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Driving Systemic Change to Prevent Domestic Violence Fatalities

June 06, 2023

Crime scene
Crime scene

The Quattrone Center and the City of San Francisco have released a report recommending policies and procedures to reduce domestic violence-related fatalities.

The Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Carey Law School, in coordination with the San Francisco District Attorney’s Office (SFDA) and the Department on the Status of Women in the City and the County of San Francisco (DOSW), has released the Domestic Violence Death Review Team’s (DVDRT) Lethality Assessment Report, which details 16 recommendations to the San Francisco Police Department (SFPD) and the City of San Francisco related to a well-known and high-publicized fatal case of domestic violence that took place in October 2014. The findings are intended to prevent similar domestic violence incidents from occurring in the future.

The pilot—a collaboration between the SFDA and the DOSW, pursuant to the provisions of California Penal Code 11163.3—engaged the Quattrone Center to assist in the coordination and moderation of the Pilot and resulting report. The City and the County of San Francisco have a long-established commitment to reviewing domestic violence-related fatalities, strengthening system policies and procedures, and identifying prevention strategies to reduce future incidents of domestic violence-related injuries and deaths.

The Quattrone Center is a national thought leader in sentinel event reviews in criminal justice and has assisted jurisdictions across the country in the conduct of such reviews in a variety of different contexts within the criminal justice system.

John Hollway C'92, MAPP'18, Executive Director of the Quattrone Center for the Fair Administration of Justice John Hollway C'92, MAPP'18, Executive Director of the Quattrone Center for the Fair Administration of Justice“The assembly of the DVDRT team, and this first review and report, represent a substantial addition to the City’s efforts to improve the San Francisco Police, DA’s Office, Sheriff’s Office and community efforts to work together to prevent domestic violence fatalities,” said John Hollway C’92, MAPP’18, Executive Director of the Quattrone Center. “While jurisdictions are often hesitant to conduct reviews of highly charged undesirable outcomes in the criminal justice system, this process can be a model for other jurisdictions as they seek to prevent domestic violence fatalities in the future.”

The fatality under review occurred despite multiple efforts by SFPD to de-escalate the situation and provide separation and distance between the assailant and victim. The DVDRT carefully analyzed the events of the night to understand the various factors that led to the tragic outcome and to design modifications to the city’s response to domestic violence incidents that will lead to better outcomes.

The DVDRT team identified a common challenge in helping SFPD officers to effectively respond to domestic violence calls: a gap in providing responding officers with all the information that might help them diagnose the risk that a domestic dispute could escalate to lethality.

“The San Francisco Police Department is committed to serving victims and people affected by domestic violence and hold those accountable within the criminal justice system,” said SFPD Captain Sean Perdomo. “We have already made great changes in the way we respond to domestic violence calls as a result of the Domestic Violence Death Review Team.”

Community-based domestic violence advocates and professionals provided DVDRT Pilot participants with expertise on domestic violence indicators, responses, and support, assisted in identifying factors that may contribute to domestic violence-related fatalities, and helped to design recommendations for systemic change that have the potential to prevent future such injuries or fatalities.

“We’ve come so far in San Francisco, but we must do more to prevent domestic violence-related deaths,” said Beverly Upton, Executive Director of the San Francisco Domestic Violence Consortium and Co-Chair of the San Francisco Family Violence Council. “Each tragic death holds so many keys for change and improvement. We seek to learn all we can while honoring those who have lost their lives.”

Together, the team evaluated various aspects of the fatal incident to identify contributing factors and make recommendations for system changes to prevent similar events from happening in the future. Key recommendations include:

  • Ensure that Department of Emergency Management (DEM) professionals who handle calls for service to San Francisco’s 911 hotline have real-time access to experts in the management of domestic violence situations.
  • Provide victims’ advocates who can accompany SFPD to domestic violence calls for emergency services; advocates should be required in situations where a single address has been the source of more than one call for emergency services in a 48-hour period.

  • SFPD should memorialize observed security risks at locations where they are called for domestic violence using, among other tools, the SF Safe home assessment, and the Cal VCB home security improvements.

  • The City and County of San Francisco should provide SFPD officers with tools other than arrest to create separation and space between a potential or actual DV victim and the assailant.

  • The Department of Emergency Management (DEM) and SFPD should prioritize and/or expedite SFPD responses to repeated allegations of domestic violence from the same address. SFPD should instruct DEM, and DEM should flag the address as a “Hazard Premise” upon the receipt of a second call from the same address in a 24-hour period.

“We appreciate the tremendous work of the Domestic Violence Death Review team in helping to reduce the number of domestic violence related fatalities by identifying actionable prevention strategies and policies,” said District Attorney Brooke Jenkins. “My office is committed to standing with and fighting for victims of crime, especially those that are not safe at home. Working in partnership with advocates, law enforcement, and our community stakeholders, we will create a better system to serve survivors who often suffer in silence and oust of sight with few options of escape and help ensure that abusers are held accountable and face consequences.”

Other principal participants in the Pilot included the San Francisco Police Department, the San Francisco Medical Examiner’s Office, the San Francisco Department of Emergency Management, the San Francisco Sheriff’s Department, and the Cooperative Restraining Order Clinic (CROC).

A full list of recommendations for SFPD and the City of San Francisco is available in the report here.

This project was supported by Grant No. 2017-MU-MU-K021 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice’s Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Learn more about the Quattrone Center and its pathbreaking work.