Fourth Annual Report: January 2013 to December 2013 ‘History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again.’ Maya Angelou (1928–2014) Ng¯a mate aitu¯a o t¯atou Ka tangihia e t¯atou i t¯enei w¯a Haere, haere, haere. The dead, the afflicted, both yours and ours We lament for them at this time Farewell, farewell, farewell. Citation: Family Violence Death Review Committee, 2014. Fourth Annual Report: January 2013 to December 2013. Wellington: Family Violence Death Review Committee. Published in June 2014 by the Health Quality & Safety Commission, PO Box 25496, Wellington 6146, New Zealand ISBN 978-0-478-38571-7 (Print) ISBN 978-0-478-38575-5 (Online) This document is available on the Health Quality & Safety Commission’s website: www.hqsc.govt.nz For information on this report, please contact [email protected] Acknowledgements The Family Violence Death Review Committee is grateful to: • the advisors to the Family Violence Death Review Committee • the Mortality Review Committee secretariat based at the Health Quality & Safety Commission, particularly: Rachel Smith, Lead Coordinator, Family Violence Death Review Committee Brandy Griffin, Senior Policy Advisor Joanna Minster, Policy Advisor Dez McCormack, Mortality Review Committees’ Coordinator Shelley Hanifan, Manager • the Mortality Review Committees’ M¯aori Caucus • Irene de Haan, Chair of the Family Violence Death Review Committee regional panels • Lynn Sadler, epidemiologist at Auckland District Health Board and the University of Auckland • all of the Family Violence Death Review Committee regional panel members, and particularly the time, commitment and work of the participating agency members to gather and prepare agency records for the death reviews. The Family Violence Death Review Committee also thanks the people who have lent their assistance and expertise to the writing of this report. FAMILY VIOLENCE DEATH REVIEW COMMITTEE FOURTH ANNUAL REPORT JANUARY 2013 TO DECEMBER 2013 1 2 Foreword Violence within families has serious long-term social effects and a profound impact on the health of all concerned, even in those cases not resulting in death. Addressing family violence is an issue of great concern to all New Zealanders and is therefore of particular importance to the Health Quality & Safety Commission. I welcome the Family Violence Death Review Committee’s fourth annual report and commend the Committee for its dedication and commitment to shining a light on matters of such significance to society. The report sets out information, findings and recommendations from data on all family violence homicides in the four years from 2009 to 2012, and from in-depth regional reviews of 17 family violence death events. It goes beyond previous reports. For the first time, the pattern of violence has been included in the analysis of all family violence deaths, which better addresses the context in which these distressing events occur. This broader brush provides insights into the responses required to prevent future deaths. The report suggests the family violence workforce needs to think differently if it is to respond effectively and safely to people living with family violence. It recommends improved family violence training, a stronger response to risk factors, and changes in legislation to better support those victimised by family violence. Normalising or minimising family violence fails people who are at risk of being killed. The report advocates campaigning to encourage safe and effective interventions by friends, family, neighbours and workmates. The report has a strong focus on children, and the impact family violence has on them. In particular, it calls for more support for children left behind after their parents, caregivers, brothers or sisters have been killed by family members. Some of these circumstances are just horrifying: one parent dead, and the other in prison, for example. The Committee and its Chair, Associate Professor Julia Tolmie, have engaged with the many individuals and groups involved in responding to family violence. Those consulted during the preparation of this report include people who have lost family members through family violence. It is very pleasing to see the broad level of support for the Committee’s recommendations for change. This report calls for families, communities and organisations in New Zealand to challenge the unacceptable levels of intergenerational violence in our families, and to work towards the prevention of further deaths and the development of a gentler and more functional culture in which all our children can grow up safely. Professor Alan Merry ONZM Chair, Health Quality & Safety Commission June 2014 FAMILY VIOLENCE DEATH REVIEW COMMITTEE FOURTH ANNUAL REPORT JANUARY 2013 TO DECEMBER 2013 3 4 Chair’s introduction In 2013, the Family Violence Death Review Committee (the Committee) set up the last of its five regional death review panels. The Committee’s tier two regional death review process is now fully operational nationally. In addition, the Committee continued to conduct regional death reviews – completing eight in-depth reviews in 2013. These reviews add to the rich body of qualitative information the Committee has been compiling about how the social sector responds to the most dangerous and chronic cases of family violence in Aotearoa New Zealand. The tier one database – which will store general information about every family violence death in Aotearoa New Zealand – has also been designed and will be built in 2014. The social sector that responds to family violence consists of a wide range of governmental and non-governmental agencies and individuals, each of whom will have different pieces of information, engagement with different family members, different disciplinary mindsets and different powers, cultures, capabilities, capacities and constraints. Furthermore, practitioners working in the family violence crisis response sectors often make decisions in dynamic situations characterised by uncertainty and risk. Their everyday work environment generally includes large and complex caseloads, along with stretched or limited resources. Complexity and ambiguity can never be eliminated with the result that responding to family violence is not amenable to simplistic thinking or simple solutions. As described in this report, the purpose of the family violence death review process is to consider how we can strengthen the resilience of the multi-agency family violence system so it can respond more effectively in the face of this complexity. Whilst the Committee strongly supports primary prevention strategies for addressing family violence, the death reviews show that, for a number of New Zealanders, violence has always been present in their lives. Children are conceived and born into families that are already characterised by dangerous abuse. Some women and children are living amidst gang cultures and are at risk of experiencing more frequent and extreme violence from abusive gang-affiliated partners, as well as greater levels of entrapment. If we are to be serious about tackling family violence then, in addition to developing primary and secondary prevention strategies, there is the need for an effective systemic response to chronic violence that works for all New Zealanders, and specifically those represented in our findings. The Committee notes that practitioners, as well as family and community members, are at risk from the unacceptably high incidence and seriousness of family violence in Aotearoa New Zealand. For practitioners working within New Zealand Police, Child, Youth and Family and the Department of Corrections, for example, the abuse of children and adults is such a regular occurrence that it can be unintentionally normalised and minimised. The challenge for senior managers is to proactively ensure that, within their workforce, the unacceptable does not become acceptable. Whilst the deaths from family violence documented in this report are small in number compared to some other types of death under review by companion committees (such as fetal and neonatal deaths), they are costly and largely preventable deaths. They also represent an undercount of even the most chronic cases of family violence. For example, Jacqueline Campbell1 makes the point that for every intimate partner violence (IPV) homicide that occurs there are approximately eight or nine attempted IPV homicides. Captured in this report, although not counted in our core data on family violence deaths, are suicides by family violence homicide offenders when these take place immediately after the death event. Not captured are suicides by victims of family violence. 1 J. Campbell and A.D. Wolf, Guns and Domestic Violence Homicide, Unpublished presentation reporting on findings of Multi City Intimate Partner Femicide Study, Johns Hopkins University School of Nursing, n.d. FAMILY VIOLENCE DEATH REVIEW COMMITTEE FOURTH ANNUAL REPORT JANUARY 2013 TO DECEMBER 2013 5 We note that the impact of the deaths goes well beyond the individual victims involved. For example, the 37 children who were killed by a family member between 2009 and 2012 had 55 siblings and half-siblings and there were 21 children of the offenders who were not related to the children who died. Over the same four years, a further 164 children or step-children lost a parent through fatal IPV. These are the children we know about – the actual number is likely to be higher. These 240 children may well have also been victims of abuse and must now