Collection of data

Since its inception in 2003, a variety of data has been collected from homicide cases involving domestic violence that have been investigated by the Office of the Chief Coroner. As the committee has evolved, so too have the processes for reviewing, collecting and analyzing information that has been obtained. The DVDRC strives to provide information and analyses that are accurate, valid and useful to relevant stakeholders.

Types of data

It is important to recognize that there are two separate and distinct sets of data relating to domestic violence homicides in Ontario:

  1. Data relating to the actual number of homicide cases where domestic violence has been identified as an involvement factor.

In Ontario, a Coroner’s Investigation Statement (Form 3) is prepared for all cases investigated by a coroner. The Form 3 includes basic personal information (e.g. date of death, age, address, etc.) pertaining to the deceased, as well as a narrative that describes the circumstances surrounding the death.  Investigating coroners are encouraged to identify death factors (e.g. trauma – cuts-stabs, shooting – shotgun, asphyxia-hanging, etc.) and involvement factors (e.g. abuse – domestic violence, alcohol involvement, Children’s Aid involvement, etc.).  The Form 3 also identifies the ‘manner of death’ or ’by what means’ the death occurred.  In Ontario, manner of death must be classified as one of the following:  natural, accident, suicide, homicide or undetermined. Information from the Form 3, for all coroners’ investigations, is maintained within the electronic Coroner’s Information System (CIS) maintained by the Office of the Chief Coroner.

Statistics generated for the purposes of this annual report reflect a 16-year period of cases occurring from 2002-2017 where: ’homicide’ has been identified as the manner of death for at least one victim; ‘abuse – domestic violence’ has been identified and coded as an involvement; and the case meets the DVDRC’s definition of a domestic violence death.  Some cases, where the manner of death is ‘undetermined’ and where there is involvement of domestic violence, are included in the data set.

It is important to note that some homicide cases identified with the ‘abuse – domestic violence’ involvement code occurring between 2002-2017 may still be pending review by the DVDRC. In many cases, DVDRC reviews have not commenced because legal or other proceedings are still underway or pending. The number of pending cases has been significantly reduced due to a concerted effort by the DVDRC to review outstanding cases. 

  1. Data relating to the findings of cases that have been reviewed by the DVDRC.

The second set of data relates to cases that have undergone review by the DVDRC. This data would include information pertaining to risk factors, type and length of relationship and number/sex of victims and perpetrators. This data is collected in the thorough review conducted by the DVDRC.

The following statistics reflect the findings of analyses of the two different data sources.

Statistical overview: Homicides with domestic violence involvement (2002-2017)

 The following statistics relate to homicides in Ontario occurring between 2002-2017 where ‘abuse – domestic violence’ has been identified as an involvement code, and that meet the DVDRC’s definition of a domestic violence death. Some of these cases may have already undergone review by the DVDRC while others are pending review upon completion of other proceedings (e.g. criminal trials).

Chart one:  Homicides in Ontario with domestic violence involvement code (2002-2017)

Chart One
 2002200320042005200620072008200920102011201220132014201520162017Totals 2002-2017
Number of cases30222329362820202530222418212220390
Homicides19181421291815151922131911141617280
(72%)
Homicide-Suicides114987105568957763110
(28%)
Total number of Deaths46263337534529303238323029303023543
Total number of Homicide Victims35222429463524252630232522232420433
(80%)
Female (adult)26192129282920202127192213211717349
(81%)
Female (child)411080031000202022
(5%)
Male (adult)412034424333325144
(10%)
Male (child)110072000010400218
(4%)
Average age of Homicide Victim35.934.939.838.227.434.943.337.236.54445.337.729.440.143.843.438.2
Total number Perpetrator deaths (suicide or other)114987105568957763110
(20%)
Female (adult)00100100000000103
(3%)
Male (adult)11488795568957753107
(97%)
Average age of Deceased Perpetrator48.545.542.24551.145.243.86044.750.859.64147.15842.568.349.6

 Chart One: Summary

  • There were 390 domestic homicide and/or homicide-suicide cases that occurred in Ontario between 2002-2017 (based on cases investigated by the Office of the Chief Coroner for Ontario, where domestic violence was identified as an involvement code). 
  • Of those 390 cases, 280 (72%) were homicides and 110 (28%) of the cases were homicide-suicides.
  • The 390 cases resulted in a total of 543 deaths. 
  • Of the 543 deaths, 433 (80%) were homicide victims and 110 (20%) were perpetrators who committed suicide or were otherwise killed (e.g.shot by police).
  • There was an average of 24 domestic homicide and/or homicide-suicide cases per year from 2002-2017. Some of these cases may have included multiple victims.
  • There have been 433 domestic homicide victims from 2002-2017.
  • There was an average of 27 domestic homicide victim deaths per year from 2002-2017.
  • Of the 433 homicide victims, 349 (81%) were adult females, 40 (9%) were children and 44 (10%) were adult males.
  • Of the 110 perpetrator deaths, 107 (97%) were adult males.
  • The average age of homicide victims was 38.2 years.
  • The average age of perpetrators who died was 49.6 years.

Graph One:  Number of DV cases based on year (2002-2017) in Ontario – based on cases with DV involvement code in Coroner’s Information System

  • Graph One shows the number of domestic violence cases that occurred per year from 2002-2017.  The number of case occurrences per year has varied from 18 cases in 2014 to 36 cases in 2006.  Some cases may involve multiple victims.  There was an average of 24 domestic homicide and/or homicide-suicide cases per year from 2002-2017.

Graph Two:  Number of DV Homicide Victims (2002-2017)

  • Graph Two shows the number of domestic violence homicide victims per year from 2002-2017.  The number of homicide victims per year has varied from 20 in 2017 to 46 in 2006.  There was an average of 27 domestic homicide victim deaths per year from 2002-2017.

Death factors

Death factors are utilized within the Coroner’s Information System (CIS) to assist with data retrieval/extraction and analysis. Death factors describe the underlying mechanism or force responsible for non-natural deaths (e.g. trauma – motor vehicle collision) or the anatomical area or system involved for natural deaths (e.g. cardiovascular system, central nervous system). Coroners are encouraged to identify the death factor most appropriate to the circumstances of the situation, and which lead to the fatal injuries sustained by the victim.

Chart Two illustrates the death factors most commonly cited in domestic violence deaths (homicides and perpetrator deaths) identified in the CIS from 2002-2017.

Chart Two:  Top death factors in dDomestic violence deaths (2002-2017) based on CIS data

Chart Two
Death Factor2002200320042005200620072008200920102011201220132014201520162017Total DV Deaths (2002-2017)Percent of Total DV Deaths (2002-2017)
Trauma - cuts, stabs158119211481116156121398718334%
Trauma - beating, assault5445620033240303448%
Shooting - handgun85241913316422766412%
Shooting - rifle2035533212000530346%
Shooting - shotgun7122221260562401438%
Shooting - weapon (not specified)001000100000000020%
Asphyxia - airway obstruction0110010112100301122%
Asphyxia - strangulation0355644003311111387%
Asphyxia - neck compression0001202300011010112%
Other94461010982129210310411221%
Total46263337534529303238323029303023543

Note: percentages are rounded off.

Note: includes all deaths, including perpetrator suicides.

Summary of Chart Two: Top Death Factors in Domestic Violence Deaths (2002-2017)

  • Trauma (i.e. cuts/stabs and beating/assault) was a death factor in 42% of the deaths.
  • Shooting (i.e. handgun, rifle, shotgun or gun not specified) was a death factor in 26% of the deaths.
  • Asphyxia (i.e. airway obstruction, strangulation and/or neck compression) was a death factor in 11% of the deaths.
  • Other death factors such as:  trauma by motor vehicle, train/vehicle or blunt force, asphyxia from hanging, anoxic environment and carbon monoxide,  drug toxicity, jump/fall, fire with smoke inhalation or thermal injury, and burns–thermal drowning, were present in 21% of the deaths.

Statistical overview: Cases reviewed by the DVDRC (2003-2018)

From 2003-2018, the DVDRC has reviewed 329 cases that involved a total of 470 deaths.  Reviews are conducted by the DVDRC only after all other investigations and proceedings – including criminal trials and appeals – have been completed. As such, DVDRC reviews often take place several years after the actual incident. 

The following statistics relate to all cases reviewed by the DVDRC from 2003-2018 inclusive.

Chart Three:  Number of Cases Reviewed by the DVDRC (2003-2018)

Chart Three
YearNumber of cases reviewed# of deaths involvedCase type: HomicidesCase type: Homicide -Suicides
2003112438
200491154
2005141959
2006132149
2007152578
20081517132
20091625610
20101836612
20113341276
20122032146
20131922172
20141415131
2015 Full2129129
2015 Executive4957463
201622361111
201722351210
20181825153
Total329470216 (66%)113 (34%)

Note: In 2015, a dedicated effort was made to address the accumulation of pending cases awaiting review by the DVDRC. All of the pending cases (49 in total), underwent “executive review” by a core team of representatives of the DVDRC. The executive review included a thorough analysis of the circumstances surrounding the deaths and compilation of risk factors identified in each case. None of the executive reviews conducted resulted in recommendations. 

Summary of Chart Three: Number of Cases Reviewed by the DVDRC (2003-2018)

  • In the period between 2003 and 2018, the DVDRC reviewed 329 cases, involving 470 deaths (including perpetrator suicides).
  • Of the 329 cases, 216 (66%) were homicides and 113 (34%) were homicide-suicides.

Analysis of Risk Factors: Common Risk Factors

Based on extensive research, the DVDRC has created a list of risk factors that indicate the potential for lethality within the relationship examined. For a number of years, 40 risk factors were assessed. In 2017, the additional risk factor of victim vulnerability was added to make 41 risk factors. The recognition of multiple risk factors within a relationship potentially allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence through appropriate interventions by criminal justice system and healthcare partners, including high risk case identification and management.

A complete list of all risk factors analyzed, as well as the definition of each, is included in Appendix B

When reviewing a case, the DVDRC identifies which, if any, of the 41 risk factors were present in the relationship between the victim and the perpetrator.

Graph Three: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2018)

Summary of Graph Three: Frequency of Common Risk Factors in DVDRC Cases Reviewed (2003-2018)

  • When reviewing a case, the DVDRC identifies which of the 41 established risk factors were present in the relationship between the perpetrator and the victim.
  • In 71% of all cases reviewed from 2003-2018, there was a history of domestic violence (past or present).
  • In 67% of the cases, the couple had an actual or pending separation.
  • In 50% of the cases, the perpetrator was depressed (diagnosed and/or undiagnosed).
  • In 46% of the cases, obsessive behaviour was displayed by the perpetrator.
  • In 44% of the cases, the perpetrator had threatened or attempted at suicide.
  • In 43% of the cases, the victims had an intuitive sense of fear.
  • In 39% of the cases, the perpetrator displayed sexual jealousy.
  • In 36% of the cases, there were prior threats to kill the victim.
  • In 40% of the cases, excessive alcohol and/or drug use was involved.
  • In 39% of the cases, the perpetrator was unemployed.
  • In 33% of the cases, there was a history of violence outside of the family.
  • In 33% of the cases, there was an escalation of violence.
  • In 29% of the cases there was an attempt to isolate the victim.
  • In 30% of the cases there was an actual or perceived new partner in the victim’s life.

Note: includes all reviews, including executive reviews in 2015

Analysis of risk factors: Number of risk factors per case

Chart Four: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2018), demonstrates that 70% of all cases reviewed by the DVDRC had seven or more risk factors identified. The significance of this finding is that many domestic homicides may have been predicted and prevented with earlier recognition and action towards identified risk factors for future lethality.

Chart Four:  Number of Risk Factors per Case – All DVDRC Cases Reviewed (2003-2018)

Chart Four
Number of risk factors per case2003-2017 (n=311)2018 (n=18)2003-2018 (n=329)Percent of total cases
no factors4041%
1 to 3 factors4134413%
4 to 6 factors4645015%
7 or more factors2201123170%

The percentage of total cases based on number of risk factors is shown in a pie graph in Graph Four: Percent (%) of cases based on number of risk factors per case – All DVDRC cases reviewed (2003-2018).

Graph Four:  Percent (%) of cases based on number of risk factors per case – All DVDRC cases reviewed (2003-2018)

Summary of Chart Four and Graph Four: Number of Risk Factors per Case – All DVDRC cases reviewed (2003-2018)

  • In 70% of the cases reviewed from 2003-2018, seven or more risk factors were identified.
  • In 15% of the cases reviewed from 2003-2018, four to six risk factors were identified.
  • The combined proportion of cases with four or more risk factors was 85%.
  • In 13% of the cases reviewed from 2003-2018, one to three risk factors were identified.
  • In 1% of the cases reviewed from 2003-2018, no risk factors were identified.
  • The recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence.

Statistical overview: Cases reviewed by the DVDRC in 2018

The DVDRC  conducted 18 full case reviews in 2018 – 15 homicide and three homicide-suicide cases, resulting in a total of  25 deaths (22 homicide victims and three perpetrator suicides).

A detailed summary, including the type of case (i.e. homicide or homicide-suicide) age and sex of victims and perpetrators, number of risk factors and relevant themes for each, is included in Appendix C.

A brief narrative on the circumstances surrounding the death(s), as well as recommendations towards the prevention of future similar deaths, is included in Appendix D.

Full, redacted versions of individual cases reviewed by the DVDRC in 2018  may be requested directly from the Executive Lead, Committee Management at the Office of the Chief Coroner:  occ.inquiries@ontario.ca

Chart 5 – Summary of Cases reviewed in 2018

Chart Five
Cases ReviewedNumber of cases
Total number of cases reviewed:18
# of homicide cases15
# of homicide-suicide cases3
Total number of deaths reviewed:25
Homicide deaths:22
Homicide Female (adult)13
Homicide Female (child)2
Homicide Male (adult)5
Homicide Male (child)2
Average age of victim:39.3
Suicide deaths:3
Suicide Female0
Suicide Male3
Average age of all perpetrators:44
# of male perpetrators14
# of female perpetrators4
# of cases with less than 7 risk factors:7
# of cases with 7 or more risk factors:11
Average number of risk factors:7.5
# of cases involving age 65 or older:2
Homicide-suicides w/elderly1
# of cases involving Indigenous peoples3
# of recommendations made:28

Chart 5 – Summary of Cases reviewed in 2018, demonstrates that:

  • There were 18 case reviews conducted by the DVDRC in 2018. This included 15 homicide cases and three homicide-suicide cases, resulting in 25 deaths (22 homicide victims and three perpetrator suicides).
  • As a result of these reviews, there were 28 recommendations made towards the prevention of future similar deaths. 
  • Of the 22 homicide victims in the cases reviewed, 13 (59%) were adult females, five (23%) were adult males, two (9%) were female children and two (9%) were male children.  
  • Of the 18 cases, 14 (78%) involved male perpetrators and four (22%) involved a female perpetrator. 
  • In 11 (61%) of the cases, seven or more risk factors were identified.
  • The average number of risk factors identified in cases reviewed in 2018 was 7.5.

Further analysis of the cases reviewed in 2018 demonstrated that:

  • The victims ranged in age from four to 82 years.
  • The average age of victims was 39.3 years.
  • The perpetrators ranged in age from 23 to 82  years.
  • The average age of perpetrators (deceased and living) was 44 years.
  • The number of risk factors for individual cases ranged from one to 17.
  • There were three cases involving individuals (either victims and/or perpetrators) that identified as Indigenous.

Analysis of risk factors: Number of risk factors per case

The data in Chart Six:  Number of Risk Factors Identified in Cases Reviewed (2018), are consistent with the findings with all cases reviewed by the DVDRC from 2003-2018 which clearly demonstrates that the vast majority of cases resulting in domestic homicide or homicide-suicide, had a significant number of risk factors (i.e. seven or more) and therefore were potentially predictable and preventable. It is important to again stress that the recognition of multiple risk factors within a relationship allows for enhanced risk assessment, safety planning and possible prevention of future deaths related to domestic violence. The number of risk factors for cases reviewed in 2018 ranged from one to 17.

For a number of years, 40 risk factors were assessed for each case reviewed. In 2017, the additional risk factor of victim vulnerability was added to make 41 risk factors. 

A complete list of all risk factors analyzed, as well as the definition of each, is included in Appendix B

Chart Six:  Number of Risk Factors Identified in Cases Reviewed (2018)

Chart Six
# and % of risk factors per case2018 Reviews (n=18)Total Reviews
2003-2018
(n=329)
no factors04
%(0)(1%)
1 to 3 factors344
%(17%)(13%)
4 to 6 factors450
%(22%)(15%)
7 or more factors11231
%(61%)(70%)

Chart Six breaks down the number of identified risk factors in the cases reviewed in 2018 and compares them to the number of risk factors for all cases reviewed from 2003-2018.

The chart indicates that:

  • In 2018, no cases had zero risk factors identified.  This compares to 1% of all cases reviewed from 2003-2018.
  • In 2018, three (17%) cases reviewed had one to three risk factors identified. This compares to 13% of all cases reviewed from 2003-2018.
  • In 2018, four (22%) cases reviewed had four to six risk factors identified. This compares to 15% of all cases reviewed from 2003-2018.
  • In 2018, 11 (61%) of cases reviewed had seven or more risk factors identified. This compares to 70% of all cases reviewed from 2003-2018.
  • The risk factor findings for cases reviewed in 2018 is consistent with the findings shown in Chart Four and Graph Four which indicate that the majority of all cases reviewed from 2003-2018 have seven or more risk factors.

Analysis of Death Factors

Chart Seven: Death factors for cases reviewed in 2018 shows that 32% of the cases involved some type of trauma (including cuts, stabs, beatings, assaults). Of the cases reviewed, 28% involved the use of a firearm, 12% were due to asphyxia (i.e. hanging, airway obstruction, strangulation or neck compression), 16% were from drowning and 12% from fire-related injuries.  

Chart Seven: Death factors for cases reviewed in 2018

Chart Seven
Death FactorVictimPerpTotal
Trauma - cuts, stabs6-6
Trauma - beating, assault1-1
Trauma - blunt force1-1
Shooting - handgun2-2
Shooting - rifle213
Shooting - shotgun112
Asphyxia - strangulation3-3
Drowning4-4
Fire - smoke inhalation112
Fire - thermal1-1
Total Deaths22325

Note: Death Factor percentages for 2018 were Trauma 32%, Shooting 28%, Asphyxia 12%, Drowning 16% and Fire 12%.

Recommendations made from 2018 case reviews

In 2018, 28 recommendations were made from reviews conducted by the DVDRC.

In addition to new recommendations made, when appropriate, the DVDRC referenced previous recommendations that were relevant to the circumstances of the case under review. 

Recommendations focused on:

  • Services and resources for new immigrants living in Ontario
  • Risk assessment, safety planning and risk management in Indigenous communities
  • Probation services and safety planning
  • Workplace strategies for addressing domestic violence
  • Awareness and training on risk factors for intimate partner homicide by physicians, nurses, mental health care providers, addiction counsellors, family law lawyers and crown attorneys
  • The impact of intimate partner violence on children.

A summary of all recommendations made in 2018 is included in Appendix D.

Discussion and significant findings for cases reviewed in 2018

The findings from reviews conducted in 2018 are consistent with the overall results from all reviews conducted from 2003-2018.  Specifically:

  • The majority of domestic violence homicide victims were female. 
  • The age range of victims is broad. In 2018, the range was from four to 82 years.   
  • The age range for perpetrators is also broad. In 2018, the range was from 23 to 82 years.
  • The majority of cases reviewed had seven or more risk factors identified. The implication of numerous risk factors associated with these cases is that there was likely significant opportunity to predict (and prevent) future lethality in these cases.
  • Trauma (e.g. stabs, beating, blunt force injury) was the top death factor, followed by shooting.