Big changes could be coming to domestic killings review committee

For 20 years, a committee trying to prevent domestic killings in Ontario has made hundreds upon hundreds of recommendations to stop them, but the numbers aren't dropping. Now, both the work and membership of the Domestic Violence Death Review Committee is being reviewed.

Intimate partner violence not declining after 20 years of committee recommendations in Ontario

A man clasps his hands at a microphone.
Prabhu Rajan, chair of the Domestic Violence Death Review Committee and chief counsel for the Office of the Chief Coroner for Ontario, also served as counsel during the inquest into the 2015 murders of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam in June. (Sean Kilpatrick/The Canadian Press)

For the past 20 years, a committee trying to prevent domestic killings of women, men and children in Ontario has made hundreds upon hundreds of recommendations to stop them, but the number of deaths isn't dropping.

In fact, intimate partner violence (IPV) has only worsened during the pandemic, said Prabhu Rajan, chair of the Domestic Violence Death Review Committee and chief counsel for the Office of the Chief Coroner for Ontario, in a conference call with reporters Monday.

Now both the work and membership of the Domestic Violence Death Review Committee, formed in 2003, is being reviewed.

A call went out over the summer for new, more diverse members. At the same time, the coroner's office waded into weeks of testimony at an inquest into the murders of three women west of Ottawa in 2015 by a man who had known all of them. (You can read the 86 recommendations stemming from that inquest here).

From left: Anastasia Kuzyk, Nathalie Warmerdam and Carol Culleton were murdered in and around Renfrew County, west of Ottawa, on Sept. 22, 2015. (Photo illustration/CBC)

A broad spectrum of about 35 people ended up applying and Rajan said they hope to have about 15 brought on board by the end of 2022.

Two members who have been part of the committee since day one — Peter Jaffe and Deborah Sinclair — will be made members emeritus to guide the group through the changes and into the future, Rajan added.

Much could change aside from membership, from how the committee reviews cases, to how recommendations are created and distributed, to how responses to those recommendations can be analyzed and reported.

Fewer committee reports on the table

Rajan said repeatedly Monday he doesn't want to be the one to introduce all the ideas about what could or should change. He talked about a group of up to 15 core members "and maybe less," with a cast of supporters, to help out with specific areas of expertise, such as immigration.

He also discussed a possible fundamental shift to the committee's reporting system, which has traditionally reviewed each incident separately, where they cut down from dozens to one or two reports a year to "summarize all the issues."

As an example, a report for 2023 could lay out five identified themes and the common threads, systemic issues, gaps and barriers uniting them — which would "be more impactful," he argued.

A woman in a mask looks down.
Valerie Warmerdam, daughter of murder victim Nathalie Warmerdam, takes part in a press conference following the inquest jury's release of recommendations in Pembroke, Ont., on June 28. The Domestic Violence Death Review Committee was the subject of three recommendations. (Sean Kilpatrick/The Canadian Press)

Looping in government and systems under critique

Rajan also talked about generating better recommendations, something he'd mentioned before the June inquest into the Renfrew County murders.

Getting substantive responses from government, police forces and other organizations can be hampered by "recommendation fatigue" — getting similar suggestions and responding the same way — as well as recommendations that "may have no application or frankly don't actually fit the system that they're intended to fit into," Rajan said.

To combat the latter, maybe consulting with the very governmental, judicial and policing bodies under critique ahead of recommendations being formed would help, Rajan suggested.

Accountability and followup

The committee has so far made more than 400 recommendations in annual reports stemming from reviews of more than 250 cases up to 2019-2020, the last year its annual report was released.

Ahead of the June inquest into the Renfrew County murders, the chief coroner's office did not provide any examples of implementing recommendations from the death review committee, and did not answer questions about why that information is not available.

The office also did not provide any statistics about the number of committee recommendations that are implemented, saying only that "tracking is complicated" and some responses aren't received.

A picture of a woman next to flowers.
A picture of murder victim Nathalie Warmerdam is displayed during a vigil at the Women's Monument in Petawawa, Ont., on June 28. (Sean Kilpatrick/The Canadian Press)

Rajan said the coroner's office is hampered by some "tricky privacy requirements" when it comes to the public accessing the committee's recommendations and the responses to them, and that it will be a topic of discussion with new members.

He also said three recommendations from the June inquest that apply to the committee "are being seriously considered," and he personally supports them:

  • Ensuring that the committee reviews its mandate with a view to enhancing its impact on IPV and provide the committee with improved supports.
  • Ensuring committee annual reports are published online in a timely manner.
  • Ensuring committee reports and responses to recommendations are publicly available and will continue to be available without charge.

Making implementation mandatory not on the table

The committee's recommendations are not legally binding, nor are the recommendations made by inquest juries.

The Office of the Chief Coroner hands them off to relevant organizations for implementation, and recipients are asked to report back within six months. No one is obligated to make change happen, or even to respond.

"That is the eternal struggle both of inquests and committee work, or the constant criticism — whether to make these recommendations mandatory," Rajan acknowledged. 

He said he can't speak to how the government might change that legal framework and that it isn't the purview of the committee.


Kristy Nease


CBC Ottawa reporter Kristy Nease has covered news in the capital for nearly 15 years, and previously worked at the Ottawa Citizen. Get in touch: