Domestic Violence Fatality Review Team

Chattanooga Family Justice Alliance
300 East 8th Street, Chattanooga, TN 37403
423-757-2386 E-Mail: charlotte@dvcchatt.orgThis e-mail address is being protected from spambots, you need JavaScript enabled to view it


Annual Report 2007

Team Structure

The Domestic Violence Death Review Team was implemented in January, 2007 and consists of 12 members as outlined in TCA § 36-3-624. Enabling statutory language lists a number of agencies that are required to be represented and the Hamilton County team includes representatives from those entities. The goal in structuring the team was to have multidisciplinary representation and perspective. A representative from the Tennessee Department of Children’s Services was added in order to enable the team to follow child witnesses to abuse who may have entered their system. The project was created and implemented without support of paid staff. It is chaired by the Eleventh Judicial District Attorney General.

36-3-624. Death review teams established – Protocol – Composition of teams – Disclosure of communications – Authority to subpoena.  
  (a) A county may establish an interagency domestic abuse death review team to assist local agencies in identifying and reviewing domestic abuse deaths, including homicides and suicides, and facilitating communication among the various agencies involved in domestic abuse cases.    
(b) For purposes of this section, “domestic abuse” has the meaning set forth in § 36-3-601.    
  (c) A county may develop a protocol that may be used as a guideline to assist coroners and other persons who perform autopsies on domestic abuse victims in the identification of domestic abuse, in the determination of whether domestic abuse contributed to death or whether domestic abuse had occurred prior to death but was not the actual cause of death, and in the proper written reporting procedures for domestic abuse, including the designation of the cause and mode of death.    
  (d) County domestic abuse death review teams may be comprised of, but not limited to, the following  
  (1) Experts in the field of forensic pathology
  (2) Medical personnel with expertise in domestic violence abuse
  (3) Coroners and medical examiners;  
  (4) Criminologists;    
  (5) District attorneys general and city attorneys;    
  (6) Domestic abuse shelter staff;    
  (7) Legal aid attorneys who represent victims of abuse;    
  (8) A representative of the local bar association;    
  (9) Law enforcement personnel;    
  (10) Representatives of local agencies that are involved with domestic abuse reporting;    
  (11) County health department staff who deal with domestic abuse victims’ health issues;    
  (12) Representatives of local child abuse agencies; and    
  (13) Local professional associations of persons described in subdivisions (d)(1)-(10), inclusive.    
  (e) An oral or written communication or a document shared within or produced by a domestic abuse death review team related to a domestic abuse death is confidential and not subject to disclosure or discoverable by a third party. An oral or written communication or a document provided by a third party to a domestic abuse death review team is confidential and not subject to disclosure or discoverable by a third party. Notwithstanding the foregoing, recommendations of a domestic abuse death review team upon the completion of a review may be disclosed at the discretion of a majority of the members of a domestic abuse death review team.    
  (f) To complete a review of a domestic abuse death, whether confirmed or suspected, each domestic abuse death review team shall have access to and subpoena power to obtain all records of any nature maintained by any public or private entity that pertain to a death being investigated by the team. Such records include, but are not limited to, police investigations and reports, medical examiner investigative data and reports, and social service agency reports, as well as medical records maintained by a private health care provider or health care agency. Any entity or individual providing such information to the local team shall not be held liable for providing the information.  
  [Acts 2000, ch. 788, § 1.]    

Chattanooga Family Justice Alliance Death Review Team Members include:
District Attorney General- Bill Cox

Physician – U.T. Medical Units: Ron Blankenbaker, M. D.

Hamilton County Medical Examiner – Frank King, M. D.

Criminologist – Roger Thompson, Ph. D

Coalition President! Alliance Coordinator – Charlotte Boatwright, Ph. D

Legal Aid Attorney – Cathy Allshouse, Esq

Law Enforcement – Lt. Tim Carroll, Sgt. Jerome Halbert (CPD); Alan Branum – (HCSD), Det. Chris Chambers

Family Violence Shelter – Regina McDevitt, M.Ed.

Child Abuse – Children’s Advocacy Center: Jennifer Mitchell

Chattanooga, Hamilton County Health Department – Diana Kreider, R.N.

Other professionals may be called in for specific cases when appropriate

Case Selection

Cases selected for review by the team were closed to further legal activity including opportunities for appeal. All cases such as a homicide/suicide where no criminal prosecution would take place were at least one year old when they were reviewed. This policy was based on recommendations of several jurisdictions that were well versed in the review process. In their experience, letting time pass after the incident allowed some of the emotion and tension to dissipate, allowing for more open and honest discussion during case reviews.

The Team reviewed twelve cases during 2007, three at each meeting. Detectives from Chattanooga Police Department and Hamilton County Sheriff’s Department randomly selected cases and prepared them for presentation. Homicide/suicide cases were included since these cases comprise a significant portion of domestic homicides.

Case Review Process

After a case was selected for review, it was presented to the team in the CFJA Case Review Summary Report format. Some cases were presented in PowerPoint format and included case description and crime scene photos which made the cases more real for the team. Usually police and prosecution files provided information sufficient to identify other agencies that may have records that were important in reviewing the case.

Each Review Team meeting started with members signing a confidentiality agreement. Officers who prepared the cases for review presented them and reported findings. The team reviewed cases using questions for review to identify areas where different interventions may have resulted in different outcomes. They identified areas where interventions may have failed and they also identified successful interventions. The Review Team identified key issues and recommendations related to each case and issues that required further investigation. Members were allowed the opportunity to discuss their views in regard to the cases.

Things to remember while reading this report

• The perpetrator is solely responsible for the homicide. All members of the project recognize that regardless of changes that could have been made or may in the future be made by agencies or individuals, the responsibility for the homicide rests with the person who committed the crime. There is no room in the fatality review process for blaming anyone for the outcome in the case. Every individual who participated in this process did so in an effort to learn from the tragedy and to improve performance of staff and agency policies related to domestic violence.

• Many incidents reflected exemplary responses to domestic violence both inside and outside the justice system.
Since the report is geared toward addressing areas that need improvement, it may appear more negative than was the Team’s experience in reviewing the cases. Cases often revealed exemplary response to domestic violence.

• Every finding identified in the report is prompted by a specific homicide case or cases.
Many of the Review Team members had extensive experience with domestic violence cases. Consequently,
there was a temptation to draw on that broader experience when identifying the findings. The Team believed that one of its most important functions was to identify the types of issues that are a factor in domestic homicide cases as compared to more general concerns in the area of domestic violence. There were significant advantages to having multiple disciplines together to discuss cases and different perspectives raised varying questions. The team decided to make all findings case-based. Those working in the domestic violence field will not be surprised by many of the findings or opportunities for improvement identified by the Team. The Team hopes, however, that these issues take on greater importance since they are linked to actual deaths of persons in real cases reviewed.

• Findings are primarily based on information in official reports and records about the parties before and after the homicide.
Findings of the Review Team are limited to the availability of information reported in and from available sources. In many cases, questions arose that could not be answered by available information sources, such as how the case impacted surviving children in the years following the homicide. The Team occasionally used assumptions when it believed certain actions may have been taken but could not locate specific details in documents or interviews to support an assumption. The Team did not have resources to go to extraordinary means to locate documents.

• Findings should not be used as an indicator of lethality.
Much has been written on the subject of lethality assessment. Many of the scenarios that occurred in these cases may be present in cases that do not become lethal. The Review Team does believe, however, that many of the findings are indicators of the level of potential danger to the victim.

• The Team has identified “opportunities for intervention.” Since reviews are based only on cases arising in Hamilton County, suggestions for best practices should be considered for local use only.

• Perpetrators are referred to with male pronouns. In nine of the twelve cases reviewed, the person who committed the homicide(s) was male. According to the Bureau of Justice Statistics, over 90 percent of domestic homicides are committed by males against their female intimate partners; therefore the Review Team felt it was appropriate to use male pronouns when referring to perpetrators.

• The dates of the cases reviewed ranged from 1992 to 2006. The Review Team acknowledges that most agencies have made or are in the process of making changes in procedure and protocols since these homicides occurred. Observations made are based on review of actual case histories, so the Review Team believes its observations will benefit not only involved Hamilton County agencies in effecting change but others throughout the area who review this report.

• We will never know if any of these deaths could have been prevented if recommended interventions in this report had been implemented. In most instances, however, there would have been an improved response to the danger that existed in the relationship or in the response.

Opportunities for Intervention
Review Team members spent hours preparing, discussing and digesting volumes of information generated by case reviews. One of the most difficult tasks was to begin to identify and agree upon key categories to organize the many issues identified in a manner that could be easily read and understood. One team member developed a spread sheet to categorize categories to enable the Team to better examine data. Like many complex social issues, matters surrounding domestic violence and the homicides related to it cannot be neatly categorized.
Many issues overlap and wind their way in and out of case scenarios. The Team has done its best to structure this section in a way that will assist the reader in understanding the issues identified in the case reviews. Four main categories were identified to capture opportunities for intervention. A fifth category was added to absorb
opportunities that did not fit into the other sections. The sections are:

• Perpetrator Violence and Records
• Involvement of Children
• Treatment and Mental Health Issues
• Justice System Performance
• Other Opportunities for Improvement



  1. Many perpetrators have a history of abuse in previous relationships. Law enforcement and prosecutor’s office need better access to records for review to determine history of assault, stalking and property damage. There is a great need to improve historical review of records to determine trends.
  2. It is important to seek records from other states (NCIC) to determine a pattern of family violence. Interstate Identification Index (III) provides records of DV arrests. Wider use should be made by judges and magistrates of these records for arrest, setting bond, probation and conditions of release.We recommend that access be made available for magistrates after business hours.
  3. We recommend better breakdown and use of the Case Summary used by the team to look for patterns in domestic violence in Hamilton County. Explore sources for broader scope of information, i.e., juvenile records, DCS files, parent’s names, etc.
  4. Cases should be reviewed prior to presentation to the team to determine if supporting files will be needed for the for the review.
  5. Joint city and county authority is needed to obtain accurate data from all justice system agencies and bring information together in a meaningful way. Funding is needed for a research analyst who can organize statistics together so that we can identify trends and make recommendations based on solid data.
  6. We need to develop systems that provide better data depicting patterns of domestic violence in Hamilton County. We need to capture information such as cases where children are involved, what patterns when intervention could prevent escalation of domestic violence.


  1. Children often witness the death of parent. We recommend follow up on children to determine how witnessing abuse in the home impacts their success in school, relationships, behavior, etc.
  2. Therapy for children who witness abuse requires specially trained professional therapists and is unavailable in Hamilton County. Efforts should be made to make assessment and treatment available for these children in order to end the cycle of abuse in families.
  3. Most cities the size of Chattanooga have a supervised visitation center for children and parents when needed to provide a safe place for visits and transfer of children between parents. We recommend that a supervised visitation center be developed locally as the nearest one is in Lafayette, Georgia.


  1. Medical records should be part of the criminal record. While we recognize that HIPPA restrictions create problems with getting records, we often need to determine whether the victim has sought medical attention in Emergency Rooms, Urgent Care Centers or physician’s offices.
  2. We recommend addition of a liaison to check with local hospitals about how to access records, locate medical records resource persons in the major area hospitals and formalize an agreement to access information for presentation for the team to use in review of cases similar to the process used in Child Death Review. We have added a representative from a major health insurance company on the Chattanooga Family Justice Alliance Health Care Task Force.
  3. Mandatory reporting with appropriate immunity (such as the Child Abuse Reporting law) by health care providers is needed. We recommend implementation of such legislation in the next legislative session.


  1. We recommend education about domestic violence for all parts of the judicial system.
  2. We suggest compliance with established courts protocols is necessary to ensure consistency in disposition of cases and give the message that domestic violence is a crime.
  3. When counseling is ordered by the court or is included as part of conditions for release, we recommend creation of a mechanism to ensure a coordinated effort between courts and therapist to communicate progress.
  4. We recommend that perpetrators only be mandated to treatment in state certified batterer intervention programs.
  5. We recommend judicial review every 30 days when counseling is required in order to determine compliance with remedies outlined in the court protocol that will be applied if the perpetrator is found to be non-compliant.
  6. We recommend that the Courts Protocols Task Force develop protocols for judicial review and for follow up of cases where counseling is mandated in domestic violence cases.
  7. Access to weapons is a powerful risk factor for family violence. If conditions are being lifted, it is recommended that the order be maintained to allow no weapons in the residence. This recommendation should be conveyed to judges and magistrates. We suggest that Judges and magistrates use every legal procedure to ensure that convicted perpetrators of abuse do not have access to firearms or other lethal weapons.
  8. We recommend statutory change that would require that all firearms seized by law enforcement upon issuance of an Order of Protection be held until such time as the order is no longer in force. Handgun permits are still authorization to carry. The courts should have authority to revoke any handgun permit. In domestic violence cases, revocation should be automatic.
  9. It is recommended that all law enforcement agencies in Hamilton County train officers on the Hamilton County protocols and enforce their implementation and use throughout each jurisdiction.
  10. We recommend that each jurisdiction have input to the annual review and evaluation of the law enforcement protocol.
  11. We recommend that a risk assessment be included in the protocol and used by all law enforcement officers to assess lethality at all domestic violence arrests.
  12. We recommend that judges and magistrates use lethality indicators for setting bond. (Jacqueline Campbell Lethality Assessment recommended)
  13. We recommended that a safety plan and acknowledgement of receipt of a listing of victim’s rights and resources available in the community be signed by and given to the victim with a copy included in the police file.
  14. In compliance with TCA § 36-3- 615 requiring victim notification of release of perpetrator, it is recommended that jail staff document and make a phone call to the victim prior to release of the perpetrator. (New system to be installed in 2008 to provide automated victim notification)


  1. We recommend resources be allocated for educating business and industry about family violence, its cost and impact on their business and the need to be proactive in order to reduce costs. We also need to emphasize and educate in regard to the relationship between family and workplace violence and encourage employers to develop programs to provide support and referral for victims of abuse. Employers often serve as resources for information. One victim wrote to her employer about her abuse. If the employer had had a program in place to assist abuse victims, the tragic outcome in her case could possibly have been altered.
  2. We recommend that we engage support from the Chamber of Commerce to put hotline numbers and other resource information in workplaces and funding is needed to assist workplaces in developing protocols for use when an employee is being abused or a perpetrator is identified as an employee.
  3. We recommend allocation of local government funding for a public relations campaign to increase professional and public awareness about domestic abuse. Education about abuse and its impact is important to all segments of the population. Information about available resources should be readily available in the community. Public service announcements (PSA’s), billboards and print ads should be running regularly. We must provide for education and public awareness to make all people knowledgeable about the damaging impact of abuse and how to assist victims.
  4. We recommend that information about community resources and referral information about domestic violence be made available to every person who can make referrals.
  5. We recommend that resources be made available to make victim advocates available to all victims in the courts prior to criminal hearing. Education of victims is necessary to make them aware of potential lethality in their situations.
  6. Safety issues should be addressed in the courts. Space should be allocated for advocates to meet with victims and for victims to be seated in a separated area from alleged perpetrators to await court hearings.
    Several cases reinforced the need for safety planning, whether victims plan to stay or leave abusive relationships. We recommend that we redouble our efforts to make the hotline number and safety plans more readily available and educate the public about how to seek help with safety planning.
  7. We recommend that information about community resources such as the hotline number, Coalition web site and safety plans be made available anytime law enforcement is called to the scene or when victims come to court for civil or criminal hearings related to family violence.
  8. We recommend that resources be made available for education about family violence, the likelihood of being a victim and information about what to do if family violence is witnessed in the community.

Approved on 3 June, 2008

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