DOMESTIC ABUSE DEATH REVIEW TEAM Fatality Review Data Collection Form. Unknown

Transcription

1 DOMESTIC ABUSE DEATH REVIEW TEAM Fatality Review Data Collection Form Case ID#: Date Reviewed: Reviewed By: Chart Includes: Coroner Court Records Newspaper Death Certificate DOC MH/SA LE Local # Family DA Shelter DCI Rpt# CVAD Med. Rec. CPA Other I. CASE SUMMARY Number of Homicides Time of Incident Number of Suicides Undetermined Number of Survivors Involved with Homicide Date of Incident II. FACTORS RELATED TO THE HOMICIDE Homicide/Suicide Dispute/Argument Financial Problems Divorce Gambling Gang Involvement Burglary Sexual Assault Robbery End of Relationship/ New Partner Custody Conflict Rejection Alcohol Drug Jealousy Control Isolation Service of Protection Access to Firearms Order Other 1

2 III. CHILDREN INVOLVED IN HOMICIDE Age Child of DA Victim Child of DA Perp. Witness Injured Killed Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N IV. CASE SYNOPSIS AT RISK IDENTIFIERS: SYSTEM INTERVENTION/FAILURES: PREVENTION ISSUES: 2

3 V. VICTIM/PERP/SURVIVOR INFO PRIMARY VICTIM DEMOGRAPHICS Perpetrator Outcome Suicide Attempted suicide Murder 1 Murder 2 Suicide Yes No Manslaughter Acquitted No charges filed Other Corner ID# Child Yes Age No Homicide Victim was (check one) DA Perpetrator DA Victim DA Victim & Perp DA Victim Child DA Perp Child Child of Both DA Victim New Partner DA Perp New Partner Other Full name: Residence: County of residence: Date of birth: Gender: Female Male County of death: Age at death: Education Level: <8 th 8 th - <12 th HS Graduate Some College/Tech School BA/BS >BA/BS Occupation: Race: Caucasian Hispanic Native American African American Asian American Other: INFORMATION ABOUT THE DEATH Pronounced Dead Date Time (military) Cause of Death: Gunshot wound to head Blunt trauma to head Multiple gunshot wounds Asphyxia Cranial cerebral trauma Traumatic stab wounds Other Multiple wounds Method: Stabbing Beating Shooting Strangulation Other Multiple weapons Weapon: Knife Hands Firearm Other Multiple weapons 3

4 Number of wounds Autopsy Evidence of Previous Injury Yes No List Location of Incident Joint Residence Victim s residence Perp s residence Workplace Other Where body was found Ethanol Yes No If Yes, Level Other Drugs Yes No If Yes, Level Was a Sexual Assault Analysis Conducted Yes No If Yes Positive Negative Pregnant Yes No Not Applicable Trimester Not Applicable ABUSE HISTORY OF PARTY INVOLVED: Is this person in the index relationship (relationship with suspected abuse): Yes No Neither History of Abuse Behavior Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who History of Abuse by Homicide Perpetrator Physical Yes No If Yes, Previous Injuries? Yes No Documentation Medical Record Law Enforcement Family Other Emotional Yes No Sexual Yes No History of Abuse by Others Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who Length of Relationship with Perpetrator No Relationship <1 year 1-<3 years 3-<5 years 5-<10 years 10+years End of Relationship/Separation Yes No If yes, How Long <1 week 1 week-1 month 2-3 months 4-6 months 7 months-1 year >1 year 4

5 Evidence of Prior Stalking Against Homicide Victim Yes No If Yes, Who Prior Homicide Threats Against Victim Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Homicide Threats Made by Victim Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Suicide Threats Yes No Prior Suicide Attempts Yes No Prior Police Calls Yes No If Yes, By Victim for Domestic Abuse? Yes No If Yes, Other Yes No If yes, specify Prior DA Services/Shelter Yes No Legal History of Victim: Prior Arrests Yes No Charges Burglary Substance Abuse DA Assault Sexual Crime Juvenile Crime Other Prior Incarceration Yes No Current Probation/Parole Yes No Prior BEP Yes No If Yes, Assigned Yes No If Yes, Completed Yes No Protection Orders Sought by Victim: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Protection Orders Sought Against Victim: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No 5

6 Under order for weapons seizure Yes No Perpetrated Abuse Against Children Yes No Founded CPA by DHS Yes No Founded CPA by Other Sources Yes No Medical and Mental Health History: History of Substance Abuse Yes No Alcohol Yes No Illegal Drugs Yes No Specify Substance Abuse Treatment Yes No History of Mental Health Problems Yes No Mental Health Treatment Yes No If Yes, Diagnosis Medications Yes No If Yes, Type Medical/Physical Condition Yes No If Yes, Type NOTES: 6

7 PERPETRATOR DEMOGRAPHICS Perpetrator Outcome Suicide Attempted suicide Murder 1 Murder 2 Manslaughter Acquitted No charges filed Other Suicide Yes No Correction File # Police ID# Corner ID# Child Yes Age No Homicide Perp was (check one) DA Perpetrator DA Victim DA Victim & Perp DA Victim Child DA Perp Child Child of Both DA Victim New Partner DA Perp New Partner Other Full name: Residence: County of residence: Date of birth: Gender: Female Male County of death: Age at death: Education Level: <8 th 8 th - <12 th HS Graduate Some College/Tech School BA/BS >BA/BS Occupation: Race: Caucasian Hispanic Native American African American Asian American Other: INFORMATION ABOUT THE DEATH Pronounced Dead Date Time (military) Cause of Death: Gunshot wound to head Blunt trauma to head Multiple gunshot wounds Asphyxia Cranial cerebral trauma Traumatic stab wounds Other Multiple wounds Method: Stabbing Beating Shooting Strangulation Other Multiple weapons Weapon: Knife Hands Firearm Other Multiple weapons Number of wounds Autopsy Evidence of Previous Injury Yes No List 7

8 Location of Incident Joint Residence Victim s residence Perp s residence Workplace Other Where body was found Ethanol Yes No If Yes, Level Other Drugs Yes No If Yes, Level Was a Sexual Assault Analysis Conducted Yes No If Yes Positive Negative Pregnant Yes No Not Applicable Trimester Not Applicable ABUSE HISTORY OF PARTY INVOLVED: Is this person in the index relationship (relationship with suspected abuse): Yes No Neither History of Abuse Behavior Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who History of Abuse by Homicide Victim Physical Yes No If Yes, Previous Injuries? Yes No Documentation Medical Record Law Enforcement Family Other Emotional Yes No Sexual Yes No History of Abuse by Others Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who Length of Relationship with Victim No Relationship <1 year 1-<3 years 3-<5 years 5-<10 years 10+years End of Relationship/Separation Yes No If yes, How Long <1 week 1 week-1 month 2-3 months 4-6 months 7 months-1 year >1 year Evidence of Prior Stalking Against Homicide Perpetrator Yes No If Yes, Who 8

9 Prior Homicide Threats Against Perp Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Homicide Threats Made by Perp Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Suicide Threats Yes No Prior Suicide Attempts Yes No Prior Police Calls Yes No If Yes, By Victim for Domestic Abuse? Yes No If Yes, Other Yes No If yes, specify Prior DA Services/Shelter Yes No Legal History of Perpetrator: Prior Arrests Yes No Charges Burglary Substance Abuse DA Assault Sexual Crime Juvenile Crime Other Prior Incarceration Yes No Current Probation/Parole Yes No Prior BEP Yes No If Yes, Assigned Yes No If Yes, Completed Yes No Protection Orders Sought by Perpetrator: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Protection Orders Sought Against Perpetrator: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Under order for weapons seizure Yes No Perpetrated Abuse Against Children Yes No 9

10 Founded CPA by DHS Yes No Founded CPA by Other Sources Yes No Medical and Mental Health History: History of Substance Abuse Yes No Alcohol Yes No Illegal Drugs Yes No Specify Substance Abuse Treatment Yes No History of Mental Health Problems Yes No Mental Health Treatment Yes No If Yes, Diagnosis Medications Yes No If Yes, Type Medical/Physical Condition Yes No If Yes, Type NOTES: 10

11 SURVIVORS INVOLVED WITH HOMICIDE DEMOGRAPHICS Perpetrator Outcome Suicide Attempted suicide Murder 1 Murder 2 Manslaughter Acquitted No charges filed Other Were you: Witness Yes No Child Yes Age No Injured Yes No Survivor was (check one) DA Perpetrator DA Victim DA Victim & Perp DA Victim Child DA Perp Child Child of Both DA Victim New Partner DA Perp New Partner Other Full name: Residence: County of residence: Date of birth: Gender: Female Male Education Level: <8 th 8 th - <12 th HS Graduate Some College/Tech School BA/BS >BA/BS Occupation: Race: Caucasian Hispanic Native American African American Asian American Other: ABUSE HISTORY OF PARTY INVOLVED: Is this person in the index relationship (relationship with suspected abuse): Yes No Neither History of Abuse Behavior Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who History of Abuse by Homicide Perpetrator/Victim (depending on party involved) Physical Yes No If Yes, Previous Injuries? Yes No Documentation Medical Record Law Enforcement Family Other 11

12 Emotional Yes No Sexual Yes No History of Abuse by Others Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who Length of Relationship with Perpetrator/Victim (depending on party involved) No Relationship <1 year 1-<3 years 3-<5 years 5-<10 years 10+years End of Relationship/Separation Yes No If yes, How Long <1 week 1 week-1 month 2-3 months 4-6 months 7 months-1 year >1 year Evidence of Prior Stalking Against Homicide Survivor Yes No If Yes, Who Prior Homicide Threats Against Survivor Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Homicide Threats Made by Survivor Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Suicide Threats Yes No Prior Suicide Attempts Yes No Prior Police Calls Yes No If Yes, By Victim for Domestic Abuse? Yes No If Yes, Other Yes No If yes, specify Prior DA Services/Shelter Yes No Legal History of Party Involved: Prior Arrests Yes No Charges Burglary Substance Abuse DA Assault Sexual Crime Juvenile Crime Other Prior Incarceration Yes No Current Probation/Parole Yes No Prior BEP Yes No If Yes, Assigned Yes No If Yes, Completed Yes No 12

13 Protection Orders Sought by Survivor: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Protection Orders Sought Against Survivor: Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Under order for weapons seizure Yes No Perpetrated Abuse Against Children Yes No Founded CPA by DHS Yes No Founded CPA by Other Sources Yes No Medical and Mental Health History: History of Substance Abuse Yes No Alcohol Yes No Illegal Drugs Yes No Specify Substance Abuse Treatment Yes No History of Mental Health Problems Yes No Mental Health Treatment Yes No If Yes, Diagnosis Medications Yes No If Yes, Type Medical/Physical Condition Yes No If Yes, Type 13

14 NOTES: 14

15 OTHER HOMICIDE VICTIM NUMBER DEMOGRAPHICS Perpetrator Outcome Suicide Attempted suicide Murder 1 Murder 2 Suicide Yes No Manslaughter Acquitted No charges filed Other Corner ID# Child Yes Age No Homicide Victim was (check one) DA Perpetrator DA Victim DA Victim & Perp DA Victim Child DA Perp Child Child of Both DA Victim New Partner DA Perp New Partner Other Full name: Residence: County of residence: Date of birth: Gender: Female Male County of death: Age at death: Education Level: <8 th 8 th - <12 th HS Graduate Some College/Tech School BA/BS >BA/BS Occupation: Race: Caucasian Hispanic Native American African American Asian American Other: INFORMATION ABOUT THE DEATH Pronounced Dead Date Time (military) Cause of Death: Gunshot wound to head Blunt trauma to head Multiple gunshot wounds Asphyxia Cranial cerebral trauma Traumatic stab wounds Other Multiple methods Method: Stabbing Beating Shooting Strangulation Other Multiple weapons Weapon: Knife Hands Firearm Other Multiple weapons Number of wounds Autopsy Evidence of Previous Injury Yes No List 15

16 Location of Incident Joint Residence Victim s residence Perp s residence Workplace Other Where body was found Ethanol Yes No If Yes, Level Other Drugs Yes No If Yes, Level Was a Sexual Assault Analysis Conducted Yes No If Yes Positive Negative Pregnant Yes No Not Applicable Trimester Not Applicable ABUSE HISTORY OF PARTY INVOLVED: Is this person in the index relationship (relationship with suspected abuse): Yes No Neither History of Abuse Behavior Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who History of Abuse by Homicide Perpetrator/Victim (depending on party involved) Physical Yes No If Yes, Previous Injuries? Yes No Documentation Medical Record Law Enforcement Family Other Emotional Yes No Sexual Yes No History of Abuse by Others Physical Yes No If Yes, Who Emotional Yes No If Yes, Who Sexual Yes No If Yes, Who Length of Relationship with Perpetrator/Victim (depending on party involved) No Relationship <1 year 1-<3 years 3-<5 years 5-<10 years 10+years End of Relationship/Separation Yes No If yes, How Long <1 week 1 week-1 month 2-3 months 4-6 months 7 months-1 year >1 year Evidence of Prior Stalking Against Homicide Perp/Victim Yes No 16

17 If Yes, Who Prior Homicide Threats Against Perp/Victim Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Homicide Threats Made by Perp/Victim Yes No If Yes, Heard by Victim Child Other Family Friends Other Prior Suicide Threats Yes No Prior Suicide Attempts Yes No Prior Police Calls Yes No If Yes, By Victim for Domestic Abuse? Yes No If Yes, Other Yes No If yes, specify Prior DA Services/Shelter Yes No Legal History of Party Involved: Prior Arrests Yes No Charges Burglary Substance Abuse DA Assault Sexual Crime Juvenile Crime Other Prior Incarceration Yes No Current Probation/Parole Yes No Prior BEP Yes No If Yes, Assigned Yes No If Yes, Completed Yes No Protection Orders Sought by Perp/Victim (depending on party involved): Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Protection Orders Sought Against Perp/Victim (depending on party involved): Current No Criminal Civil Previous No Criminal Civil Other Partner Yes No Under order for weapons seizure Yes No 17

18 Perpetrated Abuse Against Children Yes No Founded CPA by DHS Yes No Founded CPA by Other Sources Yes No Medical and Mental Health History: History of Substance Abuse Yes No Alcohol Yes No Illegal Drugs Yes No Specify Substance Abuse Treatment Yes No History of Mental Health Problems Yes No Mental Health Treatment Yes No If Yes, Diagnosis Medications Yes No If Yes, Type Medical/Physical Condition Yes No If Yes, Type NOTES: 18