| 2020-01 | This case involved the death of a 25-year-old woman by her 29-year-old boyfriend. The perpetrator had a long history of violent and criminal activity and had been declared a violent offender. At the time of the homicide, the perpetrator lived in a half-way house and was allowed out on weekends to visit with the victim and their child. There were 19 risk factors for intimate partner homicide identified. | To Correctional Services Canada: - Correctional Services Canada should conduct a lessons-learned case review of the circumstances surrounding this case including:
- reviewing their policies related to this case with a view to enhance counselling and monitoring of high-risk offenders, especially those deemed “dangerous offenders” involved in intimate relationships including random visits to the home, drug and alcohol testing and interviews with their intimate partners regarding their safety
- role of child welfare services with a registered dangerous offender
- protocols to alert police in the community, and alert Children's Aid Society when a person with dangerous offender status has access to children.
- The federal Minister of Justice could consider if the first-degree murder definitions in the criminal code should be expanded to include murder committed by individuals that had been declared a dangerous offender, under long-term supervision and in violation of the terms of their supervision.
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| 2020-02 | This case involved the death of a 31-year-old woman by her 31-year-old boyfriend. The perpetrator had a history of domestic violence. The couple had recently split up and the victim had started a new relationship. There were 18 risk factors for intimate partner homicide identified. | To the Ministry of the Solicitor General: - Police referrals to victim services should be strongly considered for all domestic violence calls – even when victims may be reluctant to disclose enough information for charges to be laid.
To the Ministry of Government and Consumer Services and the Ministry of Children, Community and Social Services (Children’s and Women’s Issues): - The Ministry of Government and Consumer Services and the Ministry of Children, Community and Social Services should ensure that all dating sites in the province have warnings about abuse in dating relationships based on current material developed by provincial campaigns such as Neighbours, Friends and Family that remind consumers the extent of violence in dating relationships, definitions, warning signs, safe separations and where to seek help. Currently, the only warnings on government web-sites relate to financial and personal information matters.
To the Ministry of Children, Community and Social Services (Children’s and Women’s Issues): - The Ministry of Children, Community and Social Services (Children’s and Women’s Issues) should develop public education material related to violence against women for bars/drinking establishments and should be considered as part of licensing these establishments.
- The Ministry of Children, Community and Social Services should undertake a study to explore the extent to which children living with the aftermath of domestic homicide have counselling and trauma support in place across the province.
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| 2020-03 | This case involved the homicide of a 26-year-old Black woman by her 33-year-old White common-law partner. The couple were in a relationship for four years. The victim was a sex worker and the perpetrator was reportedly her pimp. The victim went missing in 2010 and her remains were located in 2012. There were 13 risks factors for intimate partner homicide. | To the Ministry of Children, Community and Social Services - It is recommended that the Ministry of Children, Community and Social Services develop a public and professional education campaign to address the harm to children living with intimate partner violence. The campaign should also provide education and resources on individuals’ duty to report to child protection services when they know or suspect that a child has been exposed to intimate partner violence.
- It is recommended that the Ministry of Children, Community and Social Services consult with experts in non-fatal strangulation and the gender-based violence sector, develop training and create culturally responsive resources and materials on the warning signs, dangers and risks of strangulation, and safe intervention strategies and make such materials available and accessible across all workplaces and communities.
To the Ministry of Labour: - As part of the domestic violence in the workplace initiatives under the Occupational Health and Safety legislation, the Ministry of Labour should give employers responsibilities to protect victims and co-workers, as well as address the behaviour of abusers using a progressive accountability framework (see resource developed by Western University, FETCO, and the Canadian Labour Congress). It is also recommended that the Ministry of Labour adapt culturally responsive resources and materials on the warning signs, dangers and risks of intimate partner violence and homicide developed by the University of Western Ontario, the Ontario Council of Agencies Serving Immigrants, and the Rexdale Women’s Centre, and make such materials available and accessible across all workplaces.
To the Human Resources Professionals Association: - It is recommended that the Human Resources Professionals Association consider creating a template regarding a “Progressive Accountability” policy pertaining to intimate partner violence leading to violence in the workplace that can be shared with their members.
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| 2020-04 | This case involved the death of a 26-year-old woman by her 27-year-old male common-law partner. The perpetrator had no criminal history and had legal access to firearms. The victim was considering ending the relationship just prior to her death. There were seven risk factors for intimate partner homicide identified. | No new recommendations. |
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| 2020-05 | The case involved the death of a seven-year-old male child by his 43-year-old stepfather. The victim’s mother was in a common-law relationship with the perpetrator and was in the process of separating. The perpetrator was unemployed and experiencing financial hardship. There were 10 risk factors for intimate partner homicide relating to the relationship between the perpetrator and the victim’s mother. | To the Ministry of Children, Community and Social Services: - The Ministry of Children, Community and Social Services should develop a public and professional education campaign to improve public awareness of the psychological and physical harm for children living with domestic violence.
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| 2020-06 | This case involved the death of a 31-year-old woman by her 52-year-old on-again off-again boyfriend. The perpetrator had a history of domestic violence with previous partners. The victim had tried to end the relationship. There were 23 risk factors for intimate partner homicide identified. | No new recommendations. |
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| 2020-07 | This case involved the death of a 26-year-old female by her 25-year-old husband. At the time of her death, the victim was pregnant and full-term. There was a history of domestic violence in the couple’s relationship. There were 14 risk factors for intimate partner homicide identified. | To College of Physicians and Surgeons, College of Nurses Ontario, College of Midwives Ontario, Society of Obstetricians and Gynaecologists, Ontario College of Family Physicians and Public Health Ontario: - Obstetrical care providers are encouraged to utilize this case report and information contained within the Domestic Violence Death Review Committee annual report for educational opportunities to reflect the significant risk that pregnant mothers face with domestic violence and domestic homicide. Although Ontario has a perinatal guide (Ontario Perinatal Record) that was created to standardize the documentation of perinatal care, it is difficult to readily find resources on domestic violence including a focus on the warning signs, screening, and appropriate responses for women experiencing domestic violence. Ongoing reminders and training in this area is essential.
To the Ministry of the Solicitor General: - Policy, procedures and training for Ontario police services should continue to outline strategies to deal with reluctant victims of domestic violence who may recant statements or refuse to support charges, especially in circumstances that reflect an ongoing pattern of abuse and high risk, based on a mandatory risk assessment required for all domestic violence occurrences.
To the Ontario College of Social Workers: - Social workers should recognize the risk of domestic homicide for victims of domestic violence. Members should be mandated to complete a risk assessment when clients disclose violence and provide safety planning. Training should be offered to members to increase awareness and skills to appropriately address domestic violence when disclosed by clients. For social workers without training or competence in this area, they should refer victims to others who can provide appropriate risk assessment and safety planning services.
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| 2020-08 | This case involved the homicides of the 55-year-old primary victim (victim 1), her 28-year-old son (victim 2) and her 88-year-old mother (victim 3). The perpetrator was a 58-year-old man who had been involved in an intimate relationship with victim 1. There were 13 risk factors for intimate partner homicide identified. | To the Ministry of the Solicitor General: - The Ministry of the Solicitor General should review its policy and training materials for police services to ensure a broad definition of domestic violence/intimate partner violence that captures the diverse nature of intimate relationships, especially in the context of dating relationships, on-line relationships and intimate relationships that may be of brief duration and more one-sided. The existing Provincial Intimate Partner Violence Coordinating Committee could be helpful in reviewing definitions as well as their consultation with experts in the field.
- The Ministry of the Solicitor General should develop clear policy and procedures as well as training at the Ontario Police College, on managing sexual assault victims who are reluctant to proceed with criminal charges, but may require additional time and counselling to recognize the risks they face from the perpetrator and the potential benefits of engaging in the criminal justice process.
- The Ministry of the Solicitor General, through the Ontario Police College, should utilize this review as a case study to illustrate the complexity of investigating domestic/intimate partner violence, dating violence and sexual assaults as multiple forms of gender-based violence.
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| 2020-09 | This case involved the homicide of a 76-year-old woman by her 70-year-old husband. The couple were in a hospital emergency department when the perpetrator shot and killed the victim. Police responded and subsequently shot and killed the perpetrator. The couple’s health was in decline and the perpetrator had a history of suicidal and homicidal ideation. There were eight risk factors for intimate partner violence identified. | To the Ministry of Labour, Training, and Skills Development; College of Nurses Ontario; Ministry of Health (Emergency Health Services Branch); Ontario Personal Support Workers Association; Health Shared Services Ontario: - It is recommended that elder abuse and intimate partner violence be a mandatory component of courses and training for personal support workers, emergency medical services and nurses.
To the Ministry of the Solicitor General: - It is recommended that elder abuse and risk assessment be a mandatory part of police training at the pre-service and ongoing professional development levels.
To the Ministry of Health: - It is recommended that the Ministry of Health establish communication policies and protocols to enhance coordination of assessments and intervention by personal support workers, emergency medical services, police and nursing, particularly around attendance at hospital emergency departments.
To the hospital involved, Local Health Integration Network and police service involved: - The hospital, Local Health Integration Network and police service involved should conduct a lessons-learned case review of the circumstances surrounding these deaths to identify system challenges and identify opportunities for developing or amending policy and practice guidelines.
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| 2020-10 | This case involves the homicide of a 51-year-old woman followed by the suicide of her 63-year-old husband. The couple were in a very unhappy marriage and the victim was in the process of separating. The couple had significant financial issues and lived in rural Ontario. There were 14 risk factors for intimate partner homicide identified. | To the Office of Women’s Issues, Ministry of Children, Community and Social Services: - The Office of Women’s Issues, Ministry of Children, Community and Social Services should review their policies and training materials to ensure a comprehensive definition of domestic violence that integrates both a historical context as well as a current analysis of the nature of the abusive tactics used against victims. It is critical to emphasize the dangers of non-physical forms of violence such as verbal, emotional, psychological and financial abuse as forms of coercive control. It is recommended that the differential impact on victims, their families and communities depending on the intersections between the family’s social location and their access to resources, be identified.
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| 2020-11 | This case involved the homicide of a 52-year-old woman by her 53-year-old husband who subsequently died by suicide. The perpetrator used illicit drugs and developed an opioid dependency while taking medications for his back pain. The perpetrator had firearms but did not have a license. There were 11 risk factors for intimate partner homicide identified. | To the government of Canada and Chief Firearms Office for Ontario: - It is recommended that educational materials be prepared and widely distributed to the public regarding how to report and dispose of firearms in the home, particularly when residents of the home are not licensed and/or have mental health issues and/or where there is violence.
To the College of Physicians and Surgeons Ontario and the College of Family Physicians Canada: - Family physicians are reminded to consider the links between addiction, mental health and suicidality when managing patient’s needs.
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| 2020-12 | This case involved the death of an 84-year-old woman by her 83-year-old husband. There was no history of violence in the couple’s relationship. The perpetrator was on medication for Alzheimer’s disease and was becoming more forgetful. The perpetrator was charged with first degree murder but was found unfit to stand trial. The perpetrator subsequently died while in custody. There was one risk factor for intimate partner homicide identified. | No new recommendations. |
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| 2020-13 | This case involved the homicide of a 35-year-old man who died while intervening in a dispute between his 59-year-old mother (the intended victim) and the 46-year-old perpetrator that she was in an intimate relationship with. Based on the relationship between the intended victim and the perpetrator, there were eight risk factors for intimate partner homicide identified. | To the government of Canada: - The government of Canada should amend the Firearms Act to ban the sale or transfer of a firearm from one person to another without proof of the recipient having a valid firearm license.
To the government of Canada and Chief Firearms Office for Ontario: - The government of Canada and the Chief Firearms Office for Ontario should enhance training and public education regarding the proper transfer of firearms.
To the Office of Women’s Issues, (Ministry of Children, Community and Social Services): - The Office of Women's Issues should raise awareness on the multiple risk factors that may be associated with an abuser's heightened risk to harm their partner including a history of growing up with violence and child abuse, mental health problems including depression and addictions and acquired brain injury.
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