judges receive continuing education on understanding and recognizing the dynamics of domestic violence and the risk factors for lethality. Judges need to receive and review all the information on a case to make appropriate decisions, for example, in bail hearings.  Furthermore, it is recommended that the Ontario Court of Justice consider using high-risk cases where judicial interim releases occurred, as reviewed by the DVDRC, as case scenarios as part of the ongoing educational programs for Justices of the Peace who conducts the majority of bail hearings in the province.

An enhanced protocol should be established between police services and Crown counsel to ensure that persons proposed as surety: are properly investigated as to their suitability to act as surety including an assessment of their lawful access to firearms; can guarantee all possessed and accessible firearms are secured from the accused for the duration of the surety contract;

are fully informed about the totality of the allegations against the accused, including information about risk factors and potential lethality; are fully informed about their responsibilities as surety, both in writing and on the court record, following required viewing of an educational videotape on their role, specific to domestic violence cases (e.g. Huron County Crown video); are warned in writing and on the court record as to their potential liability  under estreatment and as party to a criminal offence in the event they breach their duty; can accept that each police department will assign a police officer to routinely call all sureties in high risk cases to verify bail compliance and the stability of the accused.              

The Ministry of the Attorney General should review current courses and resource materials to ensure that information pertaining to restraining orders is easily available to all lawyers practicing family law.

It is recommended that the Ministry of the Attorney General require that Justices of the Peace routinely formally notify the Chief Firearms Officer about any bail conditions that include a prohibition of firearms.

It is recommended that Police Services compel Domestic Violence Coordinators to facilitate the liaison and information sharing between case managers in Domestic Violence occurrences that cross divisional and jurisdictional boundaries within their service.

The details and facts from this case should be used as a training aid for the education of law students, continuing education for practicing lawyers (e.g. Crown attorneys, family law and criminal law) and the judiciary regarding the issues and concerns facing victims of domestic violence. In particular, this case demonstrates the need for the timely and accurate sharing of information not just within the police service itself, but also between the police, judiciary, probation services and health care providers.  

2011
(2011-02)

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
(2011-02)

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
(2011-02)

Domestic violence should be part of the now mandatory CLE requirement for practicing lawyers, at least for those who practice family law.

2011
(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
(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.

2013
(2013-04)

To the Ministry of the Attorney General:

3. Family courts should develop a triage function for an initial assessment of cases to determine the degree of urgency required to hear the matter; the need for additional resources and community referrals to assure safety planning; and appropriate risk management interventions to reduce domestic violence and child abuse. 

2013
(2013-08)

To the Ministry of the Attorney General:

2. The Ministry of the Attorney General (MAG) should review policies dealing with perpetrators referred to the Partner Assault Response (PAR) program to ensure that they receive screening at intake for level of denial of their offence, in comparison to police and court findings. The courts should ensure that PARs receive a detailed account of the offence, including any victim statements, and that PARs use this to assess the client's level of denial/accountability. Perpetrators who maintain a high level of denial at program completion should be required to repeat the PAR program, or receive other community referrals. 

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

To the Ontario Alliance of Mental Health Practitioners, Ontario Psychological Association, Ontario Psychiatric Association, College of Physicians and Surgeons of Ontario, The College of Psychologists of Ontario, and the Ontario Association of Social Workers:

1. Mental health professionals (i.e. psychiatrists, psychologists and social workers) should enhance learning opportunities on the assessment and treatment of domestic violence perpetrators. 

To the Ministry of Community and Social Services:

1. Social Assistance (Ontario Works & Ontario Disability Support Program) Case Workers should receive specialized training in the dynamics of domestic violence. This training should include recognizing the signs and symptoms of domestic violence and how to effectively respond in the event they suspect a client is being abused. It is important that the training focuses on: all aspects of domestic violence including the psychological/emotional/verbal abuse that many victims experience; recognizing high risk cases such as when there is a recent or pending separation between the couple and depression on the part of the perpetrator; and education about supports in the community for victims and their children (e.g., women shelters). 

To the Ministry of the Attorney General

3. Recommend that prompt victim contact by PAR when high risk is identified, and consideration of victim referrals for newcomers or where ESL. When a perpetrator completes the intake assessment with the PAR provider, and there is evidence of high risk to the victim – the PAR agency should immediately notify the police, the referral source, the victim and the perpetrator. A partner contact needs to occur immediately in order to assess her safety and provide necessary referrals, safety assessment, supports, risk management and ongoing follow-up. The PAR program needs to pay particular attention to the issues of a victim who is a newcomer to Canada, and in particular cases where isolation and language barriers may escalate risks to her.

To the Ministry of Community and Social Services, Canadian National Institute for the Blind, Community Living Ontario, and other agencies providing services to persons with disabilities:

3. It is recommended that agencies or organizations who work with women living with disabilities receive training about their increased risk of violence, including domestic violence, such as the various ways that women with disabilities may experience violence because of their increased vulnerability in some cases.