Recommended Death Investigation Protocol For Intimate Partner Violence Cases
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Recommended Death Investigation Protocol for Intimate Partner Violence Cases
The purpose of this protocol is to assist in the implementation of Joanna’s Law and provide a standardized investigative approach for all deaths, ensuring thorough and impartial inquiries. This protocol applies to all violent, unnatural, unexplained, suspicious, or suspected deaths and includes a special section for deaths involving a history of domestic violence.
I. Purpose
The California Legislature unanimously passed SB989 – Joanna’s Law – in 2024 and it became effective on January 1, 2025. Joanna’s Law focuses on suspicious deaths with a prior history of domestic violence. Joanna’s Law can be found in California Penal Code Section 679.07. This new law will help law enforcement officers responding to apparent suicides with a history of domestic violence by including 10 Factors of a Suspicious Death in Domestic Violence Cases, developed by the Training Institute on Strangulation Prevention, a program of Alliance for HOPE International. California is the first state to recognize the need to identify apparent suicides with
a history of domestic violence as a presumptive suspicious death.
It further recognizes that domestic violence homicides are highly susceptible to staging which could hamper the ability of death investigators, coroners and medical examiners to accurately determine the cause and manner of death. Joanna’s Law mandates law enforcement to interview family members of the decedent, conduct a thorough investigation when there is a suspicious death, and advocate for an internal autopsy. The law also recognizes the need for on-going training on domestic violence-related deaths, including overcoming the challenges of staged crime scenes, and acknowledges the rights of families to obtain case information, access victim services, and request an independent review of initial findings or investigations without any cost to family members.
A suspicious death is any death that appears as a possible homicide, suicide or any death in which the cause is unknown and may not match the stated circumstances, scene or suspected cause. A staged crime scene involves the deliberate alteration of evidence by the offender to simulate events that did not occur for the purpose of misleading authorities.1 Staged crime scenes have been recognized in the literature for over a century.2 Between 19% to 43% of domestic violence homicides involve staged crimes scenes.3 Cases deemed suicides may, after time has passed become homicide cases due to the discovery of new evidence. This possibility requires that such cases, such as a suicide with a history of domestic violence, be treated as a homicide to prevent complications due to the failure to gather evidence, the loss of evidence, destruction of case files, contamination or other avoidable problems. Even when a suicide note is located or circumstances exist that clearly indicate the death is most likely a suicide, all investigative methods indicated for homicides and suspicious deaths shall be accomplished.
According to Vernon Geberth’s book on the Practical Homicide Investigation, “All death inquiries should be conducted as homicide investigations until the facts prove differently.” By initially treating every death as a potential homicide, investigators can systematically eliminate homicide as a possibility, leading to a more accurate determination of the cause of death and avoid the unpleasant position of having to explain how they missed crucial evidence.
When responding to a death scene, all deaths should initially be treated as homicide until proven otherwise after a thorough investigation.
Domestic violence-related homicides are highly susceptible to staging or alteration of the death scene before investigators can conduct a scene investigation, which hampers the responsibilities of the coroner or medical examiner and compromises the ability of investigators to evaluate death cases adequately. Research has identified 10 red flag markers in suspicious death cases, where there is a history of being victimized by domestic violence, that should be evaluated in any death investigation.
An independent right of family members of homicide victims has been created in federal law to obtain information, access victim services, and request an independent review of initial findings or the investigation of the death of their family member but the law applies only to those cases under federal jurisdiction. It is the intent of the Legislature to provide victim services and support to family members in suspicious death cases and support family members who seek a second opinion on the death of their loved one at no cost to any public agency whenever practicable.
Standards of the National Association of Medical Examiners:
Under the standards developed by the National Association Medical Examiner’s, a determination of a suicide requires a minimum 70% certainty. To make this determination, the Medical Examiner must use all information available to decide the manner of death. This may include information from his or her own investigation, police reports, staff investigations and discussions with the family and friends of the Decedent, including an autopsy, toxicology report, psychological evidence and statements from the decedent and witnesses.
“…While the finding of a medical examiner or coroner is generally given great weight, it is also not final for purposes of establishing the cause and manner of death. It can be rebutted by a preponderance of evidence. As a general rule, a medical examiner or coroner’s finding creates “a non-binding, rebuttable presumption concerning such facts in the absence of competent,credible evidence to the contrary.”
Even if the local Medical Examiner makes a finding of “undetermined,” prosecutors within that jurisdiction have an inherent right and duty to conduct their own investigation and, where warranted, pursue murder charges.
Confirmation Bias:
Confirmation bias—the tendency to favor information that supports preexisting beliefs—can be particularly dangerous in staged crime scenes involving intimate partner violence (IPV) homicides. Research shows that forensic pathologists may be influenced by contextual factors, such as initial law enforcement reports, leading to misclassification of homicides as suicides or accidents.
Studies indicate that racial and gender biases also affect determinations, with IPV-related deaths sometimes dismissed due to assumptions about victim behavior. To ensure accuracy, investigators must approach each case objectively, use forensic evidence over assumptions, and implement blind review procedures to reduce bias in death determination.
Suicide Statistics:
Men are more likely to die by suicide than women.
Men are more likely to die by suicide by violent means (gunshot or hanging).
Women are less likely to die by violent means.
Women are more likely to choose private places (home, bedroom, bathroom, garage).
In Gender, Place and Method of Suicide, researchers found women were over 73% less likely to use firearms than men, and women were over 4 times more likely to die from drug poisoning/overdose than males.
It is also recognized that victims of domestic violence are certainly at risk of contemplating and committing suicide because of the trauma they experienced
by their partner.
II. Incorporation of NIJ Death Investigation Protocol
This protocol expands to include the complete National Institute of Justice (NIJ)
Death Investigation Protocol, covering the following key areas:
Initial Notification and Determination of Response. Document initial death report, retain/release jurisdiction, determine scene response, and prepare for collaboration.
Arriving at the Scene. Ensure safety and security, confirm or pronounce death, conduct scene walkthrough, and establish chain of custody.
Documenting and Evaluating the Scene. Photograph scene, develop descriptive documentation, establish probable location of injury, safeguard property and evidence, and interview witnesses.
Documenting and Evaluating the Body. Conduct external examination, preserve evidence, establish decedent identification, document postmortem changes, and determine notification procedures.
Recording Decedent Profile Information. Document discovery history, circumstances of death, medical and mental health history, and social background.
Completing the Scene Investigation. Ensure proper disposition, perform exit procedures, assist family, and release custody of the body.
Public Statements & Confidentiality. Media statements must be cleared by lead investigators, and victim information must remain confidential.
Independent Review for High-Risk Cases. If indicators of domestic violence are present, conduct a secondary review before ruling a case as suicide or accidental.
The complete NIJ protocol can be found at nij.ojp.gov.
Multidisciplinary Team Approach
The use of a multidisciplinary review team in death investigations offers significant benefits.
They bring together diverse expertise from various fields, such as forensic pathology, toxicology, anthropology, and criminalistics. It allows for a more comprehensive analysis of evidence, improved accuracy in determining the cause of death, and a greater chance of contributing factors that might be missed with a single-discipline approach. This approach leads to more thorough and reliable investigations, especially in complex cases involving multiple potential causes of death or unusual circumstances.
The key benefits of a multidisciplinary review in death investigations include a holistic perspective, enhanced accuracy, identification of hidden clues, improved case resolution, and stronger legal standing.
Team members should include:
Law Enforcement
Prosecution
Coroner’s Office
Forensic Pathologist
Toxicologist
Forensic Anthropologist
Forensic Entomologist
Forensic Biologist
Forensic Chemist
Digital Forensics Expert
Victim Advocates
III. SCENE CONTROL AND INITIAL PROCEDURES
A. DISPATCHER
The initial staging of a crime scene often begins with the 911 call. This is the first step in the offender’s attempts to misdirect the investigation. This verbal staging involves the caller implanting false information. An example of this includes a report of suicide to 911, causing law enforcement to respond to the scene with the mindset they are responding to a suicide. One study of staged homicides found that 21.5% involved verbal staging.2 Dispatcher training becomes crucial to prevent the beginning of confirmation bias.
As a part of the law enforcement team, dispatchers should be included in training involving staged crime scenes.
The dispatcher should inquire what was occurring prior to the alleged incident (was there any argument).
A search history should be conducted for prior calls to the residence and history of the decedent, partner, and reporting party. This information should be transmitted
to the officers on scene.While the dispatcher will relay information to responding officers, the dispatcher should be aware that the information from the caller might not always be accurate and/or truthful.
B. FIRST RESPONDER RESPONSIBILITIES
Secure the scene: Prevent unauthorized access and ensure preservation of physical evidence.
Determine if the victim is deceased:
If life is present, initiate medical intervention.
If deceased, document body position without moving it.
Make initial assessments:
Identify any immediate threats.
Document environmental conditions (temperature, lighting, odors).
Prevent contamination:
Do not move or alter evidence unless necessary for safety.
Identify potential witnesses and separate them for statements.
Notify proper authorities:
Medical Examiner or Coroner.
Criminal Investigation Division (CID) or Homicide Unit.
Crime Scene Investigation (CSI) Unit.
Domestic Violence Unit (if applicable).
District Attorney’s Office (as needed).
C. SCENE WALKTHROUGH AND DOCUMENTATION
Conduct an initial walkthrough to identify:
Body position and potential cause of death.
Presence of blood, weapons, ligatures, or any items suggesting defensive wounds.
Signs of staging (e.g., body moved, suicide note, displaced objects, recent cleaning).
Photograph and video-record the scene before altering anything.
Establish chain of custody for all evidence collected.
Conduct victimology:
Interview friends, family, and cohabitants about the deceased’s mental, emotional,
and relationship history.Identify any history of domestic violence, strangulation, or coercive control.
Conduct a Danger Assessment utilizing friends and family members of the decedent.
IV. Deaths Involving a History of Domestic Violence
Inquire about history of domestic violence or coercive control. This involves an inquiry beyond the person(s) with whom the decedent had an intimate partner relationship, by interviewing the decedent’s other family members, friends, neighbors, and co-workers.
In cases where the deceased had an identifiable history of domestic violence, either documented or through witness interviews, additional investigative steps are required. Use the 10 Factors listed below as a tool to help identify a suspicious death. It should be used as part of the initial investigation. It does not replace a full investigation.
A. 10 Factors of Suspicious Death in Domestic Violence Cases
The victim dies prematurely or unexpectedly.
The scene is staged as a suicide or accident.
One partner wanted to end the relationship.
Prior history of domestic violence (including coercive control).
Victim found dead at home or a personal residence.
Victim discovered by a current or former partner.
Prior strangulation/suffocation attempts by the partner.
The partner was the last person to see the victim alive.
Partner had control of the crime scene before law enforcement arrived.
Evidence at the scene appears altered.
If three or more of these factors are present, the case must be investigated as a homicide until proven otherwise.
B. SPECIAL INVESTIGATIVE CONSIDERATIONS
Autopsy Requirements:
If the victim has a history of strangulation, coercion, or abuse, law enforcement should request a full forensic autopsy.
Specific tests should include hyoid bone fractures, petechiae, and deep tissue bruising to determine signs of strangulation.
Layered neck dissection including posterior neck dissection.
Interview past victims of the suspect, if applicable.
Conduct post-mortem danger assessment using either the DA-5, DA-LE or DA-20.
Review of Prior Domestic Violence Incidents:
Check for previous police reports, restraining orders, medical records, and witness statements.
Interview family members and close friends about history of strangulation or sexual choking with decedent and/or prior partners.
Identification of Staged Crime Scenes:
Look for inconsistencies in the suspect’s statement vs. physical evidence.
Identify signs of pre-staging, such as the suspect calling 911 with a story about the victim being suicidal when there is no history of suicidal ideation.
Evidence that the scene has been cleaned.
Decedent died by violent means including hanging and/or gunshot.
The absence of a suicide note.
Examine suicide notes for authenticity, handwriting analysis, and coerced writing indicators.
Victim-Centered Investigations:
Conduct interviews with family, friends, and co-workers to determine recent threats, coercion, financial control, and emotional abuse.
Assess mental health records and social media for prior threats from the suspect.
Assess for prior suicide attempts.
Consider utilizing an expert to assess suicide ideation and/or the Columbia Suicide Assessment tool available at cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/.
Forensic Evidence Collection:
Perform toxicology testing to determine if the victim was drugged before death.
Test for DNA under fingernails, bruising in hidden areas (torso, back of neck), and evidence of defensive wounds.
If the suicide was by gunshot, check for gunshot residue on the decedent and any partner or former partner.
If the suicide was by hanging, preserve the ligature and test for DNA.
If the decedent is naked or partially or oddly dressed, consider conducting a sexual assault exam.
Consider a forensic exam of the decedent’s partner or other person of interest.
Look for clothing, shoes and other items that might have been worn at the time of death as opposed to the items found on the victim.
Digital evidence (phones, laptops, watches, Burla, Alexa, Arlo).
Consider whether the use of GSR testing will be helpful to the investigation.
Alternate Light Source (ALS) and other Technology. Consider if ALS or other technology might help refine the investigation. Even if such evidence is not admissible, it might help direct you to evidence which is admissible.
Victim Assessment
Who is the victim?
Conduct a thorough Suicide Assessment
An ACE (Adverse Childhood Experience) history?
History of violence?
Offender Assessment
Who is this person?
Any ACE (Adverse Childhood Experience) history?
History of violence or “quick to anger”
Motive – another relationship, decedent wanted to end the relationship and money (insurance policy, inheritance, she was the bread winner)
Coercive Control
Look for actions of coercive control. A list of coercive control actions can be found in the Describe Abuse table on page 3 in the DV100 form available at courts.ca.gov.
Law Enforcement Training & Mandates:
Officers investigating suspicious domestic violence-related deaths must be current in specialized domestic violence and domestic violence homicide training.
All findings must be documented in a comprehensive case file, ensuring prosecution readiness.
V. Family Considerations
National best practices recommend every agency conducting an investigation of a suspicious death should adopt a victim-centered and a trauma informed approach in every interview and contact with victims, witnesses and family members of lost loved ones. A victim-centered approach recognizes the needs and concerns of family members to ensure compassionate and sensitive interactions with family members. Victim advocates can assist law enforcement in integrating victim-centered approaches into death investigation. Investigators must receive trauma-informed training. This includes training investigators to understand that family members can be retraumatized during investigations and that investigators themselves can suffer from secondary trauma. This includes understanding the longer a case is under investigation, under consideration or goes unsolved, the greater the potential for the relationship between law enforcement and family members may turn adversarial. Include a detailed plan for communication with family members of suspicious death victims. Please refer to National Best Practices for Implementing
nd Sustaining a Cold Case Unit.
VI. Victim Rights
Access to Victim Services. California law gives family members have the right to have access to victim services and support. Cal Penal Code 679.07.
Access to Information. In the event the case is determined not to be a homicide and the case is closed, family members have a right to access all information involved in the case.Cal. Penal Code 679.07 and CCP 129 (autopsy records and photos).
Meeting with the ME/Coroner. Provide information on how to request a meeting with the Medical Examiner to provide additional information and/or discuss their findings.
Changing the Manner of Death. Provide information on how to change the manner of death.
VII. Suggested Reading
Please download the PDF for active hyperlinks.
Guide for Manner of Death Classification (2002).
Forensic Autopsy Performance Standards, National Association of Medical Examiners (2005)
Crime Scene Staging & It’s Detection (Hazelwood/Napier 2004)
DOJ Death Investigation: A Guide for the Scene Investigator (1999, Updated 2011, 2024)
Seven Major Mistakes in Suicide Investigation (2013)
Staged Homicides: An Examination of Common Features of Faked Burglaries, Suicides, Accidents and Car Accidents (Ferguson, 2015)
Crime Scene Staging – Investigating Suspect Misdirection of the Crime Scene(2017)
The Perfect Murder: An Exploratory Study of Staged Murder Scenes and Concealed Femicides (Bitton/Dayan, 2019)
National Best Practices for Implementing and Sustaining a Cold Case Investigation Unit (2019)
“911 What’s Your Emergency?” Deception in 911 Homicide and Suicide Staged as Homicide calls (2020)
Distinguishing between Homicide and Suicide Knots and Ligatures: A comparative analysis of case and survey data, Chisnall, 2020)
VIII. Conclusion
This Recommended Death Investigation Protocol, incorporating NIJ best practices, ensures that all deaths—particularly those involving a history of domestic violence—are thoroughly investigated. By implementing these strategies, law enforcement can prevent staged crime scenes from being misclassified and hold perpetrators accountable.
IX. Endnotes
Please download the PDF for endnotes and active hyperlinks.
1 Geberth, V. J. (2006). Staging of crime scenes. Law and Order, 54(7), 94–100.
2 Schlesinger, L. B., Reitnauer, K., & Odland, C. (2014). Staging in homicide cases: A review of the literature and case study. International Journal of Offender Therapy and Comparative Criminology, 58(11), 1297–1312. https://doi.org/10.1007/s11896-012-9114-6
3 Ferguson, C., & Petherick, W. (2016). Getting Away With Murder: An Examination of Detected Homicides Staged as Suicides. Homicide Studies, 20(1), 3-24. https://eprints.qut.edu.au/82035/1/e-prints%20PDF.pdf
4 Geberth, V. J. (2013). Practical homicide investigation: Tactics, procedures, and forensic techniques (5th ed.). CRC Press / Taylor & Francis. https://www.taylorfrancis.com/books/mono/10.4324/9781003095835/practical-homicide-investigation-vernon-geberth
5 National Center for Health Statistics. (2003). Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting (April 2003 rev.). U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/misc/hb_me.pdf
6 Estate of Severt v. Wood, 107 Ohio App. 3d 123, 667 N.E.2d 628 (Ohio Ct. App. 1995).
7 People v. Feldman, 2024 COA 119 (Colo. Ct. App. Nov. 7, 2024) (No. 22CA0792), 2024 WL 4703105. https://caselaw.findlaw.com/court/col-crt-app-div-i/116675639.html
8 Murphy, G. E. (1998). Why women are less likely than men to commit suicide. Comprehensive Psychiatry, 39(4), 165–175. https://doi.org/10.1016/S0010-440X(98)90057-8
9 Curtin, S. C., Warner, M., & Hedegaard, H. (2016). Increase in suicide in the United States, 1999–2014. NCHS Data Brief, (241). National Center for Health Statistics.
https://www.cdc.gov/nchs/products/databriefs/db241.htm
10 Centers for Disease Control and Prevention. (2023). Surveillance for violent deaths—National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2020. Morbidity and Mortality Weekly Report: Surveillance Summaries, 72(5), 1–42. https://doi.org/10.15585/mmwr.ss7205a1
11 Kposowa, A. J., & McElvain, J. P. (2006). Gender, place, and method of suicide. Social Psychiatry and Psychiatric Epidemiology, 41(6), 435–443. https://pubmed.ncbi.nlm.nih.gov/16565913/
12 Cavanaugh, C. E., Messing, J. T., Del-Colle, M., O’Sullivan, C., & Campbell, J. C. (2011). Intimate partner violence and suicidal ideation in abused women. Violence and Victims, 26(1), 105–120. https://pubmed.ncbi.nlm.nih.gov/21535096/
X. Acknowledgements
The Training Institute on Strangulation Prevention recognizes and appreciates the significant contributions made by members of the Legal Committee under the leadership of Co-Chairs Jerry Fineman and Dan Rincon in preparing this Draft Death Investigation Protocol to help identify suspicious death cases in intimate partner situations. Together, we thank and acknowledge all those who contributed their time, comments and expertise to develop this Death Investigation Protocol. As the first draft of its kind, we also welcome feedback. Please send any comments to either Jerry Fineman at dvtrainingtips@gmail.com or Gael Strack at gael@allianceforhope.com.
Det. Mike Agnew, Fresno Police Department (ret)
Megan Ahsens, First Assistant Attorney General, Officer of Kansas Attorney General, Major Crime Division
Joe Bianco, Assistant Director, Training Institute on Strangulation Prevention, Alliance for HOPE International
Steve Campman, M.D., Chief Deputy Medical Examiner, San Diego County (Ret)
Bob Frechette, Chief Investigator, Strafford County Attorney’s Office
Gerald Fineman, Assistant District Attorney (Retired), Riverside County District Attorneys Office
Rachael Frost, Master Investigator Riverside County (ret)
Det. Nate Griesse, Missoula Police Department
Casey Gwinn, Esq., Founder, Alliance for HOPE International
Cpl. Josh Helton, Davis Police Department
Det. Bill Hernandez, Napa Police Department
Meagan Quinn, M.D., American Board of Pathology Diplomate, Anatomic, Clinical, Forensic Pathology
Lt. Dan Rincon, Scottsdale Police Department (ret)
Bill Smock, M.D., Police Surgeon, Louisville Metro Police Department
Gael Strack, Esq., Founder, Alliance for HOPE International
Laura Zimm, Assistant Public Defender, State of Minnesota
