Saskatchewan has the worst rate of domestic violence and homicides by intimate partners among Canadian provinces, yet it's never had a coroner's inquest or formal review of any killing of that type.
In comparison, Ontario reviews every domestic homicide, about 30 a year, through the chief coroner's domestic violence death review committee.
"When someone dies, whether it's a plane crash or whether it's domestic homicide, the public has a right to know, 'What happened?'" said psychologist Peter Jaffe.
Jaffe is the director of Western University's centre for research on violence against women and children and a member of Ontario's review committee since its inception in 2003.
"It's learning from the tragedies and hopefully saving lives in the future," Jaffe told CBC News.
In his 10 years in office, Saskatchewan's Chief Coroner Kent Stewart has yet to call an inquest into a domestic homicide or make any recommendations on how to prevent similar tragedies.
"We haven't had the numbers," Stewart said.
There were 58 intimate partner homicides in Saskatchewan between 2000 and 2010, the highest rate of any province in that period, according to Statistics Canada.
However, Stewart told CBC News that he now believes it's a "critical issue" that could demand further review.
'It is certainly a wake-up call.' — Kent Stewart, Saskatchewan's Chief Coroner
The past year has been particularly deadly in the province, with three murder-suicides in the past eight months alone, leaving nine people dead.
In April, Latasha Gosling and her children were slain in their Tisdale, Sask., home. Her common-law husband later killed himself at his mother's house.
Most recently, a domestic violence counsellor, Celeste Yawney, was found dead inside her Regina home. Her ex-boyfriend, who had a history of assaulting her, is charged with second-degree murder.
"We have not seen this level of violence in Saskatchewan — I mean, deaths — in my history here. It is certainly a wake-up call," the coroner said.
Ontario reviews every domestic homicide
In 2003, Ontario formed the first domestic violence death review committee in Canada after major inquests into the killings of two women by abusive husbands.
In 1996, Arlene May was shot by her common-law husband in Oshawa before he turned the gun on himself. Four years later, Gillian Hadley's husband killed her, then himself, in their Pickering home. Both men were on bail for assault charges against their wives and forbidden from making contact.
Ontario's committee has since reviewed more than 250 deaths and concluded that 75 per cent of domestic homicides are "predictable and potentially preventable."
It has compiled a list of 39 risk factors and determined that a person with seven or more well-known risk factors is more likely to kill a family member. Red flags include a pending or recent separation, a history of domestic violence, escalating violence, obsessive behaviour, depression and prior death threats.
"It's not out of the blue," Jaffe said.
Now, in Ontario, police responding to a domestic assault are equipped with a risk assessment checklist to help them interview a victim
The expert panel has also made public recommendations to courts, victims' services, mental health professionals, family doctors and those who help perpetrators of violence.
Three other provinces have followed Ontario's lead and formed similar committees — New Brunswick, Alberta and Manitoba — and British Columbia conducted a one-time review in 2010 of 11 domestic homicides.
Death reviews considered 'best practice'
"It only makes sense and we could only benefit from having the panel and the committee," said Jen Renwick, a senior domestic violence worker at Family Services Regina.
At Saskatchewan's Ministry of Justice, the government's leading expert on family violence, Betty Ann Pottruff, acknowledged that death reviews are considered "best practice" across the country.
"There's certainly not been a rejection of it," Pottruff said, defending the lack of reviews in Saskatchewan.
Pottruff said a government committee meets every month to consider ways to prevent family violence.
She points to a recent expansion of victims services programs province-wide and the formation of three specialized domestic violence courts that expedite treatment for offenders and services for victims. Pottruff is concerned about shifting resources away from training and interventions to focus on a review.
'It's not rocket science'
Jaffe, at Western University, who is considered one of Canada's top experts in this field, insists that domestic violence and homicides deserve public inquiry and accountability.
"It's not rocket science — what it is is a commitment to uncover the truth and not bury it and pretend it never happened."