From Teams of Experts to Expert Teams: Reviewing Domestic Violence Deaths

Adults in Classroom


May 9, 2017 

The National Transportation Safety Board’s (NTSB) comprehensive, professional and independent investigations of plane crashes has greatly improved the safety of U.S. commercial aviation.[i] Teamwork among airlines is common as they share vital crash data. Accident reconstructions contribute to new life-saving safety procedures by identifying for example, the role of small, unchecked errors that multiplied prior to a crash. As a result, deaths per passenger-mile flown over the last 40 years have diminished greatly—proving the positive impact critical questioning and collaborative reviews can have on safety procedures and protocols.

Flight crews have also come to recognize the life-saving potential of cockpit teamwork. In the aviation industry, it is accepted practice for junior pilots to question the decisions of their seniors. Captain Sullenberger explained the collaborative nature of aviation risk management, “You take a team of experts and make them into an expert team.”[ii]

Using philosophies similar to those of the NTSB, roughly 200 Domestic Violence Fatality Review teams have been formed in 44 states since the 1990s. These teams have no regulatory or enforcement function. They build case timelines and explore the circumstances of a domestic violence death or near death. Teams examine the role of agencies, stakeholders, and community members and the degree of communication, collaboration, and coordination among them. Using the deceased life as a central frame of reference, they recommend preventive interventions intentionally avoiding blaming or shaming individuals, agencies or stakeholders.

By including different experts (e.g., law enforcement, victim advocates, prosecutors), teams optimize opportunities to learn about and share the way their systems handle domestic violence cases. Team reviews often reveal how domestic violence victims perceive services as confusing, alienating, dangerous or irrelevant rather than helpful and potentially lifesaving. Many victims perished without accessing domestic violence services; a fact we ought to take seriously. Other victims experienced various system interventions (e.g., advocacy, arrest of suspected abusers, orders of protection), seemingly to no avail. In cases with substantial system contacts, teams usually find numerous missed intervention opportunities.

The most promising reviews analyze the complex ways a case flows through systems and identify opportunities to better collaborate, improve communication and transform case handling practices. Such reviews re-frame domestic violence cases as community challenges rather than criminal justice problems and increase the social connectivity between state and civil society, reinforce the rule of law and identify new ways to reduce the number of domestic violence fatalities.

Teamwork is more than just working together; it includes critical questioning, constructive criticism and a commitment to constant improvement. Building expert teams to analyze complex cases and lives is crucial to preventing fatalities. Working together to review deaths and near deaths caused by, related to or somehow traceable to domestic violence has the potential to uncover intervention opportunities and reduce fatality rates.

The National Domestic Fatality Review Initiative is a one-of-a-kind resource center dedicated to domestic violence fatality review. It is funded by the Office on Violence Against Women (OVW), a branch of the U.S. Department of Justice. Working closely with project partners and OVW, the initiative integrates fatality reviews into the broader national initiatives to combat violence against women. For more information, visit

Click here to learn how the OJP Diagnostic Center helped Charlottesville, VA address domestic violence through data-driven solutions.


[i] Fielding, E., Lo, A.W., & Yang, J.H., 2011, The National Transportation Safety Board: A model for systemic risk management, Journal of Investment Management, 9, 1: 17-49.

[ii] Quoted in Mike Ferguson, 2016, “U.S. Airways hero talks up the values of preparation and teamwork,” Billings Gazette, March 31, 2016.