Summary of Cases and Recommendations – 2018 Case Reviews
Case Number Summary Recommendation(s)
2018-01 This case involved the homicide of a 42-year-old woman by her 36-year-old common-law husband.  Police had been involved with the couple on several occasions prior to the homicide.  Mental health concerns pertaining to both the victim and perpetrator may have played a role.  There were 11 risk factors for intimate partner homicide identified. No new recommendations.
Relevant recommendations from previous reviews:
2003-05 - 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.
2008-07 - 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.
2010-04 - The DVSR should be used not only to indicate the presence of risk-enhancing factors towards violence, 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.
2014-01 - 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).
2014-07 - It is recommended that there be ongoing training for police on the appropriate response to domestic violence cases that involve victims with disabilities (in the current case, the victim had a speech impediment). 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.
2014-08 - 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.
2014-09 - 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.
2018-02 This case involved the homicides of Victim 1 (51-year-old first wife of Perpetrator 1), Victim 2 (19-year-old daughter of Perpetrators 1 and 2), Victim 3 (17-year-old daughter of Perpetrators 1 and 2) and Victim 4 (13-year-old daughter of Perpetrators 1 and 2) by Perpetrator 1 (the husband of Victim 1 and father to Victims 2, 3 and 4 and Perpetrator 3), Perpetrator 2 (second wife of Perpetrator 1 and mother to Victims 2, 3 and 4 and Perpetrator 3) and Perpetrator 3 (the son of Perpetrators 1 and 2 and brother to Victims 2, 3 and 4).  The perpetrators were not pleased that the victims were adapting western values that were not “honourable” and contrary to the strict religious values and behaviours that were expected of them. To the Ministry of Citizenship and Immigration; Ministry of Children, Community and Social Services, and Immigration and Citizenship Canada:
  1. Individuals involved in the immigration process (before and after) should be provided with resources/programs and information sessions in order to educate them about potential problems associated with cultural integration and/or perceived transgression of norms or values as their families become exposed to the Canadian culture (i.e. Westernization). They should also be provided with appropriate assistance and support (e.g. resources/family counselling) when experiencing conflict within the family. 
  1. New immigrants and their homeland families should be provided with resources (including contacts, shelters, resource centres, etc.) that can assist them with understanding Canadian law (e.g. immigration, domestic violence), equality, women’s rights, employment and education.  New immigrants should also be made aware of and encouraged to initiate contact with police and/or other resources. 
To the Ministry of Citizenship and Immigration;  Ministry of Children, Community and Social Services; Ministry of Education; Ministry of Health and Long Term Care and Ministry of Community Safety and Correctional Services:
  1. Police and other agencies (e.g. schools, healthcare institutions, community resources, children’s aid societies) dealing with new immigrants should be educated about potential problems of cultural integration and/or perceived transgression of norms or values, cultural beliefs/diversity and honour violence when involved with these families.
2018-03 This case involved the homicide of a 31-year-old woman by her 29-year-old husband from an arranged marriage. The perpetrator was a recent immigrant and had difficulty adjusting to Canadian culture.   There were 11 risk factors for intimate partner homicide identified. To the Office of the Status of Women:
  1. The importance of safe separation should be reinforced in public education campaigns dealing with violence against women and issues associated with the role of culture should be considered in the educational material.
2018-04 This case involved the homicide of an 82-year-old woman by her 82-year-old husband.  The perpetrator killed his wife after she berated him for causing injury to their grandson following a lawn mower accident.  There was one risk factor for intimate partner homicide identified. No new recommendations.
2018-05 This case involved the homicide of a 61-year-old  man by his 39-year-old former girlfriend and the 31-year-old male that she was now in a relationship with.  There was a long history of domestic violence between the victim and the female perpetrator.  Alcohol was a contributing factor to the previous incidents and in the homicide. There were 13 risk factors for intimate partner homicide identified. To the Ministry of Community Safety and Correctional Services:
  1. The Ministry of Community Safety and Correctional Services should engage and work with the community to develop guidelines to assist First Nations Police Services in responding to chronic domestic violence.
To the First Nation Police Service involved:
  1. The First Nation police service involved should conduct an internal review of their involvement with this case to examine potential missed opportunities to prevent the homicide with a particular focus on risk assessment, safety planning and risk management of chronic domestic violence.
  1. The police service involved should organize a community review of the homicide with appropriate professionals and community members to examine strategies to prevent a death in similar circumstances in the future including enhanced collaboration with friends, family, neighbours as well as professionals in social service, health and corrections.
To the Ministry of Community Safety and Correctional Services:
  1. Probation services should review this case as part of an examination of community corrections’ strategies in dealing with chronic offenders with problems related to domestic violence, addictions and poverty.
2018-06 This case involved the homicide of a 35-year-old man by his 41-year-old female common-law partner.  There had been a history of domestic violence between the couple, including instances where the victim assaulted the perpetrator.  Alcohol was a significant factor in their relationship. There were five risk factors for intimate partner homicide identified. No new recommendations. 
Previous relevant recommendation:
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.
2018-07 This case involved the homicide of a 37-year-old woman by her 34-year-old boyfriend.  The victim had been the perpetrator of intimate partner violence with previous partners.  Both the victim and perpetrator abused alcohol.  There were seven risk factors for intimate partner homicide identified. To the Ministry of Community Safety and Correctional Services:
  1. It is recommended that conditions of probation should include regular monitoring of the domestic violence 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. 
  1. It is recommended that probation officers consider the development of safety planning for suitable probation candidates. 
2018-08 This case involved the homicide of a 40-year-old man by his 36-year-old wife. The couple had recently emigrated from China and had a daughter together.  There was no history of domestic violence and the homicide may have been financially motivated.  There was one risk factor for intimate partner homicide identified. To the Ontario Ministry of the Status of Women:
  1. Encourage the Neighbours, Friends and Families Campaign for Immigrant and Refugee Communities to develop  specific outreach campaigns for several cultural groups (e.g., ethno-specific websites, newspapers, radio, television, social media, etc.)
To the Ministry of Labour:    
  1. 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. 
    • developing and implementing a plan for those staff who demonstrate well-known red flags of domestic violence in the workplace of potentially abusive and bullying behaviours by a perpetrator
    • assisting managers to learn ways of dealing with angry and abusive staff, and the impact it has on their staff. 
2018-09 This case involved the homicide of a 27-year-old woman by her 28-year-old male common-law partner.  The couple had been in a relationship for approximately five years.  There were eight risk factors for intimate partner homicide identified. To the Ministry of the Attorney General:
  1. Partner Assault Response (PAR) programs should be promoted to voluntary referrals in addition to court mandated referrals through the Ministry or a partner Ministry in order to promote early intervention and prevention efforts for perpetrators of domestic violence.
2018-10 This case involved the homicide of a 50-year-old woman by her 49-year-old husband.  The victim was in the process of ending the marriage.  The perpetrator had access to firearms and was known to be depressed.  The victim was more concerned that the perpetrator would harm himself and was less concerned about her own safety.  There were 11 risk factors for intimate partner homicide identified. To the College of Physicians and Surgeons of Ontario:
  1. It is recommended that the College of Physicians and Surgeons of Ontario develop a mandatory course on domestic violence and homicide. The course curriculum should 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 depression and/or are experiencing problems in their intimate relationship. The course should highlight the risks associated with patients who are depressed, may be experiencing a possible separation from their intimate partner, and have access to firearms. The course should include ways for physicians to raise awareness with patients about the risk of homicide and suicide with firearms in the home and potential strategies for relinquishing firearms or working with the police to remove firearms from the home where there is a risk of harm.
  1. It is recommended that the College of Physicians and Surgeons of Ontario provide information on how physicians’ can begin the process of encouraging patients to relinquish firearms or collaborating with police to remove firearms from a patient’s home when they are experiencing depression and/or suicidal/homicidal ideation and/or if they are experiencing conflict within their intimate relationship (e.g., pending or actual separation). The information should include assessing risk, how to talk with patients about the risk of firearms in the home, and protocols for how to work with police to remove firearms when risk is assessed.
Previous relevant recommendations:
2003 – 01, 02, 08 – 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. 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 through a separation or the individual is showing signs of depression or suicidal or homicidal thoughts.
2003 – 05 - 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.
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.  2016-01 - Screening of individuals applying for, or renewing,  Possession and Acquisition Licenses (PALs) should be improved to include:
  • interviewing of applicants and their references, particularly those applicants who have been previously convicted of a crime against a person or convicted of a firearms offence
2015-14 - The Deans or Chairs of Departments of Social Work, Psychology and Medicine should ensure courses are provided on domestic violence and risk assessment and risk management. Professional Colleges for these professional groups should share information on the links between depression, suicidal ideation and domestic homicide.
2018-11 This case involved the homicide of a 22-year-old woman by her 23-year-old boyfriend.  Both the victim and perpetrator had a long history of mental health issues.  The couple met and resided for a time, at a homeless shelter for youth.  There were 17 risk factors for intimate partner homicide identified. To the Ministry of Community Safety and Correctional Services (MCSCS):
  1. The MCSCS probation and parole domestic violence protocol should apply as soon as a client is charged with a domestic violence offence, as opposed to after conviction.
  1. The MCSCS should develop a policy that in all cases where an offender is being released from custody after a domestic offence (even if the domestic violence protocol does not yet apply), probation and parole officers be required to contact the domestic violence victim to inform of release, offer supports, discuss safety planning and collect risk assessment information.
  1. The MCSCS training for probation and parole officers should address the synergistic risk created by the combination of mental health issues, domestic violence and victim vulnerability.
To the Board of Directors for the shelter involved and to the Ministry of Children, Community and Social Services:
  1. Youth shelters are encouraged to examine counselling and other evidenced-based interventions for residents that may be victims or perpetrators of intimate partner violence.
2018-12 This case involved the homicide of a 63-year-old woman by her 60-year-old husband.  The perpetrator had physical and financial challenges which lead to depression.  The perpetrator had access to firearms.  There were seven risk factors for intimate partner homicide identified. To the College of Physicians and Surgeons, College of Nurses of Ontario, College of Psychologists of Ontario and Ontario Psychiatric Association:
  1. Mental health professionals are encouraged to review the common risk factors for intimate partner homicide that have been identified in the annual reports of the Domestic Violence Death Review Committee. The presence of risk factors such as access to firearms and depression should trigger efforts for risk assessment, safety planning and risk management with patients as potential perpetrators/victims.
  1. When an individual is diagnosed with depression, efforts should made by the mental health professionals to encourage families to remove the individual’s access to firearms. 
To the College of Physicians and Surgeons, College of Nurses of Ontario, Ministry of Health and Long Term Care (Local Health Integration Networks – Home and Community Care):
  1. Healthcare providers should emphasize or discuss the importance of care options or mechanisms for couples experiencing declining health or disabilities and work with their families to identify appropriate mechanisms when one partner is being treated for depression or other related mental health issues and, in particular, if there is evidence of depression, suicidal ideation, previous suicide attempts and access to firearms. 
2018-13 This case involved the homicide of a 77-year-old male by his 62-year-old male common-law partner.  The couple had been in a committed relationship for over 40 years and there was no history of domestic violence.  Both the victim and perpetrator had recently been charged with a historical sexual assault.  It is believed that couple had originally planned on committing suicide together, but when that failed, the perpetrator shot the victim, then himself. There were three risk factors for intimate partner homicide identified. No new recommendations.
2018-14 This case involved the homicide of a 51-year-old woman by her 46-year-old husband.  The victim’s business partner was injured during the incident that resulted in the victim’s death.  There were six risk factors for intimate partner homicide identified. To the Ministry of Attorney General:
  1. It is recommended that Crown Attorneys receive enhanced training and education about why victims of domestic violence may recant and/or fail to appear for trials against their abusers and to review policies laid out in Ontario’s Domestic Violence Court Program that recognize special procedures are to be followed in these cases, where possible, so that that they may proceed with charges against an accused even when a victim does not subsequently cooperate with the proceedings.
2018-15 The case involved the death of a 35-year-old man by his 28-year-old common-law wife; the couple lived in a remote community.  Both the victim and perpetrator had substance abuse issues and a history of domestic violence.  The perpetrator had previously experienced domestic violence inflicted on her by the victim.  There were 10 risk factors for intimate partner violence identified. Charges against the perpetrator relating to the death of the victim were subsequently withdrawn as it was felt that she was acting in self defence. To the Ministry of Health and Long Term Care (MOHLTC), College of Physicians and Surgeons and College of Nurses:
  1. Health professionals (including addiction counsellors and nurses) who are involved with Indigenous communities should receive additional training and education on the issue of domestic violence and how it may be impacted by substance abuse, mental health and other factors within the community. 
Previous relevant recommendations:
2016 - Enhanced public education programs should be targeted to victims of domestic violence in First Nations communities to reduce or eliminate the stigma which leads to non-reporting of domestic violence to authorities or to agencies able to assist with victims in a domestic violence crisis. Currently available programs, such as the Kanwayhitowin Campaign, are a valuable resource that can assist in education of both victims and their friends and family who may witness the violence in their communities. Where required, additional funding should be provided to ensure that such programs are in place and/or are effective.
2016 - It is recommended that Kanawayhitowin, a public awareness campaign launched in 2007 to raise awareness on the signs of woman abuse in First Nations communities, include information on the potential risk of lethal violence at the time of relationship breakdown and recommendations on how to engage in and/or support a “safe” break-up/separation for couples experiencing domestic violence.
2007 - 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 - 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.
2018-16 This case involved the death of a 36-year-old woman by her 43-year-old husband.  The couple had been experiencing marital problems since immigrating to Canada from Iran.  The perpetrator had a history of mental health issues and a history of suicide attempts.  There were four risk factors for intimate partner homicide identified. To the Ontario Ministry of Citizenship and Immigration and the Ontario Council of Agencies Serving Immigrants (OCASI):
  1. The Ministry of Citizenship and Immigration and OCASI are encouraged to continue outreach with new immigrants who may be experiencing mental health, physical health and social consequences arising from their recent immigration to Canada.
To the Ministry of Health and Long-Term Care (MOHLTC):
  1. The MOHLTC is encouraged to establish more dedicated long-term mental health resources to support patients who have been admitted as mental health inpatients.  
2018-17 This case involved the deaths of two children (ages 4 and 10), followed by the suicide of their 36-year-old father. The perpetrator and his wife (the intended victim) had been seeking to adopt a foster child, however they also appeared to be in the process of ending their relationship.  The perpetrator lived part of the time in another city and appeared to have a “secret” life there. There were seven risk factors identified for intimate partner homicide  identified. To The Ministry of the Status of Women and Ministry of Children and Youth Services:
  1. It is recommended that the Ministry of the Status of Women and the Ministry of Children and Youth Services develop initiatives that will enhance a broader public and professionals’ awareness about the risk of lethal violence for children living with domestic violence, particularly at the time of a pending or actual parental separation.  Information on how to support a “safe” separation should include safety measures for children.
To The Ministry of Children and Youth Services and the Ontario Association of Childrens Aid Societies:
  1. It is recommended that this case be shared with child protection services across the province to highlight the risks of domestic violence to children and the need to verify employment and education background of potential adoptive parents. 
2018-18 This case involved the homicide of a 62-year-old woman by her 64-year-old husband who subsequently died by suicide. The couple had been married for 40 years and was in the process of separating.  The perpetrator had a valid firearms license. There were five risk factors for intimate partner homicide identified. No new recommendations.